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Hosadurg N, Watts K, Wang S, Wingerter KE, Taylor AM, Villines TC, Patel AR, Bourque JM, Lindner JR, Kramer CM, Sharma G, Rodriguez Lozano PF. Emerging Pathway to a Precision Medicine Approach for Angina With Nonobstructive Coronary Arteries in Women. JACC. ADVANCES 2024; 3:101074. [PMID: 39055270 PMCID: PMC11269914 DOI: 10.1016/j.jacadv.2024.101074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/24/2024] [Indexed: 07/27/2024]
Abstract
Women are disproportionately affected by symptoms of angina with nonobstructive coronary arteries (ANOCA) which is associated with significant mortality and economic impact. Although distinct endotypes of ANOCA have been defined, it is underdiagnosed and is often incompletely characterized when identified. Patients are often unresponsive to traditional therapeutic options, which are typically antianginal, and the current ability to guide treatment modification by specific pathways is limited. Studies have associated specific genetic loci, transcriptomic features, and biomarkers with ANOCA. Such panomic data, in combination with known imaging and invasive diagnostic techniques, should be utilized to define more precise pathophysiologic subtypes of ANOCA in women, which will in turn help to identify targeted, effective therapies. A precision medicine-based approach to managing ANOCA incorporating these techniques in women has the potential to significantly improve their clinical care.
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Affiliation(s)
- Nisha Hosadurg
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Kelsey Watts
- Center for Public Health Genomics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Shuo Wang
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Kelly E. Wingerter
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Angela M. Taylor
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Todd C. Villines
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Amit R. Patel
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Jamieson M. Bourque
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Jonathan R. Lindner
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Christopher M. Kramer
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia, USA
| | - Garima Sharma
- INOVA Heart and Vascular Institute, Fairfax, Virginia, USA
| | - Patricia F. Rodriguez Lozano
- Cardiovascular Division, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia, USA
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Patel NH, Dave EK, Fatade YA, De Cecco CN, Ko YA, Chen Y, Sharma A, Rashid F, Vatsa N, Samady H, Toleva O, Quyyumi A, Mehta PK, Stillman AE. Epicardial adipose tissue attenuation on computed tomography in women with coronary microvascular dysfunction: A pilot, hypothesis generating study. Atherosclerosis 2024; 395:118520. [PMID: 38944545 PMCID: PMC11274044 DOI: 10.1016/j.atherosclerosis.2024.118520] [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: 02/02/2024] [Revised: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Patients with myocardial ischemia without obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) and associated increased risk of cardiovascular (CV) events and anginal hospitalizations. Epicardial adipose tissue (EAT) covers much of the myocardium and coronary arteries and when dysfunctional, secretes proinflammatory cytokines and is associated with CV events. While oxidative stress and systemic inflammation are associated with CMD, the relationship between EAT and CMD in women is not well known. METHODS Women diagnosed with CMD (n = 21) who underwent coronary computed tomography with coronary artery calcium (CAC) scoring were compared to a reference group (RG) of women referred for CAC screening for preventive risk assessment (n = 181). EAT attenuation (Hounsfield units (HU)) was measured adjacent to the proximal right coronary artery, along with subcutaneous adipose tissue (SCAT). Two-sample t-tests with unequal variances were utilized. RESULTS Mean age of the CMD group was 56 ± 8 years and body mass index (BMI) was 31.6 ± 6.8 kg/m2. CV risk factors in the CMD group were prevalent: 67 % hypertension, 44 % hyperlipidemia, and 33 % diabetes. Both CMD and RG had similar CAC score (25.86 ± 59.54 vs. 24.17 ± 104.6; p = 0.21. In the CMD group, 67 % had a CAC of 0. Minimal atherosclerosis (CAD-RADS 1) was present in 76 % of women with CMD. The CMD group had lower EAT attenuation than RG (-103.3 ± 6.33 HU vs. -97.9 ± 8.3 HU, p = 0.009, respectively). There were no differences in SCAT attenuation. Hypertension, smoking history, age, BMI, and CAC score did not correlate with EAT in either of the groups. CONCLUSIONS Women with CMD have decreased EAT attenuation compared to RG women. EAT-mediated inflammation and changes in vascular tone may be a mechanistic contributor to abnormal microvascular reactivity. Clinical trials testing therapeutic strategies to decrease EAT may be warranted in the management of CMD.
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Affiliation(s)
- Nidhi H Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, USA
| | - Esha K Dave
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | - Yetunde A Fatade
- J. Willis Hurst Internal Medicine Residency Program, Emory University, USA
| | - Carlo N De Cecco
- Department of Radiology, Emory University School of Medicine, USA
| | - Yi-An Ko
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Yunyun Chen
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Ashish Sharma
- Division of Hospital Medicine, Emory University School of Medicine, USA
| | - Fauzia Rashid
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | - Nishant Vatsa
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA
| | | | | | - Arshed Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA
| | - Puja K Mehta
- Emory Women's Heart Center, Division of Cardiology, Emory University School of Medicine, USA; Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA.
| | - Arthur E Stillman
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University, USA; Department of Radiology, Emory University School of Medicine, USA
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Maayah M, Latif N, Vijay A, Gallegos CM, Cigarroa N, Posada Martinez EL, Mazure CM, Miller EJ, Spatz ES, Shah SM. Evaluating Ischemic Heart Disease in Women: Focus on Angina With Nonobstructive Coronary Arteries (ANOCA). JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102195. [PMID: 39166160 PMCID: PMC11330936 DOI: 10.1016/j.jscai.2024.102195] [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: 04/02/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 08/22/2024]
Abstract
Ischemic heart disease (IHD) is common in women, and cardiovascular disease is a leading cause of morbidity and mortality. While obstructive coronary artery disease is the most common form of IHD, millions of women suffer from angina with nonobstructive coronary arteries (ANOCA), an umbrella term encompassing multiple nonatherosclerotic disorders of the coronary tree. The underlying pathology leading to ischemia in these syndromes may be challenging to diagnose, leaving many women without a diagnosis despite persistent symptoms that impact quality of life and adversely affect long-term cardiovascular prognosis. In the last decade, there have been significant advances in the recognition and diagnostic evaluation of ANOCA. Despite these advances, the standard approach to evaluating suspected IHD in women continues to focus predominantly on the assessment of atherosclerotic coronary artery disease, leading to missed opportunities to accurately diagnose and treat underlying coronary vasomotor disorders. The goal of this review is to describe advances in diagnostic testing that can be used to evaluate angina in women and present a pragmatic diagnostic algorithm to guide evaluation of ANOCA in symptomatic patients. The proposed approach for the assessment of ANOCA is consistent with prior expert consensus documents and guidelines but is predicated on the medical interview and pretest probability of disease to inform a personalized diagnostic strategy.
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Affiliation(s)
- Marah Maayah
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nida Latif
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aishwarya Vijay
- Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Cesia M. Gallegos
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Natasha Cigarroa
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Carolyn M. Mazure
- Department of Psychiatry and Women’s Health Research at Yale, Yale School of Medicine, New Haven, Connecticut
| | - Edward J. Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, Connecticut
| | - Samit M. Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
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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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Jansen TPJ, Gietman O, Crooijmans C, Bourich J, Elias-Smale S, van Royen N, Thijssen D, Damman P, Dimitriu-Leen AC. The influence of sympathetic triggering by handgrip exercise on coronary vasoreactivity and complaints in patients with angina and non-obstructive coronary arteries: a proof-of-concept study. Eur J Prev Cardiol 2024:zwae207. [PMID: 38978208 DOI: 10.1093/eurjpc/zwae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/29/2024] [Accepted: 06/06/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Olaf Gietman
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Caïa Crooijmans
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Jihane Bourich
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Dick Thijssen
- Department of Cardiovascular Physiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Aukelien C Dimitriu-Leen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
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Allison EL, Palmer WA, Rattan K, Seenarine N, Schrem E, Mills R, Mitre CA. Myocardial Infarction With Non-obstructive Coronary Arteries: A Clinical Conundrum. Cureus 2024; 16:e64135. [PMID: 39119402 PMCID: PMC11307486 DOI: 10.7759/cureus.64135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/10/2024] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined by the presence of positive cardiac biomarkers with clinical evidence of infarction, the absence of significant coronary stenosis (≥50%) on angiography, and the lack of alternative diagnosis for the index presentation. MINOCA poses a diagnostic and therapeutic challenge due to the various pathophysiologic mechanisms underlying its presentation. Coronary artery plaque disruption is recognized as a crucial mechanism contributing to MINOCA. Plaque rupture and thrombus formation with subsequent myocardial ischemia may occur without significant luminal narrowing. A high index of suspicion is needed to make an early diagnosis. Here, a 68-year-old African American male patient presented with substernal chest pain, nonspecific ST segment changes on electrocardiogram, and elevation in cardiac biomarkers only one day after undergoing diagnostic cardiac catheterization that revealed non-obstructed coronary arteries. This case provides an example of MINOCA occurring secondary to suspected coronary artery plaque disruption in the setting of recent cardiac catheterization.
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Affiliation(s)
- Elizabeth L Allison
- Department of Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Wayne-Andrew Palmer
- Department of Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Keston Rattan
- Department of Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Nitish Seenarine
- Department of Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Ezra Schrem
- Department of Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Robert Mills
- Department of Internal Medicine, Veterans Affairs New York Medical Center, Brooklyn, USA
| | - Cristina A Mitre
- Department of Cardiology, Veterans Affairs New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, USA
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Al-Mallah MH, Nayfeh M, Alrifai M. The role of cardiac PET in diagnosis and prognosis of patients with ischemia with no obstructive coronary arteries (INOCA). AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 43:100399. [PMID: 38828445 PMCID: PMC11141139 DOI: 10.1016/j.ahjo.2024.100399] [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: 02/09/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 06/05/2024]
Abstract
Chest pain, a common symptom in cardiovascular care, often leads to the investigation of obstructive coronary artery disease (CAD). However, many patients experience chest pain without obstructive CAD, termed INOCA (Ischemia with Non-Obstructive Coronary Arteries) or CMD (Coronary Microvascular Dysfunction). INOCA can be attributed to endothelial dysfunction, vascular smooth muscle dysfunction, or both, affecting about 20-30 % of patients with nonobstructive CAD. The diagnostic approach for INOCA includes both invasive and non-invasive methods, with cardiac PET (Positron Emission Tomography) playing a significant role in risk stratification and management. PET evaluates various parameters like myocardial blood flow under stress and rest, myocardial flow reserve, and myocardial ischemia. Such comprehensive assessment is essential in accurately diagnosing and managing INOCA, considering the complexity of this condition.
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Affiliation(s)
| | - Malek Nayfeh
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Mahmoud Alrifai
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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Spiro J, Ford TJ, Yong A, Zeitz C, Beltrame JF. Protocol Variation in Functional Coronary Angiography Among Patients With Suspected Angina With Non-Obstructive Coronary Arteries: A Nationwide Snapshot of Current Practice Within Australia and New Zealand. Heart Lung Circ 2024:S1443-9506(24)00588-2. [PMID: 38951052 DOI: 10.1016/j.hlc.2024.04.299] [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: 01/11/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Functional coronary angiography (FCA) for endotype characterisation (vasospastic angina [VSA], coronary microvascular disease [CMD], or mixed) is recommended among patients with angina with non-obstructive coronary arteries. Whilst clear diagnostic criteria for VSA and CMD exist, there is no standardised FCA protocol. Variations in testing protocol may limit the widespread uptake of testing, generalisability of results, and expansion of collaborative research. At present, there are no data describing protocol variation across an entire geographic region. Therefore, we aimed to capture current practice variations in the approach to FCA to improve access and standardisation for diagnosis of coronary vasomotor disorders in Australia and New Zealand. METHOD Between July 2022 and July 2023, we conducted a national survey across all centres in Australia and New Zealand with an active FCA program. The survey captured attitudes towards FCA and protocols used for diagnosis of coronary vasomotor disorders at 33 hospitals across Australia and New Zealand. RESULTS Survey responses were received from 39 clinicians from 33 centres, with representation from centres within all Australian states and territories and both North and South Islands of New Zealand. A total of 21 centres were identified as having an active FCA program. In general, respondents agreed that comprehensive physiology testing helped inform clinical management. Barriers to program expansion included cost, additional catheter laboratory time, and the absence of an agreed-upon national protocol. Across the clinical sites, there were significant variations in testing protocol, including the technique used (Doppler vs thermodilution), order of testing (hyperaemia resistance indices first vs vasomotor function testing first), rate and dose of acetylcholine administration, routine use of temporary pacing wire, and routine single vs multivessel testing. Overall, testing was performed relatively infrequently, with very little follow-on FCA performed, despite nearly all respondents believing this would be clinically useful. CONCLUSIONS This survey demonstrates, for the first time, variations in FCA protocol among testing centres across two entire countries. Furthermore, whilst FCA was deemed clinically important, testing was performed relatively infrequently with little or no follow-on testing. Development and adoption of a standardised national FCA protocol may help improve patient access to testing and facilitate further collaborative research within Australia and New Zealand.
