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Dimitriadis K, Theofilis P, Koutsopoulos G, Pyrpyris N, Beneki E, Tatakis F, Tsioufis P, Chrysohoou C, Fragkoulis C, Tsioufis K. The role of coronary microcirculation in heart failure with preserved ejection fraction: An unceasing odyssey. Heart Fail Rev 2024:10.1007/s10741-024-10445-3. [PMID: 39358622 DOI: 10.1007/s10741-024-10445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2024] [Indexed: 10/04/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents an entity with complex pathophysiologic pathways, among which coronary microvascular dysfunction (CMD) is believed to be an important orchestrator. Research in the field of CMD has highlighted impaired vasoreactivity, capillary rarefaction, and inflammation as potential mediators of its development. CMD can be diagnosed via several noninvasive methods including transthoracic echocardiography, cardiac magnetic resonance, and positron emission tomography. Moreover, invasive methods such as coronary flow reserve and index of microcirculatory resistance are commonly employed in the assessment of CMD. As far as the association between CMD and HFpEF is concerned, numerous studies have highlighted the coexistence of CMD in the majority of HFpEF patients. Additionally, patients affected by both conditions may be facing an adverse prognosis. Finally, there is limited evidence suggesting a beneficial effect of renin-angiotensin-aldosterone system blockers, ranolazine, and sodium-glucose cotransporter-2 inhibitors in CMD, with further evidence being awaited regarding the impact of other pharmacotherapies such as anti-inflammatory agents.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece.
| | - Panagiotis Theofilis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Georgios Koutsopoulos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Fotis Tatakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Panagiotis Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Christina Chrysohoou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Christos Fragkoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, 11528, Athens, PO, Greece
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Pompei G, Ganzorig N, Kotanidis CP, Alkhalil M, Collet C, Sinha A, Perera D, Beltrame J, Kunadian V. Novel diagnostic approaches and management of coronary microvascular dysfunction. Am J Prev Cardiol 2024; 19:100712. [PMID: 39161975 PMCID: PMC11332818 DOI: 10.1016/j.ajpc.2024.100712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/04/2024] [Accepted: 07/21/2024] [Indexed: 08/21/2024] Open
Abstract
The mechanism underlying ischaemic heart disease (IHD) has been primarily attributed to obstructive coronary artery disease (CAD). However, non-obstructive coronary arteries are identified in >50% of patients undergoing elective coronary angiography, recently leading to growing interest in the investigation and management of angina/ischaemia with non-obstructive coronary arteries (ANOCA/INOCA). INOCA is an umbrella term encompassing a multiple spectrum of possible pathogenetic entities, including coronary vasomotor disorders which consist of two major endotypes: coronary microvascular dysfunction (CMD) and vasospastic angina. Both conditions can coexist and be associated with concomitant obstructive CAD. Particularly, CMD refers to myocardial ischaemia due to reduced vasodilatory capacity of coronary microcirculation secondary to structural remodelling or impaired resting microvascular tone (functional) or a combination of both. CMD is not a benign condition and is more prevalent in women presenting with chronic coronary syndrome compared to men. In this setting, an impaired coronary flow reserve has been associated with increased risk of major adverse cardiovascular events. ANOCA/INOCA patients also experience impaired quality of life and associated increased healthcare costs. Therefore, research in this scenario has led to better definition, classification, and prognostic stratification based on the underlying pathophysiological mechanisms. The development and validation of non-invasive imaging modalities, invasive coronary vasomotor function testing and angiography-derived indices provide a comprehensive characterisation of CMD. The present narrative review aims to summarise current data relating to the diagnostic approach to CMD and provides details on the sequence that therapeutic management should follow.
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Affiliation(s)
- Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
| | - Christos P. Kotanidis
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Mohammad Alkhalil
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Aish Sinha
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital & The Queen Elizabeth Hospital, Adelaide, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
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Denby KJ, Zmaili M, Datta S, Das T, Ellis S, Ziada K, Lerman A, Raphael CE. Developments and Controversies in Invasive Diagnosis of Coronary Microvascular Dysfunction in Angina With Nonobstructive Coronary Arteries. Mayo Clin Proc 2024; 99:1469-1481. [PMID: 39232622 DOI: 10.1016/j.mayocp.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 09/06/2024]
Abstract
Approximately half of all coronary angiograms performed for angina do not show obstructive coronary artery disease, and many of these patients have coronary microvascular dysfunction (CMD). Invasive testing for CMD has increased with the advent and wider availability of thermodilution systems. We review CMD pathophysiology and invasive diagnostic testing using the Doppler and thermodilution systems. We report the results of a PubMed search of invasive microvascular testing and discuss limitations of current diagnostic algorithms in the diagnosis of CMD, including controversies regarding the optimal cutoff value for abnormal coronary flow reserve, use of microvascular resistance indices, and options for increasing sensitivity of testing.
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Affiliation(s)
- Kara J Denby
- Department of Cardiovascular Medicine, Saint Alphonsus Regional Medical Center, Boise, ID
| | - Mohammad Zmaili
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Sudarshana Datta
- Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston
| | - Thomas Das
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Stephen Ellis
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Khaled Ziada
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Smati H, Sellke FW, Bourque JM, Qadeer YK, Niccoli G, Montone RA, Krittanawong C. Coronary Microvascular Dysfunction: A Guide for Clinicians. Am J Med 2024; 137:810-817. [PMID: 38723930 DOI: 10.1016/j.amjmed.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 09/01/2024]
Abstract
Dysfunction of the coronary microvasculature has become increasingly recognized as an important mechanism of myocardial ischemia in patients without obstructive coronary artery disease. The causes and management of coronary microvascular dysfunction remain poorly understood and are still largely based on extrapolation of epicardial coronary artery disease data. Quantification of myocardial blood flow and flow reserve have improved diagnosis, though important questions remain. In this review, we explain current understanding of the spectrum of pathophysiology of coronary microvascular dysfunction, summarize current diagnostic techniques to assess for coronary microvascular dysfunction, and appraise the limited data on management options specifically for patients with coronary microvascular dysfunction.
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Affiliation(s)
- Hannah Smati
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Brown University Warren Alpert School of Medicine, Providence, RI
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine and Radiology, University of Virginia Health System, Charlottesville
| | - Yusuf Kamran Qadeer
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, Mich
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Italy; Division of Cardiology, Parma University Hospital, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Zhang Y, Pu J, Niu T, Fang J, Chen D, Yidilisi A, Zheng Y, Lu J, Hu Y, Koo BK, Xiang J, Wang J, Jiang J. Prognostic Value of Coronary Angiography-Derived Index of Microcirculatory Resistance in Non-ST-Segment Elevation Myocardial Infarction Patients. JACC Cardiovasc Interv 2024; 17:1874-1886. [PMID: 39115479 DOI: 10.1016/j.jcin.2024.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 08/30/2024]
Abstract
BACKGROUND The index of microcirculatory resistance is a reliable measure for evaluating coronary microvasculature, but its prognostic value in patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear. OBJECTIVES This study aimed to evaluate the prognostic impact of postpercutaneous coronary intervention (PCI) angiography-derived index of microcirculatory resistance (angio-IMR) in patients with NSTEMI. METHODS The culprit vessel's angio-IMR was measured after PCI in 2,212 NSTEMI patients at 3 sites. The primary endpoint was 2-year major adverse cardiac events (MACEs), defined as a composite of cardiac death, readmission for heart failure, myocardial reinfarction, and target vessel revascularization. RESULTS The mean post-PCI angio-IMR was 20.63 ± 4.17 in NSTEMI patients. A total of 206 patients were categorized as the high post-PCI angio-IMR group according to maximally selected log-rank statistics. Patients with angio-IMR >25 showed a higher rate of MACEs than those with angio-IMR ≤25 (32.52% vs 9.37%; P < 0.001). Post-PCI angio-IMR >25 was an independent predictor of MACEs (HR: 4.230; 95% CI: 3.151-5.679; P < 0.001) and showed incremental prognostic value compared with conventional risk factors (AUC: 0.774 vs 0.716; P < 0.001; net reclassification index: 0.317; P < 0.001; integrated discrimination improvement: 0.075; P < 0.001). CONCLUSIONS In patients undergoing PCI for NSTEMI, an increased post-PCI angio-IMR is associated with a higher risk of MACEs. The addition of post-PCI angio-IMR into conventional risk factors significantly improves the ability to reclassify patients and estimate the risk of MACEs. (Angiograph-Derived Index of Microcirculatory Resistance in Patients With Acute Myocardial Infarction; NCT05696379).
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Affiliation(s)
- Yuxuan Zhang
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tiesheng Niu
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jiacheng Fang
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Delong Chen
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Abuduwufuer Yidilisi
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Yiyue Zheng
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Jia Lu
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China
| | - Yumeng Hu
- ArteryFlow Technology Co, Ltd, Hangzhou, China
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Jian'an Wang
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China.
| | - Jun Jiang
- Department of Cardiology of The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; State Key Laboratory of Transvascular Implantation Devices, Hangzhou, China; Cardiovascular Key Laboratory Zhejiang Province, Hangzhou, China.
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Chen D, Zhang Y, Yidilisi A, Hu D, Zheng Y, Fang J, Gong Q, Huang J, Dong Q, Pu J, Niu T, Xiang J, Wang J, Jiang J. Combined risk estimates of diabetes and coronary angiography-derived index of microcirculatory resistance in patients with non-ST elevation myocardial infarction. Cardiovasc Diabetol 2024; 23:300. [PMID: 39152477 PMCID: PMC11330026 DOI: 10.1186/s12933-024-02400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/07/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Diabetes mellitus (DM) and coronary microvascular dysfunction (CMD) increase the risk of adverse cardiac events in patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study aimed to evaluate the combined risk estimates of DM and CMD, assessed by the angiography-derived index of microcirculatory resistance (angio-IMR), in patients with NSTEMI. METHODS A total of 2212 patients with NSTEMI who underwent successful percutaneous coronary intervention (PCI) were retrospectively enrolled from three centers. The primary outcome was a composite of cardiac death or readmission for heart failure at a 2-year follow-up. RESULTS Post-PCI angio-IMR did not significantly differ between the DM group and the non-DM group (20.13 [17.91-22.70] vs. 20.19 [18.14-22.77], P = 0.530). DM patients exhibited a notably higher risk of cardiac death or readmission for heart failure at 2 years compared to non-DM patients (9.5% vs. 5.4%, P < 0.001). NSTEMI patients with both DM and CMD experienced the highest cumulative incidence of cardiac death or readmission for heart failure at 2 years (24.0%, P < 0.001). The combination of DM and CMD in NSTEMI patients were identified as the most powerful independent predictor for cardiac death or readmission for heart failure at 2 years (adjusted HR: 7.894, [95% CI, 4.251-14.659], p < 0.001). CONCLUSIONS In patients with NSTEMI, the combination of DM and CMD is an independent predictor of cardiac death or readmission for heart failure. Angio-IMR could be used as an additional evaluation tool for the management of NSTEMI patients with DM. TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov ; Unique identifier: NCT05696379.
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Affiliation(s)
- Delong Chen
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Yuxuan Zhang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Abuduwufuer Yidilisi
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Die Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiyue Zheng
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiacheng Fang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qinyan Gong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Jiniu Huang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Qichao Dong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Jun Pu
- Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tiesheng Niu
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | | | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China.
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China.
| | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, 310009, China.
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China.
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Scala A, Marchini F, Meossi S, Zanarelli L, Sanguettoli F, Frascaro F, Bianchi N, Cocco M, Erriquez A, Tonet E, Campo G, Pavasini R. Future of invasive and non-invasive hemodynamic assessment for coronary artery disease management. Minerva Cardiol Angiol 2024; 72:385-404. [PMID: 38934267 DOI: 10.23736/s2724-5683.23.06461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
Coronary artery disease represents a global health challenge. Accurate diagnosis and evaluation of hemodynamic parameters are crucial for optimizing patient management and outcomes. Nowadays a wide range of both non-invasive and invasive methods are available to assess the hemodynamic impact of both epicardial coronary stenosis and vasomotor disorders. In fact, over the years, important developments have reshaped the nature of both invasive and non-invasive diagnostic techniques, and the future holds promises for further innovation and integration. Non-invasive techniques have progressively evolved and currently a broad spectrum of methods are available, from cardiac magnetic resonance imaging with pharmacological stress and coronary computed tomography (CT) to the newer application of FFR-CT and perfusion CT. Invasive methods, on the contrary, have developed to a full-physiology approach, able not only to identify functionally significant lesions but also to evaluate microcirculation and vasospastic disease. The aim of this review is to summarize the current state-of-the-art of invasive and non-invasive hemodynamic assessment for CAD management.
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Affiliation(s)
- Antonella Scala
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Federico Marchini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Sofia Meossi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Luca Zanarelli
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | | | - Federica Frascaro
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Nicola Bianchi
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Marta Cocco
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Andrea Erriquez
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Elisabetta Tonet
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy -
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy
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SenthilKumar G, Hammond ST, Zirgibel Z, Cohen KE, Beyer AM, Freed JK. Is the peripheral microcirculation a window into the human coronary microvasculature? J Mol Cell Cardiol 2024; 193:67-77. [PMID: 38848808 PMCID: PMC11260236 DOI: 10.1016/j.yjmcc.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/13/2024] [Accepted: 06/04/2024] [Indexed: 06/09/2024]
Abstract
An increasing body of evidence suggests a pivotal role for the microvasculature in the development of cardiovascular disease. A dysfunctional coronary microvascular network, specifically within endothelial cells-the inner most cell layer of vessels-is considered a strong, independent risk factor for future major adverse cardiac events. However, challenges exist with evaluating this critical vascular bed, as many of the currently available techniques are highly invasive and cost prohibitive. The more easily accessible peripheral microcirculation has surfaced as a potential surrogate in which to study mechanisms of coronary microvascular dysfunction and likewise may be used to predict poor cardiovascular outcomes. In this review, we critically evaluate a variety of prognostic, physiological, and mechanistic studies in humans to answer whether the peripheral microcirculation can add insight into coronary microvascular health. A conceptual framework is proposed that the health of the endothelium specifically may link the coronary and peripheral microvascular beds. This is supported by evidence showing a correlation between human coronary and peripheral endothelial function in vivo. Although not a replacement for investigating and understanding coronary microvascular function, the microvascular endothelium from the periphery responds similarly to (patho)physiological stress and may be leveraged to explore potential therapeutic pathways to mitigate stress-induced damage.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Stephen T Hammond
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Zachary Zirgibel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Katie E Cohen
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Andreas M Beyer
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States.
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9
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Rheum Dis Clin North Am 2024; 50:519-533. [PMID: 38942582 DOI: 10.1016/j.rdc.2024.03.004] [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: 06/30/2024]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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10
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Aetesam-Ur-Rahman M, Zhao TX, Paques K, Oliveira J, Chiu YD, Duckworth M, Khialani B, Kyranis S, Bennett MR, West NEJ, Hoole SP. Evaluation of microcirculatory protection in percutaneous revascularisation: A stent implantation technique and device comparison. Catheter Cardiovasc Interv 2024. [PMID: 39044651 DOI: 10.1002/ccd.31155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/18/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) after percutaneous coronary intervention (PCI) is prognostically important and may also be a cause of persistent angina. The stent balloon inflation technique or material properties may influence the degree of CMD post-PCI. METHODS Thirty-six patients with stable angina attending for elective PCI were randomized to either slow drug eluting stent (DES) implantation technique (DES slow group): +2 atm. every 5 s., maintained for a further 30 s or a standard stent implantation technique (DES std group): rapid inflation and deflation. PressureWire X with thermodilution at rest and hyperemia and optical coherence tomography (OCT) were performed pre- and post-PCI. Combined primary endpoints were changes in index of microvascular resistance (delta IMR) and coronary flow reserve (delta CFR) following PCI. The secondary endpoints included differences in cardiac troponin I (delta cTnI) at 6 h post-PCI, Seattle angina questionnaire (SAQ) at 1, 3, 6, and 12 months and OCT measures of stent results immediately post-PCI and at 3 months. RESULTS Both groups were well matched, with similar baseline characteristics and OCT-defined plaque characteristics. Delta IMR was significantly better in the DES slow PCI arm with a median difference of -4.14 (95% CI -10.49, -0.39, p = 0.04). Delta CFR was also numerically higher with a median difference of 0.47 (95% CI -0.52, 1.31, p = 0.46). This did not translate to improved delta median cTnI (1.5 (34.8) vs. 0 (27.5) ng/L, p = 0.75) or median SAQ score at 3 months, (85 (20) vs. 95 (17.5), p = 0.47). CONCLUSION Slow stent implantation is associated with less CMD after elective PCI in patients with stable angina.
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Affiliation(s)
| | - Tian X Zhao
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Kitty Paques
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Joana Oliveira
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Yi-Da Chiu
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Melissa Duckworth
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Bharat Khialani
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Stephen Kyranis
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Martin R Bennett
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Nick E J West
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Stephen P Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
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11
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Mohammed AA, Li S, Zhang H, Abdu FA, Mohammed AQ, Zhang W, Al-Hashedi EM, Xu Y, Che W. Prognostic impact of coronary microvascular dysfunction in patients with atrial fibrillation. Microvasc Res 2024; 154:104685. [PMID: 38593952 DOI: 10.1016/j.mvr.2024.104685] [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] [Received: 01/30/2024] [Revised: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is frequently observed in atrial fibrillation (AF), the most commonly sustained arrhythmia. Nevertheless, an in-depth prognostic significance of CMD in AF is lacking. We aimed to provide insight into the predictive impact of CMD assessed by a novel non-invasive coronary angiography-derived index of microcirculatory resistance (caIMR) for major adverse events (MACE) in AF patients. METHOD This study included patients with AF who underwent invasive coronary angiography due to suspected cardiac ischemia and did not exhibit obstructive epicardial coronary artery disease (≤50 % stenosis). The caIMR was prospectively evaluated, and the optimal cutoff value for predicting MACE was determined through ROC analysis. RESULT A total of 463 patients with AF were enrolled. During a median of 33 months of follow-up, 111 (23.97 %) patients had MACE endpoints. The best caIMR cutoff value was 39.28. In patients with MACE, both the mean caIMR and the prevalence of elevated caIMR (caIMR>39.28) were significantly higher compared to those without MACE. An elevated caIMR was linked to a higher risk of MACE (log-rank P < 0.001) and emerged as an independent predictor of clinical outcomes (HR: 4.029; 95 % CI: 2.529-6.418; P < 0.001). In addition, the risk of MACE was higher in high caIMR patients with non-paroxysmal AF (log-rank P < 0.001) and no catheter ablation (log-rank P < 0.001). CONCLUSION Elevated caIMR is common and showed a vital independent prognostic significance in AF patients. In addition to well-known risk factors, assessment of microvascular function can be a feasible approach for early prevention and a therapeutic target in AF patients.
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Affiliation(s)
- Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Internal Medicine, Faculty of Medicine and Health Science, Taiz University, Yemen
| | - Siqi Li
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hengbin Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ekhlas Mahmoud Al-Hashedi
- Department of Cardiology, First Affiliated Hospital of Xi'an Jiaotong University Xi'an, Shaanxi, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Tenth People's Hospital Chongming branch, Shanghai, China.