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Affiliation(s)
- Jon Spiro
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia.
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital, Central Coast Local Health District, Gosford, NSW, Australia
| | - Andy Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Chris Zeitz
- Department of Cardiology, Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia; University of Adelaide, Basil Hetzel Institute, Adelaide, SA, Australia
| | - John F Beltrame
- Department of Cardiology, Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia; University of Adelaide, Basil Hetzel Institute, Adelaide, SA, Australia
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Wayne N, Wu Q, Moore SC, Ferrari VA, Metzler SD, Guerraty MA. Multimodality assessment of the coronary microvasculature with TIMI frame count versus perfusion PET highlights coronary changes characteristic of coronary microvascular disease. Front Cardiovasc Med 2024; 11:1395036. [PMID: 38966750 PMCID: PMC11222597 DOI: 10.3389/fcvm.2024.1395036] [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: 03/02/2024] [Accepted: 06/07/2024] [Indexed: 07/06/2024] Open
Abstract
Background The diagnosis of coronary microvascular disease (CMVD) remains challenging. Perfusion PET-derived myocardial blood flow (MBF) reserve (MBFR) can quantify CMVD but is not widely available. Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) is an angiography-based method that has been proposed as a measure of CMVD. Here, we compare TFC and PET-derived MBF measurements to establish the role of TFC in assessing for CMVD. We use coronary modeling to elucidate the relationship between MBFR and TFC and propose TFC thresholds for identifying CMVD. Methods In a cohort of 123 individuals (age 58 ± 12.1, 63% women, 41% Caucasian) without obstructive coronary artery disease who had undergone perfusion PET and coronary angiography for clinical indications, we compared TFC and perfusion PET parameters using Pearson correlation (PCC) and linear regression modeling. We used mathematical modeling of the coronary circulation to understand the relationship between these parameters and performed Receiver Operating Curve (ROC) analysis. Results We found a significant negative correlation between TFC and MBFR. Sex, race and ethnicity, and nitroglycerin administration impact this relationship. Coronary modeling showed an uncoupling between TFC and flow in epicardial vessels. In ROC analysis, TFC performed well in women (AUC 0.84-0.89) and a moderately in men (AUC 0.68-0.78). Conclusions We established an inverse relationship between TFC and PET-derived MBFR, which is affected by patient selection and procedural factors. TFC represents a measure of the volume of the epicardial coronary compartment, which is increased in patients with CMVD, and performs well in identifying women with CMVD.
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Affiliation(s)
- Nicole Wayne
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Stephen C. Moore
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Victor A. Ferrari
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Scott D. Metzler
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Marie A. Guerraty
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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10
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Gao L, Ramirez FJ, Cabrera JTO, Varghese MV, Watanabe M, Tsuji-Hosokawa A, Zheng Q, Yang M, Razan MR, Kempf CL, Camp SM, Wang J, Garcia JGN, Makino A. eNAMPT is a novel therapeutic target for mitigation of coronary microvascular disease in type 2 diabetes. Diabetologia 2024:10.1007/s00125-024-06201-9. [PMID: 38898303 DOI: 10.1007/s00125-024-06201-9] [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: 01/09/2024] [Accepted: 04/25/2024] [Indexed: 06/21/2024]
Abstract
AIMS/HYPOTHESIS Individuals with diabetes are at high risk of cardiovascular complications, which significantly increase morbidity/mortality. Coronary microvascular disease (CMD) is recognised as a critical contributor to the increased cardiac mortality observed in people with diabetes. Therefore, there is an urgent need for treatments that are specific to CMD. eNAMPT (extracellular nicotinamide phosphoribosyltransferase) is a damage-associated molecular pattern and TLR4 ligand, whose plasma levels are elevated in people with diabetes. This study was thus designed to investigate the pathogenic role of intracellular nicotinamide phosphoribosyltransferase (iNAMPT) and eNAMPT in promoting the development of CMD in a preclinical murine model of type 2 diabetes. METHODS An inducible type 2 diabetic mouse model was generated by a single injection of low-dose streptozocin (75 mg/kg, i.p.) combined with a high-fat diet for 16 weeks. The in vivo effects of i/eNAMPT inhibition on cardiac endothelial cell (CEC) function were evaluated by using Nampt+/- heterozygous mice, chronic administration of eNAMPT-neutralising monoclonal antibody (mAb) or use of an NAMPT enzymatic inhibitor (FK866). RESULTS As expected, diabetic wild-type mice exhibited significantly lower coronary flow velocity reserve (CFVR), a determinant of coronary microvascular function, compared with control wild-type mice. eNAMPT plasma levels or expression in CECs were significantly greater in diabetic mice than in control mice. Furthermore, in comparison with diabetic wild-type mice, diabetic Nampt+/- heterozygous mice showed markedly improved CFVR, accompanied by increased left ventricular capillary density and augmented endothelium-dependent relaxation (EDR) in the coronary artery. NAMPT inhibition by FK866 or an eNAMPT-neutralising mAb significantly increased CFVR in diabetic mice. Furthermore, administration of the eNAMPT mAb upregulated expression of angiogenesis- and EDR-related genes in CECs from diabetic mice. Treatment with either eNAMPT or NAD+ significantly decreased CEC migration and reduced EDR in coronary arteries, partly linked to increased production of mitochondrial reactive oxygen species. CONCLUSIONS/INTERPRETATION These data indicate that increased i/eNAMPT expression contributes to the development of diabetic coronary microvascular dysfunction, and provide compelling support for eNAMPT inhibition as a novel and effective therapeutic strategy for CMD in diabetes.
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Affiliation(s)
- Lei Gao
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Francisco J Ramirez
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA
| | - Jody Tori O Cabrera
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | | | - Makiko Watanabe
- Department of Physiology, The University of Arizona, Tucson, AZ, USA
| | | | - Qiuyu Zheng
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mingya Yang
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA
| | - Md Rahatullah Razan
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Carrie L Kempf
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA
| | - Sara M Camp
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA
| | - Jian Wang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Joe G N Garcia
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA
| | - Ayako Makino
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA.
- Center for Inflammation Science and Systems Medicine, The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, FL, USA.
- Department of Physiology, The University of Arizona, Tucson, AZ, USA.
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Harkin KL, Loftspring E, Beaty W, Joa A, Serrano-Gomez C, Farid A, Hausvater A, Reynolds HR, Smilowitz NR. Visual Estimates of Coronary Slow Flow Are Not Associated With Invasive Wire-Based Diagnoses of Coronary Microvascular Dysfunction. Circ Cardiovasc Interv 2024; 17:e013902. [PMID: 38583174 PMCID: PMC11187652 DOI: 10.1161/circinterventions.123.013902] [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: 12/08/2023] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Coronary slow flow (CSF) by invasive coronary angiography is frequently understood to be an indicator of coronary microvascular dysfunction (CMD) in patients with ischemia with nonobstructive coronary arteries. However, the relationship between visual estimates of CSF and quantitative wire-based invasive diagnosis of CMD is uncertain. METHODS We prospectively enrolled adults aged ≥18 years with stable ischemic heart disease who were referred for invasive coronary angiography. Individuals with ≥50% epicardial coronary artery stenosis were excluded. Invasive coronary angiography was reviewed for CSF, defined as ≥3 cardiac cycles to opacify distal vessels with contrast. Coronary function testing was performed in the left anterior descending coronary artery using bolus coronary thermodilution techniques to measure coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). Invasively determined CMD was defined as abnormal CFR (<2.5), abnormal IMR (≥25), or both. RESULTS Among 104 participants, the median age was 61.5 years and 79% were female. The median CFR was 3.6 (interquartile range, 2.5-4.7) and the median IMR was 21 (interquartile range, 13.3-28.0). Overall, 24.0% of participants had abnormal CFR, 34.6% had abnormal IMR, and 48.1% had a final diagnosis of invasively determined CMD. CSF was present in 23 participants (22.1%). The proportions of patients with CMD (56.5% versus 45.7%; P=0.36), abnormal CFR (17.4% versus 25.9%; P=0.40), and abnormal IMR (43.5% versus 32.1%; P=0.31) were not different in patients with versus without CSF. CONCLUSIONS Among patients with ischemia with nonobstructive coronary artery, CSF was not associated with abnormal CFR, IMR, or either abnormal CFR or IMR. CSF is not a reliable angiographic surrogate of abnormal CFR or IMR as determined by invasive, wire-based physiology testing. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03537586.
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Affiliation(s)
- Kenneth L Harkin
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Ethan Loftspring
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - William Beaty
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Amanda Joa
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Claudia Serrano-Gomez
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Ayman Farid
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Anaïs Hausvater
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Nathaniel R Smilowitz
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Veterans Affairs New York Harbor Health Care System, Department of Medicine, Section of Cardiology (N.R.S.)
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12
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Borle SS, Liu X, Kote A, Rosenberg C, Reaso JN, Chen PS, Bairey Merz CN, Wei J. Skin sympathetic nerve activity and ST-segment depression in women. Heart Rhythm O2 2024; 5:396-402. [PMID: 38984360 PMCID: PMC11228111 DOI: 10.1016/j.hroo.2024.04.009] [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] [Indexed: 07/11/2024] Open
Abstract
Background ST-segment depression (ST depression) on exercise electrocardiogram (ECG) and ambulatory ECG monitoring may occur without myocardial ischemia. The mechanisms of nonischemic ST depression remain poorly understood. Objective The study sought to test the hypothesis that the magnitudes of skin sympathetic nerve activity (SKNA) correlate negatively with the ST-segment height (ST height) in ambulatory participants. Methods We used neuECG (simultaneous recording of SKNA and ECG) to measure ambulatory ST height and average SKNA (aSKNA) in 19 healthy women, 6 women with a history of Takotsubo syndrome (TTS), and 4 women with ischemia and no obstructive coronary arteries (INOCA). Results Baseline aSKNA was similar between healthy women, women with TTS, and women with INOCA (1.098 ± 0.291 μV, 0.980 ± 0.061 μV, and 0.919 ± 0.0397 μV, respectively; P = .22). The healthy women had only asymptomatic upsloping ST depression. All participants had a significant (P < .05) negative correlation between ST height and aSKNA. Ischemic episodes (n = 15) were identified in 2 TTS and 4 INOCA participants. The ischemic ST depression was associated with increased heart rate and elevated aSKNA compared with baseline. An analysis of SKNA burst patterns at similar heart rates revealed that SKNA total burst area was significantly higher during ischemic episodes than nonischemic episodes (0.301 ± 0.380 μV·s and 0.165 ± 0.205 μV·s; P = .023) in both the TTS and INOCA participants. Conclusion Asymptomatic ST depression in ambulatory women is associated with elevated SKNA. Heightened aSKNA is also noted during ischemic ST depression in women with TTS and INOCA. These findings suggest that ST segment depression is a physiological response to heightened sympathetic tone but may be aggravated by myocardial ischemia.
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Affiliation(s)
- Sanjana S Borle
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Xiao Liu
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anxhela Kote
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carine Rosenberg
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jewel N Reaso
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peng-Sheng Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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13
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Rasmussen LD, Murphy T, Milidonis X, Eftekhari A, Karim SR, Westra J, Dahl JN, Isaksen C, Brix L, Ejlersen JA, Nyegaard M, Johansen JK, Søndergaard HM, Mortensen J, Gormsen LC, Christiansen EH, Chiribiri A, Petersen SE, Bøttcher M, Winther S. Myocardial Blood Flow by Magnetic Resonance in Patients With Suspected Coronary Stenosis: Comparison to PET and Invasive Physiology. Circ Cardiovasc Imaging 2024; 17:e016635. [PMID: 38889213 DOI: 10.1161/circimaging.124.016635] [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: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Despite recent guideline recommendations, quantitative perfusion (QP) estimates of myocardial blood flow from cardiac magnetic resonance (CMR) have only been sparsely validated. Furthermore, the additional diagnostic value of utilizing QP in addition to the traditional visual expert interpretation of stress-perfusion CMR remains unknown. The aim was to investigate the correlation between myocardial blood flow measurements estimated by CMR, positron emission tomography, and invasive coronary thermodilution. The second aim is to investigate the diagnostic performance of CMR-QP to identify obstructive coronary artery disease (CAD). METHODS Prospectively enrolled symptomatic patients with >50% diameter stenosis on computed tomography angiography underwent dual-bolus CMR and positron emission tomography with rest and adenosine-stress myocardial blood flow measurements. Subsequently, an invasive coronary angiography (ICA) with fractional flow reserve and thermodilution-based coronary flow reserve was performed. Obstructive CAD was defined as both anatomically severe (>70% diameter stenosis on quantitative coronary angiography) or hemodynamically obstructive (ICA with fractional flow reserve ≤0.80). RESULTS About 359 patients completed all investigations. Myocardial blood flow and reserve measurements correlated weakly between estimates from CMR-QP, positron emission tomography, and ICA-coronary flow reserve (r<0.40 for all comparisons). In the diagnosis of anatomically severe CAD, the interpretation of CMR-QP by an expert reader improved the sensitivity in comparison to visual analysis alone (82% versus 88% [P=0.03]) without compromising specificity (77% versus 74% [P=0.28]). In the diagnosis of hemodynamically obstructive CAD, the accuracy was only moderate for a visual expert read and remained unchanged when additional CMR-QP measurements were interpreted. CONCLUSIONS CMR-QP correlates weakly to myocardial blood flow measurements by other modalities but improves diagnosis of anatomically severe CAD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03481712.
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
- Department of Cardiology, Aalborg University Hospital, Denmark (L.D.R.)
| | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (T.M., S.E.P.)
| | - Xenios Milidonis
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (X.M., A.C.)
| | - Ashkan Eftekhari
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Salma Raghad Karim
- Department of Cardiology (S.R.K., J.W., E.H.C.), Aarhus University Hospital, Denmark
| | - Jelmer Westra
- Department of Cardiology (S.R.K., J.W., E.H.C.), Aarhus University Hospital, Denmark
| | - Jonathan Nørtoft Dahl
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Denmark (C.I., L.B.)
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Denmark (C.I., L.B.)
| | | | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Denmark (M.N.)
| | - Jane Kirk Johansen
- Department of Cardiology, Regional Hospital Central Jutland, Silkeborg, Denmark (J.K.J.)
| | | | - Jesper Mortensen
- Department of Nuclear Medicine (J.M.), Gødstrup Hospital, Herning, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine and PET Centre (L.C.G.), Aarhus University Hospital, Denmark
| | | | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (X.M., A.C.)
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (T.M., S.E.P.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, United Kingdom (S.E.P.)
| | - Morten Bøttcher
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Simon Winther
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
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14
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Shah SM, Tremmel JA, Henry TD, Smilowitz NR, Prasad M, Kobayashi Y, Henry GA, Samady H, Samuels BA, Lerman A, Moses JW, Pietras C, Zhang Z, Tirziu D, Parise H, Cristea E, Chamié D, Grubman D, Henrici K, Matmusaeva E, Latif N, Cigarroa N, Lansky AJ. Determining the Cause of Coronary Vasomotor Disorders in Patients With Ischemia and Nonobstructive Coronary Arteries: Design and Rationale of the DISCOVER INOCA Prospective, Multicenter Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102046. [PMID: 39132594 PMCID: PMC11308755 DOI: 10.1016/j.jscai.2024.102046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 08/13/2024]
Abstract
Background Approximately 30% to 50% of patients who are referred for diagnostic coronary angiography are found to have no obstructive coronary artery disease (CAD). Ischemia and nonobstructive coronary arteries (INOCA) is increasingly recognized and encompasses coronary microvascular dysfunction, vasospastic angina, symptomatic myocardial bridging, and other vasomotor disorders. However, the prevalence of these disorders and whether underlying atherosclerotic plaque burden and morphology affect the long-term outcomes of each physiologic phenotype is unknown. Methods The DISCOVER INOCA registry is ongoing at 8 centers in the United States and plans to enroll 500 patients with ischemic heart disease referred for angiography undergoing coronary function testing (CFT). All participants will complete patient-reported outcome measures and undergo protocol-guided angiography, acetylcholine provocation, coronary thermodilution, and intravascular imaging. Follow-up assessments occur at 30 days, 6 months, 1 year, and annually for 5 years. The primary short-term end point is the prevalence of INOCA phenotypes based on physiology and the degree of atherosclerosis based on intravascular ultrasound or optical coherence tomography (intravascular imaging). The primary long-term end point is the incidence of major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, hospitalization for cardiovascular causes, or coronary revascularization at a follow-up of 5 years. At the time of this publication, 100 participants have been enrolled. Conclusions DISCOVER INOCA is the first prospective study of INOCA patients to integrate anatomic and physiologic measures of disease and correlate them with long-term outcomes. DISCOVER INOCA will report on the prevalence of INOCA phenotypes, the safety of comprehensive invasive CFT, and the impact of testing on diagnoses and medical therapy. Symptoms and cardiovascular adverse events at long-term follow-up will be determined in patients with no obstructive CAD undergoing angiography.
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Affiliation(s)
- Samit M. Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer A. Tremmel
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Timothy D. Henry
- The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio
- The Carl and Edyth Lindner Research Center at The Christ Hospital, Cincinnati, Ohio
| | - Nathaniel R. Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
- Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, New York
| | - Megha Prasad
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Yuhei Kobayashi
- NewYork-Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York
| | - Glen A. Henry
- Northeast Georgia Medical Center, Gainesville, Georgia
| | - Habib Samady
- Northeast Georgia Medical Center, Gainesville, Georgia
| | - Bruce A. Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey W. Moses
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Cody Pietras
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Zhiyuan Zhang
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Daniela Tirziu
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Helen Parise
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Ecaterina Cristea
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Chamié
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Daniel Grubman
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Kyna Henrici
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Elzar Matmusaeva
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Nida Latif
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Natasha Cigarroa
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexandra J. Lansky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
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15
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Zhang W, Liu L, Yin G, Mohammed AQ, Xiang L, Lv X, Shi T, Galip J, Wang C, Mohammed AA, Mareai RM, Yu F, Abdu FA, Che W. Triglyceride-glucose index is associated with myocardial ischemia and poor prognosis in patients with ischemia and no obstructive coronary artery disease. Cardiovasc Diabetol 2024; 23:187. [PMID: 38822373 PMCID: PMC11140859 DOI: 10.1186/s12933-024-02230-1] [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: 01/07/2024] [Accepted: 04/09/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Ischemia and no obstructive coronary artery disease (INOCA) is increasingly recognized and associated with poor outcomes. The triglyceride-glucose (TyG) index is a reliable alternative measure of insulin resistance significantly linked to cardiovascular disease and adverse prognosis. We investigated the association between the TyG index and myocardial ischemia and the prognosis in INOCA patients. METHODS INOCA patients who underwent both coronary angiography and myocardial perfusion imaging (MPI) were included consecutively. All participants were divided into three groups according to TyG tertiles (T1, T2, and T3). Abnormal MPI for myocardial ischemia in individual coronary territories was defined as summed stress score (SSS) ≥ 4 and summed difference score (SDS) ≥ 2. SSS refers to the sum of all defects in the stress images, and SDS is the difference of the sum of all defects between the rest images and stress images. All patients were followed up for major adverse cardiac events (MACE). RESULTS Among 332 INOCA patients, 113 (34.0%) had abnormal MPI. Patients with higher TyG index had a higher rate of abnormal MPI (25.5% vs. 32.4% vs. 44.1%; p = 0.012). Multivariate logistic analysis showed that a high TyG index was significantly correlated with abnormal MPI in INOCA patients (OR, 1.901; 95% CI, 1.045-3.458; P = 0.035). During the median 35 months of follow-up, 83 (25%) MACE were recorded, and a higher incidence of MACE was observed in the T3 group (T3 vs. T2 vs. T1: 36.9% vs. 21.6% vs. 16.4%, respectively; p = 0.001). In multivariate Cox regression analysis, the T3 group was significantly associated with the risk of MACE compared to the T1 group (HR, 2.338; 95% CI 1.253-4.364, P = 0.008). CONCLUSION This study indicates for the first time that the TyG index is significantly associated with myocardial ischemia and poor prognosis among INOCA patients.
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Affiliation(s)
- Wen Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Lanqing Xiang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Tingting Shi
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Jassur Galip
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Chunyue Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China
| | - Fei Yu
- Department of Nuclear Medicine, 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, 301 Yanchang Road, Shanghai, 200072, China.
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, 200072, China.
- Department of Cardiology, Shanghai Tenth People's Hospital Chongming branch, Shanghai, China.
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16
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Hohendanner F, Boegner M, Huettemeister J, Zhang K, Dreysse S, Knosalla C, Falk V, Schoenrath F, Just IA, Stawowy P. Microvascular dysfunction in heart transplantation is associated with altered cardiomyocyte mitochondrial structure and unimpaired excitation-contraction coupling. PLoS One 2024; 19:e0303540. [PMID: 38820336 PMCID: PMC11142617 DOI: 10.1371/journal.pone.0303540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/25/2024] [Indexed: 06/02/2024] Open
Abstract
INTRODUCTION Microvascular dysfunction (MVD) is a hallmark feature of chronic graft dysfunction in patients that underwent orthotopic heart transplantation (OHT) and is the main contributor to impaired long-term graft survival. The aim of this study was to determine the effect of MVD on functional and structural properties of cardiomyocytes isolated from ventricular biopsies of OHT patients. METHODS We included 14 patients post-OHT, who had been transplanted for 8.1 years [5.0; 15.7 years]. Mean age was 49.6 ± 14.3 years; 64% were male. Coronary microvasculature was assessed using guidewire-based coronary flow reserve(CFR)/index of microvascular resistance (IMR) measurements. Ventricular myocardial biopsies were obtained and cardiomyocytes were isolated using enzymatic digestion. Cells were electrically stimulated and subcellular Ca2+ signalling as well as mitochondrial density were measured using confocal imaging. RESULTS MVD measured by IMR was present in 6 of 14 patients with a mean IMR of 53±10 vs. 12±2 in MVD vs. controls (CTRL), respectively. CFR did not differ between MVD and CTRL. Ca2+ transients during excitation-contraction coupling in isolated ventricular cardiomyocytes from a subset of patients showed unaltered amplitudes. In addition, Ca2+ release and Ca2+ removal were not significantly different between MVD and CTRL. However, mitochondrial density was significantly increased in MVD vs. CTRL (34±1 vs. 29±2%), indicating subcellular changes associated with MVD. CONCLUSION In-vivo ventricular microvascular dysfunction post OHT is associated with preserved excitation-contraction coupling in-vitro, potentially owing to compensatory changes on the mitochondrial level or due to the potentially reversible cause of the disease.