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12
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Zhu C, Miao L, Wei K, Shi D, Gao J. Coronary microvascular dysfunction. Microvasc Res 2024; 153:104652. [PMID: 38211894 DOI: 10.1016/j.mvr.2024.104652] [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] [Received: 10/14/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
Coronary microvascular dysfunction (CMD) is a key mechanism underlying ischemic heart disease (IHD), yet its diagnosis and treatment remain challenging. This article presents a comprehensive overview of CMD research, covering its pathogenesis, diagnostic criteria, assessment techniques, risk factors, and therapeutic strategies. Additionally, it highlights the prospects for future CMD research. The article aims at advocating early and effective intervention for CMD and improving the prognosis of IHD.
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Affiliation(s)
- Chunlin Zhu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kangkang Wei
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Jie Gao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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13
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Ma J, Xia R, Lan Y, Wang A, Zhang Y, Ma L. Angiographic microvascular resistance in patients with obstructive hypertrophic cardiomyopathy. Microvasc Res 2024; 153:104656. [PMID: 38278289 DOI: 10.1016/j.mvr.2024.104656] [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] [Received: 10/23/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is an important feature of obstructive hypertrophic cardiomyopathy (oHCM). Angiographic microvascular resistance (AMR) offers a potent means for assessing CMD. This study sought to evaluate the prognostic value of CMD burden calculated by AMR among oHCM patients. METHODS We retrospectively screened all patients diagnosed with oHCM from Fuwai Hospital between January 2017 and November 2021. Off-line AMR assessments were performed for all 3 major coronary vessels by the independent imaging core laboratory. Patients were followed every 6 months post discharge via office visit or telephone contacts. The primary outcome was major adverse cardiovascular events (MACE), including all-cause death, and unplanned rehospitalization for heart failure. RESULTS A total of 342 patients presented with oHCM diseases enrolled in the present analyses. Mean age was 49.7, 57.6 % were men, mean 3-vessel AMR was 6.9. At a median follow-up of 18 months, high capability of 3-vessel AMR in predicting MACE was identified (AUC: 0.70) with the best cut-off value of 7.04. The primary endpoint of MACE was significantly higher in high microvascular resistance group (3-vessel AMR ≥ 7.04) as compared with low microvascular resistance group (56.5 % vs. 16.5 %; HR: 5.13; 95 % CI: 2.46-10.7; p < 0.001), which was mainly driven by the significantly higher risk of heart failure events in high microvascular resistance group. Additionally, 3-vessel AMR (HR: 4.37; 95 % CI: 1.99-9.58; p < 0.001), and age (per 1 year increase, HR: 1.03; 95 % CI: 1.01-1.06; p = 0.02) were independently associated with MACE. CONCLUSION The present retrospective study demonstrated that the novel angiography-based AMR was a useful tool for CMD evaluation among patients with oHCM. High microvascular resistance as identified by 3-vessel AMR (≥7.04) was associated with worse prognosis.
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Affiliation(s)
- Jie Ma
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ran Xia
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yue Lan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Anqi Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yaxing Zhang
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lihong Ma
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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14
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Wen X, Wang Z, Zheng B, Gong Y, Huo Y. Ability of the coronary angiography-derived index of microcirculatory resistance to predict microvascular obstruction in patients with ST-segment elevation. Front Cardiovasc Med 2024; 11:1187599. [PMID: 38711790 PMCID: PMC11071667 DOI: 10.3389/fcvm.2024.1187599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/19/2024] [Indexed: 05/08/2024] Open
Abstract
Background The coronary angiography-derived index of microvascular resistance (caIMR) correlates well with the index of microcirculatory resistance (IMR), which predicts microvascular obstruction (MVO). However, the relationship between caIMR and MVO remains unclear. Aim To evaluate the predictive ability of caIMR of MVO after ST-segment elevation myocardial infarction (STEMI). Methods CaIMR was calculated using computational flow and pressure simulation in patients with STEMI in whom MVO status had been assessed by cardiac magnetic resonance (CMR) after successful primary percutaneous intervention at Peking University First Hospital between December 2016 and August 2019. The clinical, biochemical, echocardiographic, and CMR characteristics were assessed according to MVO status. The predictive value of the clinical parameters and caIMR was evaluated. Results Fifty-three eligible patients were divided into an MVO group (n = 32) and a no-MVO group (n = 21). The caIMR tended to be higher in the MVO group (41.6 U vs. 30.1 U; p = 0.136). CaIMR and peak cardiac troponin-I (cTNI) were independent predictors of MVO (per 1-U increment in caIMR: odds ratio [OR] 1.044, 95% confidence interval [CI] 1.004-1.086, p = 0.030; per 1 ng/L increase in peak cTNI: OR 1.018, 95% CI 1.003-1.033, p = 0.022). In receiver-operating characteristic curve analysis, when a cut-off value of 45.17 U was used, caIMR had some ability to predict MVO (area under the curve 0.622, 95% CI 0.478-0.752, p = 0.127). Conclusions CaIMR and peak cTNI were independent predictors of short-term MVO in patients with STEMI who had undergone successful primary percutaneous coronary intervention and may help to identify those at high risk of MVO.
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Affiliation(s)
| | | | | | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
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15
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Zeitouni M, Procopi N, Redheuil A, Collet JP. Takotsubo syndrome : A cause of reversible microvascular coronary dysfunction. Ann Cardiol Angeiol (Paris) 2024; 73:101734. [PMID: 38354637 DOI: 10.1016/j.ancard.2024.101734] [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] [Received: 12/04/2023] [Revised: 12/07/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
Since the first description of takotsubo syndrome 30 years ago, only a little is known on the underlying physiopathology leading to peculiar left ventricular function alteration and myocardial damage related to acute emotional or physical stress. In the present case, we used continuous invasive thermodilution to evaluate coronary microvascular function at the acute phase of takotsubo and after recovery. The acute phase of takotsubo was characterized by a reduced coronary output and altered reserved flow with persistently high resistance during hyperaemia. At 6 weeks, we described a complete recovery of microvascular function, concomitant to LVEF recovery.
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Affiliation(s)
- Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, 75013, France..
| | - Niki Procopi
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, 75013, France
| | - Alban Redheuil
- Sorbonne Université, ICT Unité d'imagerie cardiovasculaire et thoracique, Hôpital La Pitié Salpêtrière (AP-HP), Laboratoire d'Imagerie Biomédicale, INSERM UMRS 1146, CNRS, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, 75013, France
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16
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Patel N, Greene N, Guynn N, Sharma A, Toleva O, Mehta PK. Ischemia but no obstructive coronary artery disease: more than meets the eye. Climacteric 2024; 27:22-31. [PMID: 38224068 DOI: 10.1080/13697137.2023.2281933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024]
Abstract
Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.
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Affiliation(s)
- N Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - N Greene
- Emory University School of Medicine, Atlanta, GA, USA
| | - N Guynn
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - A Sharma
- Department of Internal Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - O Toleva
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - P K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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17
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Cardiol Clin 2024; 42:125-135. [PMID: 37949533 PMCID: PMC11090694 DOI: 10.1016/j.ccl.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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18
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Celeski M, Nusca A, De Luca VM, Antonelli G, Cammalleri V, Melfi R, Mangiacapra F, Ricottini E, Gallo P, Cocco N, Rinaldi R, Grigioni F, Ussia GP. Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg? J Cardiovasc Dev Dis 2024; 11:39. [PMID: 38392253 PMCID: PMC10889783 DOI: 10.3390/jcdd11020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.
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Affiliation(s)
- Mihail Celeski
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Annunziata Nusca
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Valeria Maria De Luca
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Giorgio Antonelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Valeria Cammalleri
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Rosetta Melfi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Fabio Mangiacapra
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Elisabetta Ricottini
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Paolo Gallo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Nino Cocco
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Raffaele Rinaldi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Francesco Grigioni
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Gian Paolo Ussia
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
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El Farissi M, Zimmermann FM, Fearon WF. Reply: Decoding the Index of Microcirculatory Resistance: What Does it Mean in Myocardial Infarction? JACC Cardiovasc Interv 2024; 17:105. [PMID: 38199748 DOI: 10.1016/j.jcin.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024]
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20
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Paolisso P, Gallinoro E, Belmonte M, Bertolone DT, Bermpeis K, De Colle C, Shumkova M, Leone A, Caglioni S, Esposito G, Fabbricatore D, Moya A, Delrue L, Penicka M, De Bruyne B, Barbato E, Bartunek J, Vanderheyden M. Coronary Microvascular Dysfunction in Patients With Heart Failure: Characterization of Patterns in HFrEF Versus HFpEF. Circ Heart Fail 2024; 17:e010805. [PMID: 38108151 DOI: 10.1161/circheartfailure.123.010805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/18/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is involved in heart failure (HF) onset and progression, independently of HF phenotype and obstructive coronary artery disease. Invasive assessment of CMD might provide insights into phenotyping and prognosis of patients with HF. We aimed to assess absolute coronary flow, absolute microvascular resistance, myocardial perfusion, coronary flow reserve, and microvascular resistance reserve in patients with HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF). METHODS Single-center, prospective study of 56 consecutive patients with de novo HF with nonobstructive coronary artery disease divided into HF with preserved ejection fraction (n=21) and HFrEF (n=35). CMD was invasively assessed by continuous intracoronary thermodilution and defined as coronary flow reserve <2.5. Left ventricular and left anterior descending artery-related myocardial mass was quantified by echocardiography and coronary computed tomography angiography. Myocardial perfusion (mL/min per g) was calculated as the ratio between absolute coronary flow and left anterior descending artery-related mass. RESULTS Patients with HFrEF showed a higher left ventricular and left anterior descending artery-related myocardial mass compared with HF with preserved ejection fraction (P<0.010). Overall, 52% of the study population had CMD, with a similar prevalence between the 2 groups. In HFrEF, CMD was characterized by lower absolute microvascular resistance and higher absolute coronary flow at rest (functional CMD; P=0.002). CMD was an independent predictor of a lower rate of left ventricular reverse remodeling at follow-up. In patients with HF with preserved ejection fraction, CMD was mainly due to higher absolute microvascular resistance and lower absolute coronary flow during hyperemia (structural CMD; P≤0.030). CONCLUSIONS Continuous intracoronary thermodilution allows the definition and characterization of patterns with distinct CMD in patients with HF and could identify patients with HFrEF with a higher rate of left ventricular reverse remodeling at follow-up.