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Affiliation(s)
- Felix Hohendanner
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Markus Boegner
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Judith Huettemeister
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Kun Zhang
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Stephan Dreysse
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christoph Knosalla
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
| | - Volkmar Falk
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Institute of Translational Medicine, Translational Cardiovascular Technologies, Zurich, Switzerland
| | - Felix Schoenrath
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
| | - Isabell Anna Just
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
| | - Philipp Stawowy
- Department of Cardiology, Deutsches Herzzentrum der Charité, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité –Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany
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17
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Kong B, Fei H, Cheng S, Ma H, Yin H, Li M, Liu Q, Liu Y, Bai B, Liu F, Guo L, Geng Q. Mental Stress-Induced Myocardial Ischemia Detected by Global Longitudinal Strain and Quantitative Myocardial Contrast Echocardiography in Women With Nonobstructive Coronary Artery Disease. J Am Soc Echocardiogr 2024:S0894-7317(24)00231-1. [PMID: 38761987 DOI: 10.1016/j.echo.2024.05.008] [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: 01/08/2024] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND The utility of radionuclide myocardial perfusion imaging including positron emission tomography (PET) for diagnosing mental stress-induced myocardial ischemia (MSIMI) is clinically restricted. This study aims to assess the diagnostic performance of novel echocardiographic techniques, including automated strain and quantitative myocardial contrast echocardiography (MCE) with dedicated software and deep neural network model, for MSIMI detection. The secondary objective was to explore the correlation between changes in myocardial blood flow and MSIMI. METHODS Seventy-two female patients ages 18 to 75 with angina and nonobstructive coronary artery disease (ANOCA) and 23 healthy controls were prospectively recruited. Both echocardiography with contrast agent and PET imaging were performed during structured mental stress testing. Mental stress-induced myocardial ischemia was defined as a summed difference score ≥3 on PET. Echocardiographic parameters including left ventricular global longitudinal strain, β, and A × β were obtained, and their trends during mental stress testing were observed. ΔGLS was defined as the ratio of difference between global longitudinal strain values at stress and rest to the rest data. β reserve and A×β reserve were respectively calculated. RESULTS Thirty-two ANOCA patients (44%) and 1 control (4%) were diagnosed with MSIMI (P < .01). For ANOCA patients with MSIMI, left ventricular GLS, β, and A × β declined to varied extents during mental stress testing compared with those without MSIMI and the controls (P < .05). Bland-Altman plots demonstrated good consistency between β reserve and A × β reserve output by the deep neural network model and iMCE software. Receiver operating characteristic curve analyses showed that ΔGLS, β reserve, and A × β reserve demonstrated favorable ability to predict MSIMI, especially the combination of A × β reserve using iMCE analysis and ΔGLS (area under the curve, 0.94; sensitivity, 83%; specificity, 97%). CONCLUSIONS Novel technologies in echocardiography exhibit the potential to be a clinical alternative to cardiac PET for effectively detecting MSIMI. Attenuated myocardial blood flow response during structured mental stress testing was correlated with MSIMI, providing a reasonable explanation for the chest discomfort persisting in ANOCA women.
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Affiliation(s)
- Bo Kong
- Department of Echocardiography, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Hongwen Fei
- Department of Echocardiography, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Shiyao Cheng
- Department of Cardiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huan Ma
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Han Yin
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Mingqi Li
- Department of Ultrasonography, Renmin Hospital of Wuhan University, Wuhan, China
| | - Quanjun Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuting Liu
- Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Bingqing Bai
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Fengyao Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Lan Guo
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qingshan Geng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China; Department of Cardiology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China.
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18
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Merdler I, Chitturi KR, Chaturvedi A, Li J, Cellamare M, Ozturk ST, Sawant V, Ben-Dor I, Waksman R, Case BC, Hashim HD. Coronary microvascular dysfunction and inflammation: Insights from the Coronary Microvascular Disease Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00488-3. [PMID: 38789342 DOI: 10.1016/j.carrev.2024.05.020] [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: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is associated with various inflammatory conditions that worsen endothelial dysfunction. This study aimed to investigate the relationship between CMD and inflammation using common inflammatory markers derived from complete blood count (CBC) analysis. METHODS Information was gathered from the Coronary Microvascular Disease Registry to examine the neutrophil-to-lymphocyte ratio (NLR), eosinophil-to-monocyte ratio (EMR), and monocyte-to-high-density lipoprotein ratio (MHR) in a cohort of patients with angina who showed non-obstructive coronary arteries and underwent invasive physiological assessments for CMD. RESULTS Of the 171 patients studied, 126 were CMD-negative and 45 were CMD-positive, constituting two groups of interest. The average age of all patients was 61.7 ± 11.1 years, and 63.7 % were female. No significant differences were observed between the two groups in terms of baseline characteristics, cardiovascular risk factors, or potential anti-inflammatory medications. Furthermore, there were no statistically significant differences in NLR (2.54 ± 3.71 vs. 2.52 ± 2.28, p = 0.97), EMR (0.3 ± 0.21 vs. 0.34 ± 0.29, p = 0.31), or MHR (0.02 ± 0.01 vs. 0.01 ± 0.01, p = 0.54) between CMD-positive and CMD-negative patients. CONCLUSION Our findings did not show a noteworthy connection between CMD and inflammation, as suggested by various simple CBC-based biomarkers.
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Affiliation(s)
- Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jason Li
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, United States of America
| | - Matteo Cellamare
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Sevket Tolga Ozturk
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Vaishnavi Sawant
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder D Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
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19
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Lopez-Candales A, Sawalha K, Asif T. Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance. Postgrad Med 2024; 136:366-376. [PMID: 38818874 DOI: 10.1080/00325481.2024.2360888] [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: 08/09/2023] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.
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Affiliation(s)
- Angel Lopez-Candales
- Cardiovascular Medicine Division University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Khalid Sawalha
- Cardiometabolic Fellowship, University Health Truman Medical Center and the University of Missouri-Kansas City, Kansas City, USA
| | - Talal Asif
- Division of Cardiovascular Diseases, University Health Truman Medical Center and the University of Missouri-Kansas City Kansas City, Kansas City, MO, USA
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20
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Kong H, Cao J, Tian J, Yong J, An J, Zhang L, Song X, He Y. Coronary microvascular dysfunction: prevalence and aetiology in patients with suspected myocardial ischaemia. Clin Radiol 2024; 79:386-392. [PMID: 38433042 DOI: 10.1016/j.crad.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/19/2023] [Accepted: 01/09/2024] [Indexed: 03/05/2024]
Abstract
AIM To evaluate the prevalence, aetiology, and corresponding morbidity of coronary microvascular dysfunction (CMD) in patients with suspected myocardial ischaemia. MATERIALS AND METHODS The present study included 115 patients with suspected myocardial ischaemia who underwent stress perfusion cardiac magnetic resonance imaging. CMD was assessed visually based on the myocardial perfusion results. The CMR-derived myocardial perfusion reserve index (MPRI) and left ventricular (LV) strain parameters obtained using the post-processing software CVI42 were employed to evaluate LV myocardial perfusion and deformation. LV strain parameters included global longitudinal, circumferential, and radial strain (GLS, GCS, and GRS), global systolic/diastolic longitudinal, circumferential, and radial strain rates (SLSR, SCSR, SRSR, DLSR, DCSR, and DRSR). RESULTS Of the 115 patients, 12 patients were excluded and 103 patients were finally included in the study. CMD was observed in 79 % (81 patients, aged 53 ± 12 years) of patients. Regarding aetiology, 91 (88 %) patients had non-obstructive coronary artery disease (CAD), eight (8 %) had obstructive CAD, and four (4 %) had hypertrophic cardiomyopathy (HCM). The incidence of CMD was highest (100 %) in patients with HCM, followed by those with non-obstructive CAD (up to 79 %). There were no statistical differences between CMD and non-CMD groups in GCS, GRS, GLS, SRSR, SCSR, SLSR, DCSR, DRSR and DLSR. CONCLUSION The incidence of CMD was higher in patients with signs and symptoms of ischaemia. CMD occurred with non-obstructive CAD, obstructive CAD, and HCM, with the highest prevalence of CMD in HCM.
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Affiliation(s)
- H Kong
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - J Cao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - J Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - J Yong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - J An
- Siemens Shenzhen Magnetic Resonance, MR Collaboration NE Asia, Shenzhen, China
| | - L Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - X Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Y He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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21
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Bollen Pinto B, Ackland GL. Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review. Br J Anaesth 2024; 132:653-666. [PMID: 38262855 DOI: 10.1016/j.bja.2023.12.017] [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: 06/12/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.
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Affiliation(s)
- Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
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22
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Alam S, Pepine CJ. Physiology and functional significance of the coronary microcirculation: An overview of its implications in health and disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 40:100381. [PMID: 38586427 PMCID: PMC10994960 DOI: 10.1016/j.ahjo.2024.100381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 04/09/2024]
Abstract
Ischemic, Coronary Heart Disease (CHD) is a leading cause of morbidity and death worldwide.
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Affiliation(s)
- Samir Alam
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Carl J Pepine
- Department of Medicine, University of Florida, Gainesville, FL, United States of America
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23
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Almeida AG, Grapsa J, Gimelli A, Bucciarelli-Ducci C, Gerber B, Ajmone-Marsan N, Bernard A, Donal E, Dweck MR, Haugaa KH, Hristova K, Maceira A, Mandoli GE, Mulvagh S, Morrone D, Plonska-Gosciniak E, Sade LE, Shivalkar B, Schulz-Menger J, Shaw L, Sitges M, von Kemp B, Pinto FJ, Edvardsen T, Petersen SE, Cosyns B. Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology. Eur Heart J Cardiovasc Imaging 2024; 25:e116-e136. [PMID: 38198766 DOI: 10.1093/ehjci/jeae013] [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: 12/28/2023] [Accepted: 12/31/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.
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Affiliation(s)
- Ana G Almeida
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Julia Grapsa
- Cardiology Department, Guys and St Thomas NHS Trust, London, UK
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Hospitals, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, UCLouvain, Brussels, Belgium
- Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Nina Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Bernard
- EA4245 Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France
- Service de Cardiologie, CHRU de Tours, Tours, France
| | - Erwan Donal
- CHU Rennes, Inserm, LTSI-UMR 1099, University of Rennes, Rennes, France
| | - Marc R Dweck
- Centre for Cardiovascular Science, Chancellors Building, Little France Crescent, Edinburgh, UK
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Krassimira Hristova
- Center for Cardiovascular Diseases, Faculty of Medicine, Sofia University, Sofia, Bulgaria
| | - Alicia Maceira
- Ascires Biomedical Group, Valencia, Spain
- Department of Medicine, Health Sciences School, UCH-CEU University, Valencia, Spain
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Sharon Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, NS, Canada
| | - Doralisa Morrone
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | | | - Leyla Elif Sade
- Cardiology Department, University of Baskent, Ankara, Turkey
- UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jeanette Schulz-Menger
- Charité ECRC Medical Faculty of the Humboldt University Berlin and Helios-Clinics, Berlin, Germany
- DZHK, Partner site Berlin, Berlin, Germany
| | - Leslee Shaw
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai New York, NY, USA
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBERCV, Barcelona, Spain
| | - Berlinde von Kemp
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
| | - Fausto J Pinto
- Heart and Vessels Department, University Hospital Santa Maria, CAML, CCUL, Faculty of Medicine of Lisbon University, Lisbon, Portugal
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- ProCardio Center for Innovation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Bernard Cosyns
- Cardiology, Centrum voor Hart en Vaatziekten (CHVZ), Universitair Ziejkenhuis Brussel (UZB), Vrij Universiteit Brussel (VUB), Brussels, Belgium
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24
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Gowda SN, Garapati SS, Kurrelmeyer K. Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle. Methodist Debakey Cardiovasc J 2024; 20:81-93. [PMID: 38495657 PMCID: PMC10941714 DOI: 10.14797/mdcvj.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.