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Affiliation(s)
- Pasquale Paolisso
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Cardiology Unit, Galeazzi-Sant'Ambrogio Hospital, Scientific Institute for Research, Hospitalization, and Health Care (IRCCS), Milan, Italy (E.G.)
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Konstantinos Bermpeis
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Cristina De Colle
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Monika Shumkova
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Attilio Leone
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Serena Caglioni
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Italy (S.C.)
| | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Davide Fabbricatore
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy (P.P., M.B., D.T.B., C.D.C., A.L., G.E., D.F.)
| | - Ana Moya
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Leen Delrue
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Martin Penicka
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
- Department of Cardiology, Lausanne University Hospital, Switzerland (B.D.B.)
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy (E.B.)
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
| | - Marc Vanderheyden
- Cardiovascular Center Aalst, OLV Hospital, Belgium (P.P., E.G., M.B., D.T.B., K.B., C.D.C., M.S., A.L., G.E., D.F., A.M., L.D., M.P., B.D.B., J.B., M.V.)
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21
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Takeda A, Ikenaga H, Nakano T, Morita Y, Higashihara T, Watanabe N, Sada Y, Nakano Y. Relationship between the Selvester QRS Score and Coronary Microvascular Dysfunction Assessed by the Index of Microcirculatory Resistance. Intern Med 2023; 62:3591-3599. [PMID: 37121753 PMCID: PMC10781549 DOI: 10.2169/internalmedicine.1504-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
Objective The index of microvascular resistance (IMR) is an invasive method for quantifying the coronary microvasculature independent of the presence and degree of epicardial stenosis during cardiac catheterization, whereas the Selvester QRS score, which is related to myocardial damage, is a relatively simple and non-invasive measurement procedure. We investigated the relationship between the QRS score and coronary microvascular dysfunction (CMD) assessed via IMR. Methods Data from 74 patients who underwent invasive coronary physiological measurements were retrospectively reviewed. Using a coronary wire, we measured IMR by the hyperemic mean transit time and distal coronary pressure. We also determined a simplified QRS score following the Selvester QRS score criteria by 12-lead electrocardiography. After determining the best cutoff value for the QRS score to predict IMR ≥25, which was defined as CMD by the Coronary Vasomotion Disorders International Study Group, patients were categorized into the QRS score ≥3 (n=16) and the QRS score 0-2 (n=58) groups. Results IMR in the QRS score ≥3 group was significantly higher in comparison to the QRS score 0-2 group (31; IQR: 19-57 vs. 20; IQR: 14-29, p<0.01). The percentage of patients with IMR ≥25 in the QRS score ≥3 group was significantly higher than that in the QRS score 0-2 group (69% vs. 34%, p=0.01). Conclusion A higher QRS score was associated with CMD, as estimated by IMR. The Selvester QRS score is noninvasive parameter that is potentially useful for predicting CMD.
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Affiliation(s)
- Atsushi Takeda
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takayuki Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Yuichi Morita
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Tasuku Higashihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Noriaki Watanabe
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Yoshiharu Sada
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
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22
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Bora N, Balogh O, Ferenci T, Piroth Z. Functional Assessment of Long-Term Microvascular Cardiac Allograft Vasculopathy. J Pers Med 2023; 13:1686. [PMID: 38138913 PMCID: PMC10744790 DOI: 10.3390/jpm13121686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of death and retransplantation following heart transplantation (HTX). Surveillance angiography performed yearly is indicated for the early detection of the disease, but it remains of limited sensitivity. METHODS We performed bolus thermodilution-based coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) measurements in HTX patients undergoing yearly surveillance coronary angiography without overt CAV. RESULTS In total, 27 HTX patients were included who had 52 CFR, IMR, and FFR measurements at a mean of 43 months after HTX. Only five measurements were performed in the first year. CFR decreased significantly by 0.13 every year (p = 0.04) and IMR tended to increase by 0.98 every year (p = 0.051), whereas FFR did not change (p = 0.161) and remained well above 0.80 over time. After one year, CFR decreased significantly (p = 0.022) and IMR increased significantly (p = 0.015), whereas FFR remained unchanged (p = 0.72). CONCLUSIONS The functional status of the epicardial coronary arteries of transplanted hearts did not deteriorate over time. On the contrary, a significant decrease in CFR was noted. In view of the increasing IMR, this is caused by the deterioration of the function of microvasculature. CFR and IMR measurements may provide an early opportunity to diagnose CAV.
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Affiliation(s)
- Noemi Bora
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Orsolya Balogh
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
| | - Tamás Ferenci
- Physiological Controls Group, John von Neumann Faculty of Informatics, Obuda University, 1034 Budapest, Hungary;
| | - Zsolt Piroth
- Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary; (N.B.); (O.B.)
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23
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Johnsrud DO, Port SC. In 2023 invasive coronary angiography is preferred to PET myocardial perfusion imaging for the initial work-up of a symptomatic patient with a high coronary artery calcium score. J Nucl Cardiol 2023; 30:2269-2272. [PMID: 37845556 DOI: 10.1007/s12350-023-03385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
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24
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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25
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Mohammed AA, Zhang H, Li S, Liu L, Mareai RM, Xu Y, Abdu FA, Che W. Prognostic value of coronary microvascular dysfunction in patients with aortic stenosis and nonobstructed coronary arteries. J Cardiovasc Med (Hagerstown) 2023; 24:891-899. [PMID: 37942790 DOI: 10.2459/jcm.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patients with aortic valve stenosis have been postulated to have coronary microvascular dysfunction (CMD) contributing to the clinical symptoms and adverse outcomes. The coronary angiography (CAG)-derived index of microcirculatory resistance (caIMR) is proposed as a novel, less invasive and pressure-wire-free index to assess CMD. This study aimed to quantify CMD assessed by caIMR and investigate its prognostic impact in patients with aortic valve stenosis. METHODS This study included 77 moderate or severe aortic valve stenosis patients with no obstructive coronary disease (defined as having no stenosis more than 50% in diameter) who underwent caIMR measurement. CMD was defined by caIMR at least 25. Major adverse cardiovascular events (MACE) were the clinical outcomes during the median 40 months of follow-up. RESULTS The incidence of CMD was 47.7%. Seventeen MACE occurred during the follow-up duration. CMD was associated with an increased risk of MACE (log-rank P < 0.001) and an independent predictor of clinical outcomes [hazard ratio 5.467, 95% confidence interval (CI) 1.393-21.458; P = 0.015]. The receiver-operating characteristic (ROC) curve analysis demonstrated that caIMR could provide a significant predictive value for MACE in aortic valve stenosis patients (AUC 0.785, 95% CI 0.609-0.961, P < 0.001). In addition, the risk of MACE was higher in CMD patients with severe aortic valve stenosis (log-rank P < 0.001) and no aortic valve replacement (log-rank P = 0.003) than in other groups. CONCLUSION Aortic valve stenosis patients demonstrated markedly impaired caIMR. CMD assessed by caIMR increases the risk of MACE and is an independent predictor of adverse outcomes in aortic valve stenosis patients. This finding suggests that using caIMR in the clinical assessment may help identify high-risk groups and stimulate earlier intervention.
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Affiliation(s)
- Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
- Department of Internal Medicine, Faculty of Medicine and Health Science, Taiz University, Yemen
| | - Hengbin Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Siqi Li
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine; Shanghai, China
- Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China
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26
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Do T, Van A, Ataei A, Sharma S, Mohandas R. Microvascular Dysfunction in Obesity-Hypertension. Curr Hypertens Rep 2023; 25:447-453. [PMID: 37837517 DOI: 10.1007/s11906-023-01272-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the role of microvascular dysfunction in obesity-hypertension, discuss the effects obesity has on renal microvasculature, review the current methods for assessing microvascular dysfunction and available therapeutic options, and identify critical areas for further research. RECENT FINDINGS There is a strong association between obesity and hypertension. However, the pathophysiology of obesity-hypertension is not clear. Microvascular dysfunction has been linked to hypertension and obesity and could be an important mediator of obesity-related hypertension. Newer therapies for hypertension and obesity could have ameliorating effects on microvascular dysfunction, including GLP-1 agonists and SGLT-2 inhibitors. There is still much progress to be made in our understanding of the complex interplay between obesity, hypertension, and microvascular dysfunction. Continued efforts to understand microvascular dysfunction and its role in obesity-hypertension are crucial to develop precision therapy to target obesity-hypertension.
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Affiliation(s)
- Tammy Do
- Department of Medicine, LSU Health Sciences Center - New Orleans, New Orleans, LA, USA
| | - Ashley Van
- Department of Medicine, LSU Health Sciences Center - New Orleans, New Orleans, LA, USA
| | - Arash Ataei
- Department of Medicine, LSU Health Sciences Center - New Orleans, New Orleans, LA, USA
| | - Swati Sharma
- Section of Nephrology and Hypertension, LSU Health Sciences Center - New Orleans, 2021 Perdido Street, Ste 4325, New Orleans, LA, 70112, USA
| | - Rajesh Mohandas
- Section of Nephrology and Hypertension, LSU Health Sciences Center - New Orleans, 2021 Perdido Street, Ste 4325, New Orleans, LA, 70112, USA.