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Affiliation(s)
- Smitha Narayana Gowda
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Sai sita Garapati
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Karla Kurrelmeyer
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
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25
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Huang B, Han X, Xie P, Chen S. Recurrent syncope due to ischemia with non-obstructive coronary artery disease: a case report. J Med Case Rep 2024; 18:153. [PMID: 38468268 DOI: 10.1186/s13256-023-04316-y] [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] [Received: 08/30/2023] [Accepted: 12/12/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Ischemia with non-obstructive coronary artery disease is a prevalent form of ischemic heart disease. The majority of ischemia with non-obstructive coronary artery disease cases are attributed to underlying factors such as coronary microvascular dysfunction (CMD) and/or coronary artery spasm. Ischemia with non-obstructive coronary artery disease can present with various clinical manifestations. Recurrent syncope is an atypical complaint in patients with ischemia with non-obstructive coronary artery disease. CASE PRESENTATION This case report describes the presentation of a 58-year-old Chinese male patient who experienced repeated episodes of syncope. The syncope was found to be caused by concomitant coronary artery spasm and presumptive coronary microvascular dysfunctionc suggested by "slow flow" on coronary angiography. The patient was prescribed diltiazem sustained-release capsules, nicorandil, and atorvastatin. During the three-month follow-up conducted on our outpatient basis, the patient did not experience a recurrence of syncope. CONCLUSION This study highlights the importance of considering ischemia with non-obstructive coronary artery disease as a potential cause of syncope in the differential diagnosis. It emphasizes the need for early diagnosis of ischemia with non-obstructive coronary artery disease to facilitate more effective management strategies.
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Affiliation(s)
- Bihan Huang
- Department of Cardiology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Xueying Han
- Department of Intensive Care, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Peiyi Xie
- Department of Cardiology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Shaoyuan Chen
- Department of Cardiology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China.
- Department of Cardiology, The 6th Affiliated Hospital of Shenzhen University Medical School, Shenzhen, China.
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26
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Al Rifai M, Winchester D. When should myocardial perfusion imaging be a first-test choice? J Nucl Cardiol 2024; 33:101824. [PMID: 38360263 DOI: 10.1016/j.nuclcard.2024.101824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Mahmoud Al Rifai
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - David Winchester
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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27
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La S, Beltrame J, Tavella R. Sex-specific and ethnicity-specific differences in MINOCA. Nat Rev Cardiol 2024; 21:192-202. [PMID: 37775559 DOI: 10.1038/s41569-023-00927-6] [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] [Accepted: 08/28/2023] [Indexed: 10/01/2023]
Abstract
Suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) has received increasing attention over the past decade. Given the heterogeneity in the mechanisms underlying acute myocardial infarction in the absence of obstructive coronary arteries, the syndrome of MINOCA is considered a working diagnosis that requires further investigation after diagnostic angiography studies have been performed, including coronary magnetic resonance angiography and functional angiography. Although once considered an infrequent and low-risk form of myocardial infarction, recent data have shown that the prognosis of MINOCA is not as benign as previously assumed. However, despite increasing awareness of the condition, many questions remain regarding the diagnosis, risk stratification and treatment of MINOCA. Women seem to be more susceptible to MINOCA, but studies on the sex-specific differences of the disease are scarce. Similarly, ethnicity-specific factors might explain discrepancies in the observed prevalence or underlying pathophysiological mechanisms of MINOCA but data are also scarce. Therefore, in this Review, we provide an update on the latest evidence available on the sex-specific and ethnicity-specific differences in the clinical features, pathophysiological mechanisms, treatment and prognosis of MINOCA.
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Affiliation(s)
- Sarena La
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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Kanaji Y, Ahmad A, Sara JDS, Ozcan I, Akhiyat N, Prasad A, Raphael CE, Kakuta T, Lerman LO, Lerman A. Coronary Vasomotor Dysfunction Is Associated With Cardiovascular Events in Patients With Nonobstructive Coronary Artery Disease. JACC Cardiovasc Interv 2024; 17:474-487. [PMID: 38418053 DOI: 10.1016/j.jcin.2023.11.039] [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: 06/21/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Coronary vasomotor dysfunction (CVDys) can be comprehensively classified on the basis of anatomy and functional mechanisms. OBJECTIVES The aim of this study was to evaluate the association between different CVDys phenotypes and outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA). METHODS Patients with ANOCA who underwent coronary reactivity testing using an intracoronary Doppler guidewire to assess microvascular and epicardial coronary endothelium-dependent and endothelium-independent function were enrolled. Endothelium-dependent microvascular and epicardial coronary dysfunction were defined as a <50% change in coronary blood flow in response to intracoronary acetylcholine (Ach) infusion and a <-20% change in coronary artery diameter in response to Ach. Endothelium-independent microvascular and epicardial coronary dysfunction were defined as coronary flow reserve < 2.5 during adenosine-induced hyperemia and change in cross-sectional area in response to intracoronary nitroglycerin administration < 20%. Major adverse cardiac and cerebrovascular events (cardiovascular death, nonfatal MI, heart failure, stroke, and late revascularization) served as clinical outcomes. RESULTS Among the 1,196 patients with ANOCA, the prevalence of CVDys was 24.5% and 51.8% among those with endothelium-independent and endothelium-dependent microvascular dysfunction, respectively, and 47.4% and 25.4% among those with endothelium-independent and endothelium-dependent epicardial coronary dysfunction, respectively. During 6.3 years (Q1-Q3: 2.5-12.9 years) of follow-up, patients with endothelium-dependent microvascular dysfunction, endothelium-dependent epicardial coronary dysfunction, or endothelium-independent microvascular dysfunction showed significantly higher event rates compared with those without (19.5% vs 12.0% [P < 0.001], 19.7% vs 14.6% [P = 0.038] and 22.2% vs 13.8% [P = 0.001], respectively). Coronary flow reserve (HR: 0.757; 95% CI: 0.604-0.957) and percentage change in coronary blood flow in response to Ach infusion (HR: 0.998; 95% CI: 0.996-0.999) remained significant predictors of major adverse cardiac and cerebrovascular event after adjustment for conventional risk factors. CONCLUSIONS CVDys phenotype is differentially associated with worse outcomes, and endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information in patients with ANOCA.
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Affiliation(s)
- Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadia Akhiyat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Stein AP, Harder J, Holmes HR, Merz CNB, Pepine CJ, Keeley EC. Single Nucleotide Polymorphisms in Coronary Microvascular Dysfunction. J Am Heart Assoc 2024; 13:e032137. [PMID: 38348798 PMCID: PMC11010085 DOI: 10.1161/jaha.123.032137] [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: 08/08/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024]
Abstract
Coronary microvascular dysfunction is an underdiagnosed pathologic process that is associated with adverse clinical outcomes. There are data to suggest that coronary microvascular dysfunction, in some cases, may be genetically determined. We present an updated review of single nucleotide polymorphisms in coronary microvascular dysfunction.
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Affiliation(s)
| | | | | | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart CenterSmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Carl J. Pepine
- Department of MedicineUniversity of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineUniversity of FloridaGainesvilleFLUSA
| | - Ellen C. Keeley
- Department of MedicineUniversity of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineUniversity of FloridaGainesvilleFLUSA
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Zhao Y, Hu Y, Li Y, Wang Y, Xiao Y, Xu L, Ren T, Wu Q, Wang R, Wu Z, Li S, Wu P. Spherization indices measured by resting SPECT improve risk stratification in patients with ischemia with non-obstructive coronary artery disease (INOCA). EJNMMI Res 2024; 14:16. [PMID: 38324108 PMCID: PMC10850039 DOI: 10.1186/s13550-024-01075-9] [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] [Received: 09/13/2023] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND The prevalence of ischemia with non-obstructive coronary artery disease (INOCA) is substantial, but its risk stratification has been suboptimal. Resting SPECT myocardial perfusion imaging (MPI) could provide useful heart information including spherical indices. We aimed to evaluate the prognostic value of spherical indices in individuals with INOCA. RESULTS During a median follow-up of 47.2 ± 20.8 months, 49 (17.2%) patients experienced major adverse cardiac events (MACE). Compared to those without MACE, those with MACE had a higher shape index (SI) (0.60 ± 0.07 vs. 0.58 ± 0.06; P = 0.028) and a lower E2 (eccentricity index calculated by the QPS) (0.81 ± 0.05 vs. 0.83 ± 0.04; P = 0.019). MACE event-free survival analysis revealed significant differences in the SI and E2 among all patients (all log-rank P < 0.01). Multivariate Cox analysis showed abnormal SI (HR: 2.73, 95% CI 1.44-5.18, P = 0.002) and E2 (HR: 1.94, 95% CI 1.08-3.48, P = 0.026) were both independent predictors for MACE when they were put into the same model, respectively. The incorporation of the SI into the baseline model demonstrated a significant improvement in the predictive accuracy for MACEs (P = 0.026), whereas E2 did not exhibit a similar improvement (P > 0.05). CONCLUSION For patients with INOCA, spherical indices (especially the SI) were associated with long-term MACE, which could be a preferable indicator for risk stratification and prognostic prediction.
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Affiliation(s)
- Yuting Zhao
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, China
| | - Yingqi Hu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yuanyuan Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yanhui Wang
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yuxin Xiao
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Li Xu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Tailin Ren
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qiuyan Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ruonan Wang
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Zhifang Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, China
| | - Sijin Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China.
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, China.
| | - Ping Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China.
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, China.
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Januszek R, Kołtowski Ł, Tomaniak M, Wańha W, Wojakowski W, Grygier M, Siłka W, Jan Horszczaruk G, Czarniak B, Kręcki R, Guzik B, Legutko J, Pawłowski T, Wnęk P, Roik M, Sławek-Szmyt S, Jaguszewski M, Roleder T, Dziarmaga M, Bartuś S. Implementation of Microcirculation Examination in Clinical Practice-Insights from the Nationwide POL-MKW Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:277. [PMID: 38399564 PMCID: PMC10890290 DOI: 10.3390/medicina60020277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/10/2023] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: The assessment of coronary microcirculation may facilitate risk stratification and treatment adjustment. The aim of this study was to evaluate patients' clinical presentation and treatment following coronary microcirculation assessment, as well as factors associated with an abnormal coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) values. Materials and Results: This retrospective analysis included 223 patients gathered from the national registry of invasive coronary microvascular testing collected between 2018 and 2023. Results: The frequency of coronary microcirculatory assessments in Poland has steadily increased since 2018. Patients with impaired IMR (≥25) were less burdened with comorbidities. Patients with normal IMR underwent revascularisation attempts more frequently (11.9% vs. 29.8%, p = 0.003). After microcirculation testing, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors were added more often for patients with IMR and CFR abnormalities, respectively, as compared to control groups. Moreover, patients with coronary microvascular dysfunction (CMD, defined as CFR and/or IMR abnormality), regardless of treatment choice following microcirculation assessment, were provided with trimetazidine (23.2%) and dihydropyridine CCBs (26.4%) more frequently than those without CMD who were treated conservatively (6.8%) and by revascularisation (4.2% with p = 0.002 and 0% with p < 0.001, respectively). Multivariable analysis revealed no association between angina symptoms and IMR or CFR impairment. Conclusions: The frequency of coronary microcirculatory assessments in Poland has steadily increased. Angina symptoms were not associated with either IMR or CFR impairment. After microcirculation assessment, patients with impaired microcirculation, expressed as either low CFR, high IMR or both, received additional pharmacotherapy treatment more often.