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27
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Kest M, Ágoston A, Szabó GT, Kiss A, Üveges Á, Czuriga D, Komócsi A, Hizoh I, Kőszegi Z. Angiography-based coronary microvascular assessment with and without intracoronary pressure measurements: a systematic review. Clin Res Cardiol 2023:10.1007/s00392-023-02338-6. [PMID: 37987840 DOI: 10.1007/s00392-023-02338-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND In recent years, several indices have been proposed for quantifying coronary microvascular resistance. We intended to conduct a comprehensive review that systematically evaluates indices of microvascular resistance derived from angiography. OBJECTIVE The objective of this study was to identify and analyze angiography-derived indices of microvascular resistance that have been validated against an invasive reference method. We aimed to compare their limits of agreement with their reference methods and explore their advantages and inherent limitations. METHODS AND RESULTS We searched PubMed from inception until 2022 for studies on different techniques for quantifying microvascular resistance. Seven studies met the inclusion criteria. Five studies included techniques that applied calculations based solely on invasive angiography, and were validated against invasively measured thermodilution-derived index of microvascular resistance. The remaining two studies combined angiography with invasively measured intracoronary pressure data, and were validated against invasive Doppler measurements. We converted the ± 1.96 standard deviation limits of agreement with the reference method from the seven studies into percentages relative to the cut-off value of the reference method. The lower limits of agreement for angiography-based methods ranged from - 122 to - 60%, while the upper limits ranged from 74 to 135%. The range of the limits of agreement was considerably lower for the two combined angiography- and pressure-based methods, standing at - 52 to 60% and - 25 to 27%. CONCLUSION Our findings suggest that combined angiography- and pressure-based methods provide a more reliable assessment of microvascular resistance compared to methods relying solely on angiography. Central illustration. Comparative assessment of image-based methods quantifying microvascular resistance with and without intracoronary pressure measurements. Angiography-based methods rely on angiography alone to calculate the microvascular resistance by utilizing angiographic frame counting to extrapolate coronary flow (Q) and subsequently deriving distal coronary pressure using fluid dynamic equations. Combined angiography- and pressure-based methods utilize invasive intracoronary pressure gradients measured during rest and maximal vasodilation to determine coronary flow in their calculation of microvascular resistance. The combined methods showed more acceptable levels of agreement with their reference methods compared to angiography-based methods alone.
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Affiliation(s)
- Michael Kest
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - András Ágoston
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Gábor Tamás Szabó
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Áron Üveges
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Dániel Czuriga
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Hizoh
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Kőszegi
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary.
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary.
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28
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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Takahashi T, Gupta A, Samuels BA, Wei J. Invasive Coronary Assessment in Myocardial Ischemia with No Obstructive Coronary Arteries. Curr Atheroscler Rep 2023; 25:729-740. [PMID: 37682498 PMCID: PMC10564835 DOI: 10.1007/s11883-023-01144-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is threefold: (i) to give an overview of well-established invasive methods for assessing patients with ischemia with no obstructive coronary arteries (INOCA) in the cardiac catheterization laboratory; (ii) to describe the prognostic and treatment implications based on these findings, and (iii) to discuss current knowledge gaps and future perspectives. RECENT FINDINGS Recent studies have demonstrated that invasive coronary function testing not only allows for risk stratification of patients with INOCA but also guides medical therapy with improvement in symptoms and quality of life. Based on these findings, invasive coronary function assessment is now a class 2a recommendation in the 2021 ACC/AHA chest pain guideline to improve the diagnosis of coronary microvascular dysfunction and to enhance risk stratification. Invasive functional testing for patients with INOCA is well established and easily performed in the catheterization laboratory. Comprehensive invasive assessment is a key to differentiating INOCA endotypes and optimizing both medical therapy and preventive strategies including lifestyle modification.
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Affiliation(s)
| | - Aakriti Gupta
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd A3212, Los Angeles, CA, 90048, USA.
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Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, Jeremias A, Albadri A, Blair JA, Kearney KE, Wei J, Park K, Barseghian El-Farra A, Holoshitz N, Janaszek KB, Kesarwani M, Lerman A, Prasad M, Quesada O, Reynolds HR, Savage MP, Smilowitz NR, Sutton NR, Sweeny JM, Toleva O, Henry TD, Moses JW, Fearon WF, Tremmel JA. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1245-1263. [PMID: 37704315 DOI: 10.1016/j.jacc.2023.06.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 09/15/2023]
Abstract
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
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Affiliation(s)
- Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Jay Widmer
- Baylor Scott and White Health, Temple, Texas, USA
| | - Yuhei Kobayashi
- New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Steven E S Miner
- Southlake Regional Medical Centre, Newmarket, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen Jeremias
- St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Ahmed Albadri
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John A Blair
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kathleen E Kearney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Noa Holoshitz
- Ascension Columbia St Mary's, Milwaukee, Wisconsin, USA
| | | | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael P Savage
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph M Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olga Toleva
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Jeffery W Moses
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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Trøan J, Hansen KN, Noori M, Ellert-Gregersen J, Junker A, Veien KT, Hougaard M, Fallesen CO, Hansen HS, Jensen LO. The Influence of Microcirculatory Dysfunction on the Resting Full Cycle Ratio Compared to Fractional Flow Reserve. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:41-46. [PMID: 37045636 DOI: 10.1016/j.carrev.2023.03.017] [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] [Received: 03/08/2023] [Revised: 03/16/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The relation between the resting full cycle ratio (RFR) and fractional flow reserve (FFR) is not fully understood. This study aims to investigate the influence of coronary microvascular dysfunction, assessed by the index of microvascular resistance (IMR), on RFR compared to FFR in patients undergoing functional assessment for coronary stenosis. MATERIALS AND METHODS Two-hundred patients with borderline stenosis underwent functional assessment of RFR, FFR, coronary flow reserve (CFR) and IMR. Retriever operator curve analysis was performed to assess the diagnostic value of RFR in patients with (IMR ≥ 24) and (IMR < 24). RESULTS Median RFR did not differ significantly in patients with IMR ≥ 24 compared to patients with IMR < 24: 0.89 (interquartile range (IQR) 0.84, 0.95) vs. 0.90 (IQR 0.84, 0.92), p = 0.29). FFR was significantly higher in patients with IMR ≥ 24 compared to patients with IMR < 24: median FFR 0.85 (IQR (0.76, 0.92)) vs. 0.82 (IQR 0.73, 0.86), p = 0.009, and median CFR was significantly lower 1.80 (IQR 1.40, 2.55) vs. 2.70 (IQR 1.80, 3.95), p < 0.001. The diagnostic value of RFR was high (Area under the curve (AUC) 0.89 95 % Confidence Interval: [0.85, 0.93]) and AUC did not differ between patients with IMR ≥ 24 compared to patients with IMR < 24: 0.89 vs. 0.90, p = 0.89. An overall optimal cut off of 0.88 was identified. The cut off did not differ significantly between patients with IMR ≥ 24 compared to patients with IMR < 24: 0.88 vs. 0.90, p = 0.397. CONCLUSION In patients with coronary borderline stenosis, the coronary microvascular function did not influence on the cut off values or AUC of RFR compared to FFR.
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Affiliation(s)
- Jens Trøan
- Department of Cardiology Odense University Hospital, Odense, Denmark.
| | | | - Manijeh Noori
- Department of Cardiology Odense University Hospital, Odense, Denmark
| | | | - Anders Junker
- Department of Cardiology Odense University Hospital, Odense, Denmark
| | | | - Mikkel Hougaard
- Department of Cardiology Odense University Hospital, Odense, Denmark
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Marano P, Wei J, Merz CNB. Coronary Microvascular Dysfunction: What Clinicians and Investigators Should Know. Curr Atheroscler Rep 2023; 25:435-446. [PMID: 37338666 PMCID: PMC10412671 DOI: 10.1007/s11883-023-01116-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Abnormal structure and function of the coronary microvasculature have been implicated in the pathophysiology of multiple cardiovascular disease processes. This article reviews recent research progress related to coronary microvascular dysfunction (CMD) and salient clinical takeaways. RECENT FINDINGS CMD is prevalent in patients with signs and symptoms of ischemia and no obstructive epicardial coronary artery disease (INOCA), particularly in women. CMD is associated with adverse outcomes, including most frequently the development of heart failure with preserved ejection fraction. It is also associated with adverse outcomes in patient populations including hypertrophic cardiomyopathy, dilated cardiomyopathy, and acute coronary syndromes. In patients with INOCA, stratified medical therapy guided by invasive coronary function testing to define the subtype of CMD leads to improved symptoms. There are invasive and non-invasive methodologies to diagnose CMD that provide prognostic information and mechanistic information to direct treatment. Available treatments improve symptoms and myocardial blood flow; ongoing investigations aim to develop therapy to improve adverse outcomes related to CMD.
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Affiliation(s)
- Paul Marano
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA.
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
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Maurina M, Benedetti A, Stefanini G, Condorelli G, Collet C, Zivelonghi C, Smits PC, Paradies V. Coronary Vascular (DYS) Function and Invasive Physiology Assessment: Insights into Bolus and Continuous Thermodilution Methods. J Clin Med 2023; 12:4864. [PMID: 37510979 PMCID: PMC10381553 DOI: 10.3390/jcm12144864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
A considerable number of patients with angina or myocardial ischemia have no significant coronary artery disease on invasive angiography. In recent years, several steps towards a better comprehension of the pathophysiology of these conditions, angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), have been made. Nevertheless, several gaps in knowledge still remain. This review is intended to provide a comprehensive overview of ANOCA and INOCA, with a particular focus on pathophysiology, recent diagnostic innovations, gaps in knowledge and treatment modalities.