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Affiliation(s)
- Rafał Januszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, 30-705 Kraków, Poland
| | - Łukasz Kołtowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Mariusz Tomaniak
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Wojciech Siłka
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
| | - Grzegorz Jan Horszczaruk
- Faculty of Medical Science, Collegium Medicum. Cardinal Stefan Wyszyński University in Warsaw, 01-938 Warsaw, Poland;
- Department of Cardiology, Voivodeship Hospital in Łomża, 18-404 Łomża, Poland
| | - Bartosz Czarniak
- Provincial Specialist Hospital in Wloclawek, 87-800 Włocławek, Poland;
| | | | - Bartłomiej Guzik
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Tomasz Pawłowski
- Department of Cardiology, National Institute of Medicine of the Ministry of Internal Affairs and Administration, 02-507 Warsaw, Poland;
- Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Paweł Wnęk
- Provincial Specialist Hospital in Wroclaw, 51-124 Wrocław, Poland;
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Miłosz Jaguszewski
- 1st Department of Cardiology, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Tomasz Roleder
- Department of Cardiology, Wroclaw Medical University, 50-556 Wrocław, Poland;
| | - Miłosz Dziarmaga
- Department of Cardiology-Intensive Therapy and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
| | - Stanisław Bartuś
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
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Parry M, Owadally T, O’Hara A, Nickerson N, Hart D. Community- and Patient-Partner Engagement in Women's Cardiovascular Disease Research: A Rapid Review of the Evidence. CJC Open 2024; 6:485-502. [PMID: 38487065 PMCID: PMC10935688 DOI: 10.1016/j.cjco.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/13/2023] [Indexed: 03/17/2024] Open
Abstract
The primary objective of this rapid review is to describe community-partner and patient-partner engagement in women's cardiovascular disease (CVD) research. Secondary objectives are to: (i) describe the phase of the research in which community and patient partners were engaged; (ii) define the level of engagement at each research phase; and (iii) make recommendations for future engagement of community and/or patient partners in women's CVD research. Rapid review guidelines recommended by the Cochrane Rapid Reviews Methods Group and Tricco et al. were used to search 5 databases using medical subject headings (MeSH) and/or keywords. Participants included women (cis and trans) aged > 18 years who had ischemic heart disease, heart failure, or stroke. A risk of bias assessment was not undertaken. Findings are summarized and/or clustered as community-based participatory research, or patient-oriented and/or patient-partner research. Our search yielded 39,998 titles and abstracts. Of these, 35 were included in a final narrative synthesis, comprising data from 474 community and/or patient partners, including 417 (88%) women. Over 85% of community partners collaborated in the design and/or planning and implementation of women's CVD research; most originated in the US; only one originated in Canada. Most patient-oriented and patient-partner research originated in Canada. However, less than 50% of patient partners collaborated in any phase of research. Sex, gender, race, and ethnicity were rarely reported. Results suggest negligible community and inadequate patient-oriented and/or patient-partner engagement in women's CVD research in Canada. Improved CVD outcomes for women may be achieved with better community- and patient-partner collaboration across all phases of research, genders, race, and ethnicities.
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Affiliation(s)
- Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Tasneem Owadally
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Arland O’Hara
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Donna Hart
- Patient Partner, Milton, Ontario, Canada
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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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Henning RJ. The diagnosis and treatment of women with recurrent cardiac ischemia and normal coronary arteries. Curr Probl Cardiol 2024; 49:102124. [PMID: 37802164 DOI: 10.1016/j.cpcardiol.2023.102124] [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: 09/30/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Cardiac disease is the leading cause of death in women. Among women with recurrent chest pain, abnormal electrocardiograms, and/or stress tests who undergo coronary angiography, as many as 50% have normal or <50% coronary artery obstructive disease. Pharmacologic stress assessment of coronary artery flow reserve in these women frequently demonstrates an inability to increase blood flow to >2.5 times normal flow. Contributory factors include abnormal epicardial or microvascular reactivity, microvascular remodeling or rarefaction, autonomic dysfunction, or coronary plaque rupture/erosion. Assessment is necessary of serum biomarkers and coronary artery flow reserve, fractional flow reserve, microvascular resistance, and epicardial/microvascular spasm. Aggressive treatment of women with positive tests is necessary because these women have an increased incidence of recurrent chest pain, repeated hospitalizations and coronary angiograms, and cardiac death.
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Affiliation(s)
- Robert J Henning
- University of South Florida, 13201 Bruce B. Downs Blvd. Tampa, Florida 33612-3805, United States.
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35
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Théberge ET, Vikulova DN, Pimstone SN, Brunham LR, Humphries KH, Sedlak TL. The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes. CJC Open 2024; 6:279-291. [PMID: 38487074 PMCID: PMC10935675 DOI: 10.1016/j.cjco.2023.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/26/2023] [Indexed: 03/17/2024] Open
Abstract
Background Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women. Methods This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD. Results A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD. Conclusions The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.
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Affiliation(s)
| | - Diana N. Vikulova
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Simon N. Pimstone
- University of British Columbia, Vancouver, British Columbia, Canada
- University of British Columbia Hospital, Vancouver, British Columbia, Canada
| | - Liam R. Brunham
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | | | - Tara L. Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
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36
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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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Dikic AD, Dedic S, Jovanovic I, Boskovic N, Giga V, Nedeljkovic I, Tesic M, Aleksandric S, Cortigiani L, Ciampi Q, Picano E. Noninvasive evaluation of dynamic microvascular dysfunction in ischemia and no obstructive coronary artery disease patients with suspected vasospasm. J Cardiovasc Med (Hagerstown) 2024; 25:123-131. [PMID: 38064348 PMCID: PMC10754482 DOI: 10.2459/jcm.0000000000001562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/31/2023] [Accepted: 09/03/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION In patients with ischemia and no obstructive coronary artery disease (INOCA), a dynamic coronary microvascular dysfunction (CMD) is frequent but difficult to capture by noninvasive means.The aim of our study was to assess dynamic CMD in INOCA patients with stress echocardiography after vasoconstrictive and vasodilator stimuli. METHODS In this prospective single-center study, we have enrolled 40 INOCA patients (age 56.3 ± 13 years, 32 women). All participants underwent stress echocardiography with hyperventilation (HYP), followed by supine bicycle exercise (HYP+EXE) and adenosine (ADO). Stress echocardiography included an assessment of regional wall motion abnormality (RWMA) and coronary flow velocity (CFV) in the distal left anterior descending (LAD) coronary artery. RESULTS HYP induced a 30% increase in rate pressure product (rest = 10 244 ± 2353 vs. HYP = 13 214 ± 3266 mmHg x bpm, P < 0.001) accompanied by a paradoxical reduction in CFV (HYP< rest) in 21 patients (52%). HYP alone was less effective than HYP+EXE in inducing anginal pain (6/40, 15% vs. 10/40, 25%, P = 0.046), ST segment changes (6/40, 15% vs. 24/40, 60%, P < 0.001), and RWMA (6/40, 15% vs. 13/40, 32.5%, P = 0.008). ADO-induced vasodilation was preserved (≥2.0) in all patients. CONCLUSION In patients with INOCA, a coronary vasoconstriction after HYP is common, in absence of structural CMD detectable with ADO. HYP+EXE test represents a more powerful ischemia inducer than HYP alone. Stress echocardiography with LAD-CFV may allow the noninvasive assessment of dynamic and structural coronary microcirculation during stress.
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Affiliation(s)
- Ana Djordjevic Dikic
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Srdjan Dedic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Jovanovic
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Vojislav Giga
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milorad Tesic
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Srdjan Aleksandric
- University of Belgrade Faculty of Medicine, Serbia, Belgrade
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Quirino Ciampi
- Fatebenefratelli Hospital of Benevento, Benevento, Italy
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Dai N, Tang X, Weng X, Cai H, Zhuang J, Yang G, Zhou F, Wu P, Liu B, Duan S, Yu Y, Guo W, Ju Z, Zhang L, Wang Z, Wang Y, Lu B, Shi H, Qian J, Ge J. Sex Differences in Coronary Inflammation and Atherosclerosis Phenotypes in Response to Imaging Marker of Stress-Related Neural Activity. Circ Cardiovasc Imaging 2024; 17:e016057. [PMID: 38377235 DOI: 10.1161/circimaging.123.016057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/19/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Sex-specific differences in coronary phenotypes in response to stress have not been elucidated. This study investigated the sex-specific differences in the coronary computed tomography angiography-assessed coronary response to mental stress. METHODS This retrospective study included patients with coronary artery disease and without cancer who underwent resting 18F-fluorodexoyglucose positron emission tomography/computed tomography and coronary computed tomography angiography within 3 months. 18F-flourodeoxyglucose resting amygdalar uptake, an imaging biomarker of stress-related neural activity, coronary inflammation (fat attenuation index), and high-risk plaque characteristics were assessed by coronary computed tomography angiography. Their correlation and prognostic values were assessed according to sex. RESULTS A total of 364 participants (27.7% women and 72.3% men) were enrolled. Among those with heightened stress-related neural activity, women were more likely to have a higher fat attenuation index (43.0% versus 24.0%; P=0.004), while men had a higher frequency of high-risk plaques (53.7% versus 39.3%; P=0.036). High amygdalar 18F-flourodeoxyglucose uptake (B-coefficient [SE], 3.62 [0.21]; P<0.001) was selected as the strongest predictor of fat attenuation index in a fully adjusted linear regression model in women, and the first-order interaction term consisting of sex and stress-related neural activity was significant (P<0.001). Those with enhanced imaging biomarkers of stress-related neural activity showed increased risk of major adverse cardiovascular event both in women (24.5% versus 5.1%; adjusted hazard ratio, 3.62 [95% CI, 1.14-17.14]; P=0.039) and men (17.2% versus 6.9%; adjusted hazard ratio, 2.72 [95% CI, 1.10-6.69]; P=0.030). CONCLUSIONS Imaging-assessed stress-related neural activity carried prognostic values irrespective of sex; however, a sex-specific mechanism linking psychological stress to coronary plaque phenotypes existed in the current hypothesis-generating study. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05545618.
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Affiliation(s)
- Neng Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, China (N.D., X.T., X.W., J.Q., J.G.)
- National Clinical Research Center for Interventional Medicine, Shanghai, China (N.D., X.T., X.W., J.Q., J.G.)
| | - Xianglin Tang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, China (N.D., X.T., X.W., J.Q., J.G.)
- National Clinical Research Center for Interventional Medicine, Shanghai, China (N.D., X.T., X.W., J.Q., J.G.)
| | - Xinyu Weng
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, China (N.D., X.T., X.W., J.Q., J.G.)
- National Clinical Research Center for Interventional Medicine, Shanghai, China (N.D., X.T., X.W., J.Q., J.G.)
| | - Haidong Cai
- Department of Nuclear Medicine (H.C.), Shanghai Tenth People's Hospital, China
| | - Jianhui Zhuang
- Department of Cardiology (J.Z.), Shanghai Tenth People's Hospital, China
| | - Guangjie Yang
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, Shandong, China (G.Y., Z.W.)
| | - Fan Zhou
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (F.Z., L.Z.)
| | - Ping Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China (P.W.)
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, China (P.W.)
| | - Bao Liu
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China (B.L., Y.W.)
- The Nuclear Medicine and Molecular Imaging Clinical Translation Institute of Soochow University, Changzhou, China (B.L., Y.W.)
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (B.L.)
| | | | - Yongfu Yu
- School of Public Health, and The Key Laboratory of Public Health Safety of Ministry of Education (Y.Y.), Fudan University, Shanghai, China
| | - Weifeng Guo
- Department of Radiology, Zhongshan Hospital (W.G.), Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, China (W.G.)
| | - Zhiguo Ju
- College of Medical Imaging, Shanghai University of Medicine and Health Science, China (Z.J.)
| | - Longjiang Zhang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Jiangsu, China (F.Z., L.Z.)
| | - Zhenguang Wang
- Department of Nuclear Medicine, The Affiliated Hospital of Qingdao University, Shandong, China (G.Y., Z.W.)
| | - Yuetao Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China (B.L., Y.W.)
- The Nuclear Medicine and Molecular Imaging Clinical Translation Institute of Soochow University, Changzhou, China (B.L., Y.W.)
| | - Bin Lu
- State Key Laboratory of Cardiovascular Disease and National Center for Cardiovascular Diseases, Beijing, China (B.L.)
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital (H.S.), Fudan University, Shanghai, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, China (N.D., X.T., X.W., J.Q., J.G.)
- National Clinical Research Center for Interventional Medicine, Shanghai, China (N.D., X.T., X.W., J.Q., J.G.)
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, China (N.D., X.T., X.W., J.Q., J.G.)
- National Clinical Research Center for Interventional Medicine, Shanghai, China (N.D., X.T., X.W., J.Q., J.G.)
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Li S, Yuan Y, Zhao L, Lv T, She F, Liu F, Xue Y, Zhou B, Xie Y, Geng Y, Zhang P. Men with nonobstructive coronary disease have higher burden of ischemic heart disease detected by cardiopulmonary exercise test. Microcirculation 2024; 31:e12841. [PMID: 38232023 DOI: 10.1111/micc.12841] [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] [Received: 06/16/2022] [Revised: 10/29/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Nonobstructive coronary artery disease (NOCAD), characterized by the presence of myocardial ischemic symptoms and signs without obstructive coronaries, is a common clinical condition, but it is less well understood. Few studies have analyzed the gender differences in inducible myocardial ischemia assessed by cardiopulmonary exercise test (CPET) in NOCAD. METHODS We conducted a study of 289 NOCAD patients (mean age 60, 56% women) with ischemic symptoms and confirmed ⫹50% coronaries stenoses by coronary angiography who underwent symptom-limited CPET. We assessed ischemic response using predicted % peak VO2 , O2 pulse trajectory, and exercise ECG test. RESULTS Men with NOCAD had significantly lower predicted % peak VO2 (62% vs. 73%), higher proportions of flattening pattern (16% vs. 2%), and downward patterns of O2 pulse trajectory (2% vs. 0%) (p < .0001) compared with women. In contrast, women with NOCAD had a higher prevalence of shallow patterns of O2 pulse trajectory (21% vs. 6%, p < .0001). Men with NOCAD had a higher risk ischemic profile (medium risk: 63% vs. 54%, high risk: 18% vs. 4%, p < .0001). After adjustment, men with NOCAD had significantly lower predicted % peak VO2 (β -27.4, 95% CI -30.74 to -24.07), higher risk for abnormal O2 pulse trajectories (OR 4.21, 95% CI 1.93 to 9.19), and myocardial ischemia risk per CPET parameters (OR 3.14, 95% CI 1.78 to 5.54) (p < .0001). CONCLUSION Men with NOCAD had a higher risk profile for ischemic heart disease per CPET. Therefore, they should receive rigorous management and follow-up to prevent cardiovascular events.
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Affiliation(s)
- Siyuan Li
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Yifang Yuan
- Peking University Clinical Research Center, Peking University First Hospital, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Lanting Zhao
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Tingting Lv
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Fei She
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Fang Liu
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Yajun Xue
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Boda Zhou
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Ying Xie
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Yu Geng
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, China
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Shu T, Tang M, He B, Liu X, Han Y, Liu C, Jose PA, Wang H, Zhang QW, Zeng C. Assessing Global, Regional, and National Time Trends and Associated Risk Factors of the Mortality in Ischemic Heart Disease Through Global Burden of Disease 2019 Study: Population-Based Study. JMIR Public Health Surveill 2024; 10:e46821. [PMID: 38265846 PMCID: PMC10851120 DOI: 10.2196/46821] [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: 02/27/2023] [Revised: 10/05/2023] [Accepted: 11/22/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Ischemic heart disease (IHD) is the leading cause of death among noncommunicable diseases worldwide, but data on current epidemiological patterns and associated risk factors are lacking. OBJECTIVE This study assessed the global, regional, and national trends in IHD mortality and attributable risks since 1990. METHODS Mortality data were obtained from the Global Burden of Disease 2019 Study. We used an age-period-cohort model to calculate longitudinal age curves (expected longitudinal age-specific rate), net drift (overall annual percentage change), and local drift (annual percentage change in each age group) from 15 to >95 years of age and estimate cohort and period effects between 1990 and 2019. Deaths from IHD attributable to each risk factor were estimated on the basis of risk exposure, relative risks, and theoretical minimum risk exposure level. RESULTS IHD is the leading cause of death in noncommunicable disease-related mortality (118.1/598.8, 19.7%). However, the age-standardized mortality rate for IHD decreased by 30.8% (95% CI -34.83% to -27.17%) over the past 30 years, and its net drift ranged from -2.89% (95% CI -3.07% to -2.71%) in high sociodemographic index (SDI) region to -0.24% (95% CI -0.32% to -0.16%) in low-middle-SDI region. The greatest decrease in IHD mortality occurred in the Republic of Korea (high SDI) with net drift -6.06% (95% CI -6.23% to -5.88%), followed by 5 high-SDI nations (Denmark, Norway, Estonia, the Netherlands, and Ireland) and 2 high-middle-SDI nations (Israel and Bahrain) with net drift less than -5.00%. Globally, age groups of >60 years continued to have the largest proportion of IHD-related mortality, with slightly higher mortality in male than female group. For period and birth cohort effects, the trend of rate ratios for IHD mortality declined across successive period groups from 2000 to 2004 and birth cohort groups from 1985 to 2000, with noticeable improvements in high-SDI regions. In low-SDI regions, IHD mortality significantly declined in female group but fluctuated in male group across successive periods; sex differences were greater in those born after 1945 in middle- and low-middle-SDI regions and after 1970 in low-SDI regions. Metabolic risks were the leading cause of mortality from IHD worldwide in 2019. Moreover, smoking, particulate matter pollution, and dietary risks were also important risk factors, increasingly occurring at a younger age. Diets low in whole grains and legumes were prominent dietary risks in both male and female groups, and smoking and high-sodium diet mainly affect male group. CONCLUSIONS IHD, a major concern, needs focused health care attention, especially for older male individuals and those in low-SDI regions. Metabolic risks should be prioritized for prevention, and behavioral and environmental risks should attract more attention to decrease IHD mortality.
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Affiliation(s)
- Tingting Shu
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, China
| | - Ming Tang
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, China
| | - Bo He
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, China
| | - Xiaozhu Liu
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yu Han
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, China
| | - Chang Liu
- Department of Cardiac Surgery, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Pedro A Jose
- Division of Renal Diseases and Hypertension, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Hongyong Wang
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Qing-Wei Zhang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Chunyu Zeng
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, China
- Key Laboratory of Geriatric Cardiovascular and Cerebrovascular Disease Research, Ministry of Education of China, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
- Cardiovascular Research Center of Chongqing College, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Chongqing, China
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Sakai A, Nagao M, Yamamoto A, Nakao R, Arashi H, Momose M, Sato K, Yamaguchi J. 13N-ammonia positron emission tomography for diagnosis and monitoring of ischemia without obstructive coronary artery disease. Int J Cardiol 2024; 395:131392. [PMID: 37748522 DOI: 10.1016/j.ijcard.2023.131392] [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: 06/27/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Ischemia with no obstructive coronary arteries (INOCA), a chronic disorder with a poor prognosis, remains challenging to diagnose. 13N-ammonia positron emission tomography (13NH3 PET), which can quantify microcirculation, is its most reliable detection method. We aimed to investigate the differences in 13NH3 PET findings between INOCA and coronary artery disease (CAD). METHODS Overall, consecutive 433 patients with known or suspected CAD underwent adenosine-stress 13NH3 PET. Based on the European Society of Cardiology guidelines, INOCA was defined as typical angina without coronary stenosis (INOCA n = 45, CAD n = 293, no CAD n = 95). Papillary muscle ischemia (PMI) and global myocardial flow reserve (MFR) were examined as microvascular injuries using 13NH3 PET. RESULTS PMI was observed significantly more frequently in patients with INOCA than in those with CAD (40.0% vs. 11.6%, respectively; p = 0.02). Global MFR (1.84 ± 0.54 vs. 2.08 ± 0.66, respectively; p < 0.0001) and reactive hyperemia index were significantly lower in patients with INOCA than in those with CAD. Forty-five major adverse cardiac events (MACE) were recorded in a median follow-up time of 827 days. Kaplan-Meier analysis revealed that the survival rate worsened in patients with INOCA and PMI (log-rank test, p = 0.001). In the Cox proportional hazards model, PMI was an independent predictive factor for MACE (odds ratio, 4.16; 95% confidence interval, 2.13-8.15; p < 0.0001). CONCLUSIONS PMI presence and decreased MFR were 13NH3 PET findings characteristic of INOCA. 13NH3 PET can be used to monitor the treatment course.
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Affiliation(s)
- Akiko Sakai
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan.
| | - Michinobu Nagao
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Atsushi Yamamoto
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Risako Nakao
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Hiroyuki Arashi
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Mitsuru Momose
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Kayoko Sato
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
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Giorgetti A, Emdin M. Dogmas and heresies in coronary blood flow regulation. Int J Cardiol 2024; 395:131558. [PMID: 37913959 DOI: 10.1016/j.ijcard.2023.131558] [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: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Affiliation(s)
| | - Michele Emdin
- Fondazione CNR/Regione Toscana"Gabriele Monasterio", Pisa, Italy; Scuola Superiore "S. Anna", Pisa, Italy
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Heusch G. Myocardial ischemia/reperfusion: Translational pathophysiology of ischemic heart disease. MED 2024; 5:10-31. [PMID: 38218174 DOI: 10.1016/j.medj.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 01/15/2024]
Abstract
Ischemic heart disease is the greatest health burden and most frequent cause of death worldwide. Myocardial ischemia/reperfusion is the pathophysiological substrate of ischemic heart disease. Improvements in prevention and treatment of ischemic heart disease have reduced mortality in developed countries over the last decades, but further progress is now stagnant, and morbidity and mortality from ischemic heart disease in developing countries are increasing. Significant problems remain to be resolved and require a better pathophysiological understanding. The present review attempts to briefly summarize the state of the art in myocardial ischemia/reperfusion research, with a view on both its coronary vascular and myocardial aspects, and to define the cutting edges where further mechanistic knowledge is needed to facilitate translation to clinical practice.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
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Sidik NP, Stanley B, Sykes R, Morrow AJ, Bradley CP, McDermott M, Ford TJ, Roditi G, Hargreaves A, Stobo D, Adams J, Byrne J, Mahrous A, Young R, Carrick D, McGeoch R, Corcoran D, Lang NN, Heggie R, Wu O, McEntegart MB, McConnachie A, Berry C. Invasive Endotyping in Patients With Angina and No Obstructive Coronary Artery Disease: A Randomized Controlled Trial. Circulation 2024; 149:7-23. [PMID: 37795617 DOI: 10.1161/circulationaha.123.064751] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/01/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND We investigated the usefulness of invasive coronary function testing to diagnose the cause of angina in patients with no obstructive coronary arteries. METHODS Outpatients referred for coronary computed tomography angiography in 3 hospitals in the United Kingdom were prospectively screened. After coronary computed tomography angiography, patients with unobstructed coronary arteries, and who consented, underwent invasive endotyping. The diagnostic assessments included coronary angiography, fractional flow reserve (patient excluded if ≤0.80), and, for those without obstructive coronary artery disease, coronary flow reserve (abnormal <2.0), index of microvascular resistance (abnormal ≥25), and intracoronary infusion of acetylcholine (0.182, 1.82, and 18.2 μg/mL; 2 mL/min for 2 minutes) to assess for microvascular and coronary spasm. Participants were randomly assigned to disclosure of the results of the coronary function tests to the invasive cardiologist (intervention group) or nondisclosure (control group, blinded). In the control group, a diagnosis of vasomotor angina was based on medical history, noninvasive tests, and coronary angiography. The primary outcome was the between-group difference in the reclassification rate of the initial diagnosis on the basis of coronary computed tomography angiography versus the final diagnosis after invasive endotyping. The Seattle Angina Questionnaire summary score and Treatment Satisfaction Questionnaire for Medication were secondary outcomes. RESULTS Of 322 eligible patients, 250 (77.6%) underwent invasive endotyping; 19 (7.6%) had obstructive coronary disease, 127 (55.0%) had microvascular angina, 27 (11.7%) had vasospastic angina, 17 (7.4%) had both, and 60 (26.0%) had no abnormality. A total of 231 patients (mean age, 55.7 years; 64.5% women) were randomly assigned and followed up (median duration, 19.9 [12.6-26.9] months). The clinician diagnosed vasomotor angina in 51 (44.3%) patients in the intervention group and in 55 (47.4%) patients in the control group. After randomization, patients in the intervention group were 4-fold (odds ratio, 4.05 [95% CI, 2.32-7.24]; P<0.001) more likely to be diagnosed with a coronary vasomotor disorder; the frequency of this diagnosis increased to 76.5%. The frequency of normal coronary function (ie, no vasomotor disorder) was not different between the groups before randomization (51.3% versus 50.9%) but was reduced in the intervention group after randomization (23.5% versus 50.9%, P<0.001). At 6 and 12 months, the Seattle Angina Questionnaire summary score in the intervention versus control groups was 59.2±24.2 (2.3±16.2 change from baseline) versus 60.4±23.9 (4.6±16.4 change) and 63.7±23.5 (4.7±14.7 change) versus 66.0±19.3 (7.9±17.1 change), respectively, and not different between groups (global P=0.36). Compared with the control group, global treatment satisfaction was higher in the intervention group at 12 months (69.9±22.8 versus 61.7±26.9, P=0.013). CONCLUSIONS For patients with angina and no obstructive coronary arteries, a diagnosis informed by invasive functional assessment had no effect on long-term angina burden, whereas treatment satisfaction improved. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03477890.