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Affiliation(s)
- Matteo Maurina
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Alice Benedetti
- HartCentrum, Antwerpen Hospital Network (ZNA) Middelheim, 2020 Antwerp, Belgium
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, MI, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, 20089 Rozzano, MI, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
| | - Carlo Zivelonghi
- HartCentrum, Antwerpen Hospital Network (ZNA) Middelheim, 2020 Antwerp, Belgium
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, 3015 GD Rotterdam, The Netherlands
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Rafique M, Solberg OG, Gullestad L, Bendz B, Murbræch K, Nytrøen K, Rolid K, Lunde K. Effects of high-intensity interval training on cardiac remodelling, function and coronary microcirculation in de novo heart transplant patients: a substudy of the HITTS randomised controlled trial. BMJ Open Sport Exerc Med 2023; 9:e001331. [PMID: 37440977 PMCID: PMC10335410 DOI: 10.1136/bmjsem-2022-001331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives High-intensity interval training (HIT) improves peak oxygen consumption (VO2peak) in de novo heart transplant (HTx) recipients. It remains unclear whether this improvement early after HTx is solely dependent on peripheral adaptations, or due to a linked chain of central and peripheral adaptations. The objective of this study was to determine whether HIT results in structural and functional adaptations in the cardiovascular system. Methods Eighty-one de novo HTx recipients were randomly assigned to participate in either 9 months of supervised HIT or standard care exercise-based rehabilitation. Cardiac function was assessed by echocardiogram and the coronary microcirculation with the index of microcirculatory resistance (IMR) at baseline and 12 months after HTx. Results Cardiac function as assessed by global longitudinal strain was significantly better in the HIT group than in the standard care group (16.3±1.2% vs 15.6±2.2%, respectively, treatment effect = -1.1% (95% CI -2.0% to -0.2%), p=0.02), as was the end-diastolic volume (128.5±20.8 mL vs 123.4±15.5 mL, respectively, treatment effect=4.9 mL (95% CI 0.5 to 9.2 mL), p=0.03). There was a non-significant tendency for IMR to indicate improved microcirculatory function (13.8±8.0 vs 16.8±12.0, respectively, treatment effect = -4.3 (95% CI -9.1 to 0.6), p=0.08). Conclusion When initiated early after HTx, HIT leads to both structural and functional cardiovascular adaptations. Trial registration number NCT01796379.
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Affiliation(s)
- Muzammil Rafique
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ole Geir Solberg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway and Center for Heart Failure Research, Oslo University Hospital, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Klaus Murbræch
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kari Nytrøen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Katrine Rolid
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ketil Lunde
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Fujimori Y, Hashimoto S, Takahashi M, Hoshino H, Shimizu K, Terasawa Y, Wakabayashi T, Imai T. Coronary microcirculatory dysfunction can be assessed by positive dicrotic wave and amplitude index on resting distal coronary pressure waveform, a newly developed index. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead070. [PMID: 37441357 PMCID: PMC10334376 DOI: 10.1093/ehjopen/oead070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/06/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
Aims Some lesions have high resting distal coronary pressure/aortic pressure (Pd/Pa) despite low fractional flow reserve (FFR). This study aimed to assess microcirculatory dysfunction as a possible basal mechanism. Methods and results Patients were grouped into two according to coffee intake (caffeine 222 mg) before coronary angiography. Through an adenosine-induced Pd/Pa decrease, amplitude index was calculated by dividing the difference between the highest pressure after the inflection point and the minimal diastolic pressure by the pulse pressure on the Pd waveform. In 130 coronary lesions (caffeine group, n = 69; non-caffeine group, n = 61) from 113 patients, the amplitude index through the adenosine-induced Pd/Pa decrease in all lesions was 0.54 ± 0.11 at resting Pd/Pa and 0.44 ± 0.12 at FFR (P < 0.0001). The positive dicrotic wave distribution on a maximal hyperaemia (FFRnicr)-resting Pd/Pa graph was analysed. In lesions with FFRnicr <0.80 on the FFRnicr-resting Pd/Pa graph, the resting Pd/Pa was divided into three zones based on Pd/Pa values: high-remaining, intermediate, and low. The high-remaining zone had a higher amplitude index than the intermediate zone (0.60 ± 0.09 vs. 0.48 ± 0.12; P < 0.005); the low zone lesions had no inflection point (no amplitude index). The high-remaining zone correlated with a larger positive dicrotic wave than the intermediate zone (94 vs. 30%; P < 0.005). Most lesions in the high-remaining zone corresponded to the caffeine group. Conclusion In severe coronary stenosis, a high-remaining resting Pd/Pa with a high amplitude index or a positive dicrotic wave on the resting Pd waveform suggests microcirculatory dysfunction, such as insufficient arteriolar dilation reactive to myocardial ischaemia. Registration UMIN000046883.
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Affiliation(s)
| | - Satoshi Hashimoto
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Miki Takahashi
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Hirotada Hoshino
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Kenji Shimizu
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Yuya Terasawa
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Tadamasa Wakabayashi
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
| | - Taku Imai
- Department of Cardiology, Suwa Central Hospital, Tamagawa 4300, Chino, Nagano 391-8503, Japan
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36
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Xu J, Lo S, Mussap CJ, French JK, Rajaratnam R, Kadappu K, Premawardhana U, Nguyen P, Juergens CP, Leung DY. Early Effects of Ticagrelor Versus Clopidogrel on Peripheral Endothelial Function After Non-ST-Elevation Acute Coronary Syndrome and Assessment of Its Relationship With Coronary Microvascular Function. Am J Cardiol 2023; 201:16-24. [PMID: 37348152 DOI: 10.1016/j.amjcard.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023]
Abstract
Peripheral endothelial dysfunction is an independent predictor of adverse long-term prognosis after acute coronary syndrome. Data are lacking on the effects of oral P2Y12-inhibitors on peripheral endothelial function in non-ST-elevation acute coronary syndrome (NSTEACS). Furthermore, the relation between peripheral endothelial function and invasive indexes of coronary microvascular function in NSTEACS is unclear. Between March 2018 and July 2020, hospitalized patients with NSTEACS were randomized (1:1) to ticagrelor or clopidogrel. Peripheral endothelial function was assessed with brachial artery flow-mediated vasodilation (FMD). Invasive indexes of coronary microvascular function were obtained using an intracoronary pressure-temperature sensor-tipped wire. In 70 patients included, mean age was 58.6 years, 78.6% (n = 55) were male and 20% (n = 14) had diabetes mellitus. Compared with clopidogrel, ticagrelor significantly improved FMD (14.2 ± 5.4% vs 8.9 ± 5.3%, p <0.001) after a median treatment time of 41.2 hours. The FMD was significantly correlated with the index of microcirculatory resistance (IMR) measured in the infarct-related artery (r = -0.38, p = 0.001), with a stronger correlation found in those who did not have percutaneous coronary intervention (r = -0.52, p = 0.03). Using receiver operating characteristic curve analysis, an FMD of 8.2% identified an IMR of >34 as the threshold, with 77.6% sensitivity and 52.4% specificity. In patients who did not have a percutaneous coronary intervention, an FMD of 11.49% identified an IMR of >34 with 84.6% sensitivity and 80% specificity. In conclusion, ticagrelor significantly improved peripheral endothelial function compared with clopidogrel in patients with NSTEACS. There was a significant correlation between brachial artery FMD and IMR of the infarct-related artery.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Krishna Kadappu
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Upul Premawardhana
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Phong Nguyen
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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37
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Yang Z, Liu Y, Li Z, Feng S, Lin S, Ge Z, Fan Y, Wang Y, Wang X, Mao J. Coronary microvascular dysfunction and cardiovascular disease: Pathogenesis, associations and treatment strategies. Biomed Pharmacother 2023; 164:115011. [PMID: 37321056 DOI: 10.1016/j.biopha.2023.115011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is a high-risk factor for a variety of cardiovascular events. Due to its complex aetiology and concealability, knowledge of the pathophysiological mechanism of CMD is still limited at present, which greatly restricts its clinical diagnosis and treatment. Studies have shown that CMD is closely related to a variety of cardiovascular diseases, can aggravate the occurrence and development of cardiovascular diseases, and is closely related to a poor prognosis in patients with cardiovascular diseases. Improving coronary microvascular remodelling and increasing myocardial perfusion might be promising strategies for the treatment of cardiovascular diseases. In this paper, the pathogenesis and functional assessment of CMD are reviewed first, along with the relationship of CMD with cardiovascular diseases. Then, the latest strategies for the treatment of CMD and cardiovascular diseases are summarized. Finally, urgent scientific problems in CMD and cardiovascular diseases are highlighted and future research directions are proposed to provide prospective insights for the prevention and treatment of CMD and cardiovascular diseases in the future.
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Affiliation(s)
- Zhihua Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China; Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Yangxi Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhenzhen Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Shaoling Feng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Shanshan Lin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhao Ge
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yujian Fan
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yi Wang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Xianliang Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Jingyuan Mao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
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38
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Abstract
Coronary microvascular disease (CMD) causes myocardial ischemia in a variety of clinical scenarios. Clinical practice guidelines support routine testing for CMD in patients with ischemia with nonobstructive coronary artery disease. Invasive testing to identify CMD requires Doppler or thermodilution measures of flow to determine the coronary flow reserve and measures of microvascular resistance. Acetylcholine coronary reactivity testing identifies concomitant endothelial dysfunction, microvascular spasm, or epicardial coronary spasm. Comprehensive testing may improve symptoms, quality of life, and patient satisfaction by establishing a diagnosis and guiding-targeted medical therapy and lifestyle measures. Beyond ischemia with nonobstructive coronary artery disease, testing for CMD may play a role in patients with acute myocardial infarction, angina following coronary revascularization, heart failure with preserved ejection fraction, Takotsubo syndrome, and after heart transplantation. Additional education and provider awareness of CMD and its role in cardiovascular disease is needed to improve patient-centered outcomes of ischemic heart disease.
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Affiliation(s)
- Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, NY (N.R.S.)
- Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, NY (N.R.S.)
| | | | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy (A.C.)
| | - Divaka Perera
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, UK (D.P.)
- Guy's and St Thomas' Hospital, London, UK (D.P.)
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK (C.B.)
- The West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, Scotland, UK (C.B.)
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39
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Scarsini R, Portolan L, Della Mora F, Marin F, Mainardi A, Ruzzarin A, Levine MB, Banning AP, Ribichini F, Garcia Garcia HM, De Maria GL. Angiography-Derived and Sensor-Wire Methods to Assess Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction. JACC Cardiovasc Imaging 2023:S1936-878X(23)00089-X. [PMID: 37052555 DOI: 10.1016/j.jcmg.2023.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 04/14/2023]
Abstract
ST-segment elevation myocardial infarction (STEMI) treatment with primary percutaneous coronary intervention has dramatically impacted prognosis. However, despite satisfactory angiographic result, occurrence or persistence of coronary microvascular dysfunction after revascularization still affects long-term outcomes. The diagnostic and therapeutic value of understanding the status of coronary microcirculation is gaining attention in the cardiology community. However, current methods to assess microvascular function (namely, cardiac magnetic resonance and invasive wire-based coronary physiology) remain, at least in part, limited by technical and logistic aspects. On the other hand, angiography-based indices of microcirculatory resistance are emerging as valid and user-friendly tools with potential impact on prognostic stratification of patients with STEMI. This review provides an overview about conventional and novel methods to assess coronary microvascular dysfunction in patients with STEMI. The authors also provide a proposed procedural algorithm to facilitate optimal use of wire-based and angiography-based indices in the acute setting of STEMI.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federico Marin
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Andrea Mainardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Ruzzarin
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Molly B Levine
- Interventional Cardiology, MedStar Washington Hospital Centre, Washington, DC, USA
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, United Kingdom; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom; Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
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40
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de Oliveira Laterza Ribeiro M, Correia VM, Herling de Oliveira LL, Soares PR, Scudeler TL. Evolving Diagnostic and Management Advances in Coronary Heart Disease. Life (Basel) 2023; 13:951. [PMID: 37109480 PMCID: PMC10143565 DOI: 10.3390/life13040951] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Despite considerable improvement in diagnostic modalities and therapeutic options over the last few decades, the global burden of ischemic heart disease is steadily rising, remaining a major cause of death worldwide. Thus, new strategies are needed to lessen cardiovascular events. Researchers in different areas such as biotechnology and tissue engineering have developed novel therapeutic strategies such as stem cells, nanotechnology, and robotic surgery, among others (3D printing and drugs). In addition, advances in bioengineering have led to the emergence of new diagnostic and prognostic techniques, such as quantitative flow ratio (QFR), and biomarkers for atherosclerosis. In this review, we explore novel diagnostic invasive and noninvasive modalities that allow a more detailed characterization of coronary disease. We delve into new technological revascularization procedures and pharmacological agents that target several residual cardiovascular risks, including inflammatory, thrombotic, and metabolic pathways.
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Affiliation(s)
| | | | | | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-010, Brazil
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41
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Fawaz S, Khan S, Simpson R, Clesham G, Cook CM, Davies JR, Karamasis GV, Keeble TR. Invasive Detection of Coronary Microvascular Dysfunction: How It Began, and Where We Are Now. Interv Cardiol 2023; 18:e07. [PMID: 37601734 PMCID: PMC10433108 DOI: 10.15420/icr.2022.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/02/2022] [Indexed: 03/17/2023] Open
Abstract
The landscape of interventional cardiology is ever evolving. Contemporary practice has shifted from a stenosis-centred approach to the total characterisation of both the epicardial and microcirculatory vessels. Microcirculatory dysfunction plays an important role in the pathophysiology of acute and chronic coronary syndromes, and characterisation of the microcirculation has important clinical consequences. Accordingly, the invasive diagnosis of microcirculatory dysfunction is becoming a key feature of the interventional cardiologist's toolkit. This review focuses on the methodology underpinning the invasive diagnosis of microvascular dysfunction and highlights the indices that have arisen from these methodologies.
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Affiliation(s)
- Samer Fawaz
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Sarosh Khan
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Rupert Simpson
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Gerald Clesham
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Christopher M Cook
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - John R Davies
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
| | - Grigoris V Karamasis
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School Athens, Greece
| | - Thomas R Keeble
- Research Department, Roding Ward, Essex Cardiothoracic Centre, Mid and South Essex NHS Hospitals Trust Basildon, UK
- Department of Circulatory Health Research, Anglia Ruskin University Chelmsford, UK
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42
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Milasinovic D, Nedeljkovic O, Maksimovic R, Sobic-Saranovic D, Dukic D, Zobenica V, Jelic D, Zivkovic M, Dedovic V, Stankovic S, Asanin M, Vukcevic V. Coronary Microcirculation: The Next Frontier in the Management of STEMI. J Clin Med 2023; 12:jcm12041602. [PMID: 36836137 PMCID: PMC9962942 DOI: 10.3390/jcm12041602] [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: 01/16/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
Although the widespread adoption of timely invasive reperfusion strategies over the last two decades has significantly improved the prognosis of patients with ST-segment elevation myocardial infarction (STEMI), up to half of patients after angiographically successful primary percutaneous coronary intervention (PCI) still have signs of inadequate reperfusion at the level of coronary microcirculation. This phenomenon, termed coronary microvascular dysfunction (CMD), has been associated with impaired prognosis. The aim of the present review is to describe the collected evidence on the occurrence of CMD following primary PCI, means of assessment and its association with the infarct size and clinical outcomes. Therefore, the practical role of invasive assessment of CMD in the catheterization laboratory, at the end of primary PCI, is emphasized, with an overview of available technologies including thermodilution- and Doppler-based methods, as well as recently developing functional coronary angiography. In this regard, we review the conceptual background and the prognostic value of coronary flow reserve (CFR), index of microcirculatory resistance (IMR), hyperemic microvascular resistance (HMR), pressure at zero flow (PzF) and angiography-derived IMR. Finally, the so-far investigated therapeutic strategies targeting coronary microcirculation after STEMI are revisited.
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Affiliation(s)
- Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: (D.M.); (V.V.); Tel.: +381-3613653 (V.V.)
| | - Olga Nedeljkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ruzica Maksimovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Center for Radiology and Magnetic Resonance, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dragana Sobic-Saranovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Center for Nuclear Medicine with PET, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Djordje Dukic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
| | - Vladimir Zobenica
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
| | - Dario Jelic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
| | - Milorad Zivkovic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
| | - Vladimir Dedovic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Milika Asanin
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Vladan Vukcevic
- Department of Cardiology, University Clinical Center of Serbia, 26 Visegradska, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: (D.M.); (V.V.); Tel.: +381-3613653 (V.V.)
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43
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Ali ZA, Jeremias A. ResETTing the diagnostic utility of exercise tolerance testing for INOCA. EUROINTERVENTION 2023; 18:e1035-e1037. [PMID: 36760208 PMCID: PMC9909451 DOI: 10.4244/eij-e-22-00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Ziad A Ali
- St. Francis Hospital, Roslyn, NY, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | - Allen Jeremias
- St. Francis Hospital, Roslyn, NY, USA
- Cardiovascular Research Foundation, New York, NY, USA
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44
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Rehan R, Yong A, Ng M, Weaver J, Puranik R. Coronary microvascular dysfunction: A review of recent progress and clinical implications. Front Cardiovasc Med 2023; 10:1111721. [PMID: 36776251 PMCID: PMC9908997 DOI: 10.3389/fcvm.2023.1111721] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
The coronary microcirculation plays a cardinal role in regulating coronary blood flow to meet the changing metabolic demands of the myocardium. Coronary microvascular dysfunction (CMD) refers to structural and functional remodeling of the coronary microcirculation. CMD plays a role in the pathogenesis of obstructive and non-obstructive coronary syndromes as well as myocardial diseases, including heart failure with preserved ejection fraction (HFpEF). Despite recent diagnostic advancements, CMD is often under-appreciated in clinical practice, and may allow for the development of novel therapeutic targets. This review explores the diagnosis and pathogenic role of CMD across a range of cardiovascular diseases, its prognostic significance, and the current therapeutic landscape.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Martin Ng
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - James Weaver
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia,*Correspondence: Rajesh Puranik,
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45
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Schindler TH, Fearon WF, Pelletier-Galarneau M, Ambrosio G, Sechtem U, Ruddy TD, Patel KK, Bhatt DL, Bateman TM, Gewirtz H, Shirani J, Knuuti J, Gropler RJ, Chareonthaitawee P, Slart RHJA, Windecker S, Kaufmann PA, Abraham MR, Taqueti VR, Ford TJ, Camici PG, Schelbert HR, Dilsizian V. PET for Detection and Reporting Coronary Microvascular Dysfunction: A JACC: Cardiovascular Imaging Expert Panel Statement. JACC Cardiovasc Imaging 2023; 16:536-548. [PMID: 36881418 DOI: 10.1016/j.jcmg.2022.12.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 12/02/2022] [Indexed: 02/11/2023]
Abstract
Angina pectoris and dyspnea in patients with normal or nonobstructive coronary vessels remains a diagnostic challenge. Invasive coronary angiography may identify up to 60% of patients with nonobstructive coronary artery disease (CAD), of whom nearly two-thirds may, in fact, have coronary microvascular dysfunction (CMD) that may account for their symptoms. Positron emission tomography (PET) determined absolute quantitative myocardial blood flow (MBF) at rest and during hyperemic vasodilation with subsequent derivation of myocardial flow reserve (MFR) affords the noninvasive detection and delineation of CMD. Individualized or intensified medical therapies with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, angiotensin II type 1-receptor blockers, beta-blockers, ivabradine, or ranolazine may improve symptoms, quality of life, and outcome in these patients. Standardized diagnosis and reporting criteria for ischemic symptoms caused by CMD are critical for optimized and individualized treatment decisions in such patients. In this respect, it was proposed by the cardiovascular council leadership of the Society of Nuclear Medicine and Molecular Imaging to convene thoughtful leaders from around the world to serve as an independent expert panel to develop standardized diagnosis, nomenclature and nosology, and cardiac PET reporting criteria for CMD. This consensus document aims to provide an overview of the pathophysiology and clinical evidence of CMD, its invasive and noninvasive assessment, standardization of PET-determined MBFs and MFR into "classical" (predominantly related to hyperemic MBFs) and "endogen" (predominantly related to resting MBF) normal coronary microvascular function or CMD that may be critical for diagnosis of microvascular angina, subsequent patient care, and outcome of clinical CMD trials.