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Affiliation(s)
- Novalia P Sidik
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
| | - Bethany Stanley
- Robertson Centre for Biostatistics, School of Health and Wellbeing (B.S., R.Y., A. McConnachie), University of Glasgow, Glasgow, United Kingdom
| | - Robert Sykes
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
| | - Andrew J Morrow
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
| | - Conor P Bradley
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
| | - Michael McDermott
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital, Central Coast, Australia (T.J.F.)
- Faculty of Medicine, The University of Newcastle, Australia (T.J.F.)
| | - Giles Roditi
- Department of Radiology, NHS Greater Glasgow and Clyde Health Board, Glasgow, United Kingdom (G.R., D.S.)
| | - Allister Hargreaves
- Department of Cardiology, Forth Valley Royal Hospital, Larbert, United Kingdom (A.H.)
| | - David Stobo
- Department of Radiology, NHS Greater Glasgow and Clyde Health Board, Glasgow, United Kingdom (G.R., D.S.)
| | - Jacqueline Adams
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom (J.A., J.B., D. Corcoran, N.N.L.)
| | - John Byrne
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom (J.A., J.B., D. Corcoran, N.N.L.)
| | - Ahmed Mahrous
- Raigmore Hospital, Inverness, United Kingdom (A. Mahrous)
| | - Robin Young
- Robertson Centre for Biostatistics, School of Health and Wellbeing (B.S., R.Y., A. McConnachie), University of Glasgow, Glasgow, United Kingdom
| | - David Carrick
- Department of Cardiology, University Hospital Hairmyres, East Kilbride, United Kingdom (D. Carrick, R.M.)
| | - Ross McGeoch
- Department of Cardiology, University Hospital Hairmyres, East Kilbride, United Kingdom (D. Carrick, R.M.)
| | - David Corcoran
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom (J.A., J.B., D. Corcoran, N.N.L.)
| | - Ninian N Lang
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom (J.A., J.B., D. Corcoran, N.N.L.)
| | - Robert Heggie
- Health Economics and Health Technology Assessment, School of Health and Wellbeing (R.H., O.W.), University of Glasgow, Glasgow, United Kingdom
| | - Olivia Wu
- Health Economics and Health Technology Assessment, School of Health and Wellbeing (R.H., O.W.), University of Glasgow, Glasgow, United Kingdom
| | - Margaret B McEntegart
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Columbia University Medical Center, New York (M.B.M.)
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing (B.S., R.Y., A. McConnachie), University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, United Kingdom (N.P.S., R.S., A.J.M., C.P.B., M.M., M.B.M., C.B.)
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health (N.P.S., R.S., A.J.M., C.P.B., M.M., N.N.L., M.B.M., C.B.), University of Glasgow, Glasgow, United Kingdom
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Polyak A, Wei J, Gulati M, Merz NB. Clinical aspects of ischemia with no obstructive coronary artery disease (INOCA). AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 37:100352. [PMID: 38222977 PMCID: PMC10785769 DOI: 10.1016/j.ahjo.2023.100352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 01/16/2024]
Abstract
Ischemia with no obstructive coronary arteries (INOCA) is defined as patients with evidence of myocardial ischemia without obstructive coronary artery disease. About 3-4 million people in the United States have INOCA, more commonly affecting women, and carries adverse morbidity, mortality, and relatively high healthcare costs. The pathophysiology of INOCA appears to be multi-factorial with a variety of contributing mechanisms. Diagnosis of INOCA is suggested by non-invasive or invasive testing consistent with myocardial ischemia. Due to the high prevalence of coronary risk factors and atherosclerosis in the INOCA population, current treatment strategies target angina, coronary atherosclerosis, and atherosclerotic risk factors, as well as burgeoning treatment of coronary microvascular dysfunction (CMD). Ongoing clinical trials are assessing different options.
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Affiliation(s)
- Alexander Polyak
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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47
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Hagiwara AM, Montano E, Tumurkhuu G, Bose M, Bernardo M, Berman DS, Wiens GC, Nelson MD, Wallace DJ, Wei J, Ishimori M, Bairey Merz CN, Jefferies C. Reduced Left Ventricular Function on Cardiac MRI in SLE Patients Correlates with Measures of SLE Disease Activity and Inflammation. JOURNAL OF RADIOLOGY AND CLINICAL IMAGING 2023; 6:197-207. [PMID: 38505536 PMCID: PMC10949413 DOI: 10.26502/jrci.2809088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Background Women with SLE have an elevated risk of CVD morbidity and mortality and frequently report chest pain in the absence of obstructive CAD. Echocardiographic studies often demonstrate reduced LV function, correlating with higher disease activity. We used cardiac MRI (cMRI) to investigate the relationship between SLE, related inflammatory biomarkers and cardiac function in female SLE patients. Methods Women with SLE reporting chest pain with no obstructive CAD (n=13) and reference controls (n=22) were evaluated using stress-rest cMRI to measure LV structure, function, tissue characteristics, and myocardial perfusion reserve index (MPRI). Coronary microvascular dysfunction (CMD) was defined as MPRI <1.84. Serum samples were analyzed for inflammatory markers. Relationships between clinical and cMRI values of SLE subjects were assessed, and groups were compared. Results 40% of SLE subjects had MPRI < 1.84 on cMRI. Compared to controls, SLE subjects had higher LV volumes and mass and lower LV systolic function. SLICC DI was related to worse cardiac function and higher T1. CRP was related to higher cardiac output and a trend to better systolic function, while ESR and fasting insulin were related to lower LV mass. Lower fasting insulin levels correlated with increased ECV. Conclusions Among our female SLE cohort, 40% had CMD, and SLICC DI correlated with worse cardiac function and diffuse fibrosis. Higher inflammatory markers and low insulin levels may associate with LV dysfunction. Our findings underline the potential of non-invasive cMRI as a tool for monitoring cardiovascular function in SLE patients.
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Affiliation(s)
- Audrey M Hagiwara
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Erica Montano
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gantseg Tumurkhuu
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Moumita Bose
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marianne Bernardo
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center
- Department of Cardiology, Cedars-Sinai Medical Center
| | - Galen Cook Wiens
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Michael D Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Texas, USA
| | - Daniel J Wallace
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - Janet Wei
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Mariko Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA
| | - C Noel Bairey Merz
- Department of Cardiology, Cedars-Sinai Medical Center
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
| | - Caroline Jefferies
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
- Kao Autoimmunity Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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48
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Ranasinghe S, Tjoe B, Shufelt C, Wei J, Lauzon M, Luu J, Asif A, Lewis J, Pepine CJ, Shaw LJ, Handberg E, Merz CNB. Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease. Cardiovasc Diagn Ther 2023; 13:948-955. [PMID: 38162097 PMCID: PMC10753239 DOI: 10.21037/cdt-23-296] [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] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 01/03/2024]
Abstract
Background Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings. Methods Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and t-test or Wilcoxon rank-sum test for continuous variables. Results Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002]. Conclusions Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.
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Affiliation(s)
- Sachini Ranasinghe
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Benita Tjoe
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chrisandra Shufelt
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marie Lauzon
- Bioststatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Judy Luu
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anum Asif
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jannet Lewis
- Division of Cardiology, The George Washington University Medical Center, Washington, DC, USA
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Leslee J. Shaw
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eileen Handberg
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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49
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Räsänen J, Ellam S, Hartikainen J, Juutilainen A, Halonen J. Sex Differences in Red Blood Cell Transfusions and 30-Day Mortality in Cardiac Surgery: A Single Center Observational Study. J Clin Med 2023; 12:7674. [PMID: 38137742 PMCID: PMC10743830 DOI: 10.3390/jcm12247674] [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: 10/15/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
In cardiac surgery, women have higher short-term mortality and a higher risk of receiving red blood cell (RBC) transfusions than men. This study's aim was to evaluate possible sex differences in RBC transfusions in cardiac surgery and their association with preoperative hemoglobin levels, body mass index, and 30-day mortality. A single-center retrospective study was conducted with 1583 patients (1181 men and 402 women) undergoing cardiac surgery. A total of 64.4% of the women and 33.0% of the men received an RBC transfusion. In a multivariable analysis, female sex was an independent predictor of RBC transfusion (OR 3.88, 95% CI 2.95-5.11, p < 0.001). Other independent predictors of RBC transfusion were age, preoperative hemoglobin level, and body mass index. The women were more likely to receive RBC transfusions than the men, regardless of the type of cardiac surgery. Decreased transfusion risk was found in all higher-than-normal weight categories in the women, but only in the severe obesity category in the men. Preoperative hemoglobin was similarly associated with RBC transfusion in the men and women. The crude 30-day mortality rate was higher in the women than in the men (2.5% vs. 0.9%, p = 0.018). In both sexes, RBC transfusion was associated with an increased probability of death within 30 days.
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Affiliation(s)
- Jenni Räsänen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, 70029 Kuopio, Finland;
| | - Juha Hartikainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
| | - Jari Halonen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, 70211 Kuopio, Finland; (J.H.); (A.J.)
- Heart Center, Kuopio University Hospital, 70029 Kuopio, Finland
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50
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Shimokawa H. Roles of endothelial and smooth muscle cell dysfunction and vasa vasorum in vasomotor disorders in ischemia with no obstructive coronary artery disease. Vascul Pharmacol 2023; 153:107234. [PMID: 37741354 DOI: 10.1016/j.vph.2023.107234] [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: 08/31/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 09/25/2023]
Abstract
Recently, the importance has emerged of ischemia with no obstructive coronary artery disease (INOCA), for which endothelial and vascular smooth muscle cell (VSMC) dysfunctions and alterations in coronary vasa vasorum are involved. Regarding endothelial vasodilator functions, both endothelium-derived nitric oxide and endothelium-derived hyperpolarizing factor play important roles in modulating vascular tone, especially in the microcirculation. Recent studies have suggested systemic endothelial dysfunction in INOCA. Regarding VSMC dysfunction, Rho-kinase has been identified as a key molecular mechanism of VSMC hyperconstriction in INOCA. Finally, recent advances of coronary imaging have demonstrated the important role of altered adventitial vasa vasorum functions in INOCA.
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Affiliation(s)
- Hiroaki Shimokawa
- International University of Health and Welfare, 4-3 Kozunomori, Narita 286-8686, Japan.
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