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Affiliation(s)
- Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | | | - Giuseppe Ambrosio
- University of Perugia School of Medicine Ospedale S. Maria della Misericordia Perugia, Italy
| | - Udo Sechtem
- Cardiologicum Stuttgart, Stuttgart, Baden-Wuerttemberg, Germany
| | | | - Krishna K Patel
- Icahn School of Medicine at Mount Sinai, Zena, New York, New York, USA; Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Timothy M Bateman
- Saint-Lukes Health System and the Mid-America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Henry Gewirtz
- Cardiac Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jamshid Shirani
- Cardiology, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Juhani Knuuti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine-Cardiovascular, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | | | - Riemer H J A Slart
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Maria R Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, California, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thomas J Ford
- The University of Newcastle, Faculty of Medicine, Newcastle, Australia
| | - Paolo G Camici
- San Raffaele Hospital, Milan Italy; Vita Salute University, Milan, Italy
| | - Heinrich R Schelbert
- Department of Molecular Imaging and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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46
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Interv Cardiol Clin 2023; 12:119-129. [PMID: 36372455 PMCID: PMC10019932 DOI: 10.1016/j.iccl.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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47
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Fineschi M, Verna E, Barioli A, Mezzapelle G, Bartolini D, Turiano G, Guiducci V, Manari A, Lucarelli K, Uguccioni L, Repetto A, Tarantini G. One-year results from the Assessing MICRO-vascular resistances via IMR to predict outcome in ST-elevation myocardial infarction patients with multivessel disease undergoing primary PCI (AMICRO) trial. Front Cardiovasc Med 2022; 9:1051174. [PMID: 36531736 PMCID: PMC9755670 DOI: 10.3389/fcvm.2022.1051174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/21/2022] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND In ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary angioplasty (PPCI) the index of microcirculatory resistance (IMR) correlates to the extent of myocardial damage and left ventricular (LV) function recovery. Data on the IMR time-course and impact on clinical outcome in STEMI patients with multi-vessel disease (MVD) are scarce. AIMS We designed a prospective, multicenter clinical trial to assess the infarct-related artery (IRA)-IMR in STEMI patients with MVD undergoing PPCI and to explore its potential in relationship with outcome and LV remodeling. METHODS The study enrolled 242 STEMI patients with MVD. Both fractional flow reserve (FFR) and IMR of the IRA were assessed after successful PPCI. Then, FFR/IMR measurements were repeated in the IRA at a staged angiography, and FFR-guided angioplasty was performed in non-IRA lesions. The primary endpoint was the composite of cardiovascular death, re-infarction, re-hospitalization for heart failure, resuscitation or appropriate ICD shock at 1-year follow-up. RESULTS A significant improvement of IRA-IMR values (from 47.9 to 34.2, p < 0.0001) was observed early after PPCI. Staged FFR-guided angioplasty was performed in 102 non-IRA lesions. We failed to find a correlation between IRA-IMR, clinical events and LV remodeling. Notwithstanding, in patients with anterior STEMI an inverse correlation between initial IMR values and LV function at follow-up was observed. CONCLUSION After successful PPCI, a significant proportion of patients with STEMI and MVD had coronary microvascular dysfunction as assessed by IMR that recovered early after reperfusion. Higher IMR values predicted lack of improvement of LV function only in anterior STEMI. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/, identifier [NCT02325973].
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Affiliation(s)
| | - Edoardo Verna
- Ospedale di Circolo e Fondazione Macchi, Università dell’Insubria, Varese, VA, Italy
| | - Alberto Barioli
- Ospedale Ca’ Foncello, Treviso, TV, Italy
- Azienda Ospedaliera Universitaria, Padova, PD, Italy
| | | | | | | | | | | | - Katya Lucarelli
- Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, BA, Italy
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Sutariya B, Montenegro DM, Chukwu M, Ehsan P, Aburumman RN, Muthanna SI, Menon SR, Vithani V, Penumetcha SS. Emphasis on Icosapent Ethyl for Cardiovascular Risk Reduction: A Systematic Review. Cureus 2022; 14:e32346. [PMID: 36632258 PMCID: PMC9827995 DOI: 10.7759/cureus.32346] [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: 09/01/2022] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Despite the widespread use of lipid-lowering agents such as statins, cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Icosapent ethyl (IPE) (Vascepa), an ethyl ester of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA), has gained widespread popularity as an adjunctive agent that targets multiple and additional mechanisms linked to the incidence of cardiovascular (CV) events and the causative pathway of atherosclerosis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 standards were used to conduct this systematic review. In this review, we assessed various studies from PubMed, PubMed Central (PMC), and Google Scholar to evaluate the mechanisms of action and beneficial effects of IPE in the reduction of CVD outcomes. The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) has demonstrated a significant reduction in CV mortality with 4 g/day IPE as compared to placebo. All other trials and observational studies have supported the role of Vascepa in hypertriglyceridemia and CV risk reduction. In conclusion, the use of IPE has been shown to significantly reduce triglyceride levels and reduce CV risks in patients receiving optimal statin therapy.
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Affiliation(s)
- Bansi Sutariya
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Government Medical College, Surat, IND
| | - Diana M Montenegro
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Michael Chukwu
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Surgery, Pilgrim Hospital, Boston, GBR
| | - Paghunda Ehsan
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Rawia N Aburumman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Mu'tah University, Amman, JOR
| | - Shivani Ishwarya Muthanna
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | | | - Vruti Vithani
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Government Medical College, Surat, IND
| | - Sai Sri Penumetcha
- General Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
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Mehta PK, Huang J, Levit RD, Malas W, Waheed N, Bairey Merz CN. Ischemia and no obstructive coronary arteries (INOCA): A narrative review. Atherosclerosis 2022; 363:8-21. [PMID: 36423427 PMCID: PMC9840845 DOI: 10.1016/j.atherosclerosis.2022.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/30/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Myocardial ischemia with no obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is increasingly being recognized as a substantial contributor to adverse cardiovascular mortality and outcomes, including myocardial infarction and heart failure with preserved ejection fraction (HFpEF). While INOCA occurs in both women and men, women are more likely to have the finding of INOCA and are more adversely impacted by angina, with recurrent hospitalizations and a lower quality of life with this condition. Abnormal epicardial coronary vascular function and coronary microvascular dysfunction (CMD) have been identified in a majority of INOCA patients on invasive coronary function testing. CMD can co-exist with obstructive epicardial coronary artery disease (CAD), diffuse non-obstructive epicardial CAD, and with coronary vasospasm. Epicardial vasospasm can also occur with normal coronary arteries that have no atherosclerotic plaque on intravascular imaging. While all predisposing factors are not clearly understood, cardiometabolic risk factors, and endothelium dependent and independent mechanisms that increase oxidative stress and inflammation are associated with microvascular injury, CMD and INOCA. Cardiac autonomic dysfunction has also been implicated in abnormal vasoreactivity and persistent symptoms. INOCA is under-recognized and under-diagnosed, partly due to the heterogenous patient populations and mechanisms. However, diagnostic testing methods are available to guide INOCA management. Treatment of INOCA is evolving, and focuses on cardiac risk factor control, improving ischemia, reducing atherosclerosis progression, and improving angina and quality of life. This review focuses on INOCA, relations to HFpEF, available diagnostics, current and investigational therapeutic strategies, and knowledge gaps in this condition.
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Affiliation(s)
- Puja K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jingwen Huang
- J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca D Levit
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Waddah Malas
- Cardiovascular Disease Fellowship Training Program, Loyola Medical Center, Chicago, IL, USA
| | - Nida Waheed
- Cardiovascular Disease Fellowship Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
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Varrichione G, Biccirè FG, Di Pietro R, Prati F, Battisti P. The risk of acute coronary events in microvascular disease. Eur Heart J Suppl 2022; 24:I127-I130. [PMID: 36380795 PMCID: PMC9653131 DOI: 10.1093/eurheartjsupp/suac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The microvascular disease represents a widespread clinical entity in the general population, especially among women. The dysfunction of the microcirculation is often responsible for myocardial ischaemia and angina in the absence of significant stenosis of the epicardial district, while in other cases it can represent a contributing cause of angina even in the presence of coronary artery disease, cardiomyopathies or heart failure. The cardiovascular risk factors of people with microvascular disease are similar to those who develop epicardial atherosclerotic disease. However, the prognostic significance of microvascular disease remains a matter of debate. An element to be clarified, in fact, is whether subjects with dysfunction of the microcirculation and coronary tree without significant stenoses present an increased risk of myocardial infarction and sudden death. In recent years, several studies seem to confirm an association between microvascular disease and progression of coronary epicardial atherosclerosis. The prognosis of microvascular disease would therefore not be benign as was previously believed, but associated with an increased risk of cardiovascular events including revascularization, heart attack, and cardiac death.
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