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SenthilKumar G, Hammond ST, Zirgibel Z, Cohen KE, Beyer AM, Freed JK. Is the peripheral microcirculation a window into the human coronary microvasculature? J Mol Cell Cardiol 2024; 193:67-77. [PMID: 38848808 PMCID: PMC11260236 DOI: 10.1016/j.yjmcc.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/13/2024] [Accepted: 06/04/2024] [Indexed: 06/09/2024]
Abstract
An increasing body of evidence suggests a pivotal role for the microvasculature in the development of cardiovascular disease. A dysfunctional coronary microvascular network, specifically within endothelial cells-the inner most cell layer of vessels-is considered a strong, independent risk factor for future major adverse cardiac events. However, challenges exist with evaluating this critical vascular bed, as many of the currently available techniques are highly invasive and cost prohibitive. The more easily accessible peripheral microcirculation has surfaced as a potential surrogate in which to study mechanisms of coronary microvascular dysfunction and likewise may be used to predict poor cardiovascular outcomes. In this review, we critically evaluate a variety of prognostic, physiological, and mechanistic studies in humans to answer whether the peripheral microcirculation can add insight into coronary microvascular health. A conceptual framework is proposed that the health of the endothelium specifically may link the coronary and peripheral microvascular beds. This is supported by evidence showing a correlation between human coronary and peripheral endothelial function in vivo. Although not a replacement for investigating and understanding coronary microvascular function, the microvascular endothelium from the periphery responds similarly to (patho)physiological stress and may be leveraged to explore potential therapeutic pathways to mitigate stress-induced damage.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Stephen T Hammond
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Zachary Zirgibel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Katie E Cohen
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Andreas M Beyer
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States; Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States; Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States.
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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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3
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Huck DM, Divakaran S, Weber B, Brown JM, Lopez D, Souza ACDAH, Hainer J, Blankstein R, Dorbala S, Di Carli M. COMPARATIVE EFFECTIVENESS OF PET AND SPECT MPI FOR PREDICTING RISK IN PATIENTS WITH CARDIOMETABOLIC DISEASE. J Nucl Cardiol 2024:101908. [PMID: 38996910 DOI: 10.1016/j.nuclcard.2024.101908] [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: 02/09/2024] [Revised: 06/23/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND The epidemiology of coronary artery disease (CAD) has shifted, with increasing prevalence of cardiometabolic disease and decreasing findings of obstructive CAD on myocardial perfusion imaging (MPI). Coronary microvascular dysfunction (CMD), defined as impaired myocardial flow reserve (MFR) by positron emission tomography (PET), has emerged as a key mediator of risk. We aimed to assess whether PET MFR provides additive value for risk stratification of cardiometabolic disease patients compared with single-photon emission computed tomography (SPECT) MPI. METHODS We retrospectively followed patients referred for PET, exercise SPECT, or pharmacologic SPECT MPI with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. We compared rates and hazards of composite MACE (annualized cardiac mortality or acute myocardial infarction) among propensity-matched PET and SPECT patients using Poisson and Cox regression. Normal SPECT was defined as a total perfusion deficit (TPD) <5% reflecting the absence of obstructive CAD. Normal PET was defined as TPD <5% plus MFR ≥2.0. RESULTS Among 21,544 patients referred from 2006-2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (p <0.001). Obstructive CAD findings (TPD >5%) were uncommon (PET: 21% and SPECT 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, p<0.001 compared to normal PET). CONCLUSIONS Cardiometabolic disease is common among patients referred for MPI and is associated with heterogenous level of risk. Compared with pharmacologic SPECT, PET with MFR can detect nonobstructive CAD including CMD and can more accurately discriminate low-risk from higher-risk individuals.
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Affiliation(s)
- Daniel M Huck
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brittany Weber
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jenifer M Brown
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana Carolina do A H Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Soh RYH, Low TT, Sia CH, Kong WKF, Yeo TC, Loh PH, Poh KK. Ischaemia with no obstructive coronary arteries: a review with focus on the Asian population. Singapore Med J 2024; 65:380-388. [PMID: 38973187 DOI: 10.4103/singaporemedj.smj-2023-116] [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: 05/28/2023] [Accepted: 09/02/2023] [Indexed: 07/09/2024]
Abstract
ABSTRACT Ischaemia with no obstructive coronary arteries (INOCA) has been a diagnostic and therapeutic challenge for decades. Several studies have demonstrated that INOCA is associated with an increased risk of death, adverse cardiovascular events, poor quality of life and high healthcare cost. Although there is increasing recognition of this entity in the Western population, in the Asian population, INOCA remains elusive and its prevalence uncertain. Despite its prognostic significance, diagnosis of INOCA is often delayed. In this review, we identified the multiple barriers to its diagnosis and management, and proposed strategies to overcome them.
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Affiliation(s)
- Rodney Yu-Hang Soh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ting-Ting Low
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William Kok-Fai Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Poay-Huan Loh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Tsuda T, Patel G. Coronary microvascular dysfunction in childhood: An emerging pathological entity and its clinical implications. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100392. [PMID: 38680649 PMCID: PMC11046079 DOI: 10.1016/j.ahjo.2024.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
Coronary microvascular dysfunction (CMD) encompasses a spectrum of structural and functional alterations in coronary microvasculature resulting in impaired coronary blood flow and consequent myocardial ischemia without obstruction in epicardial coronary artery. The pathogenesis of CMD is complex involving both functional and structural alteration in the coronary microcirculation. In adults, CMD is predominantly discussed in context with anginal chest pain or existing ischemic heart disease and its risk factors. The presence of CMD suggests increased risk of adverse cardiovascular events independent of coronary atherosclerosis. Coronary microvascular dysfunction is also known in children but is rarely recognized due to paucity of concommitent coronary artery disease. Thus, its clinical presentation, underlying mechanism of impaired microcirculation, and prognostic significance are poorly understood. In this review article, we will overview variable CMD reported in children and delineate its emerging clinical significance.
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Affiliation(s)
- Takeshi Tsuda
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Gina Patel
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
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Moody JB, Poitrasson-Rivière A, Renaud JM, Hagio T, Alahdab F, Al-Mallah MH, Vanderver MD, Ficaro EP, Murthy VL. Self-supervised deep representation learning of a foundation transformer model enabling efficient ECG-based assessment of cardiac and coronary function with limited labels. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.10.25.23297552. [PMID: 37961713 PMCID: PMC10635192 DOI: 10.1101/2023.10.25.23297552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background: Although deep learning methods have shown great promise for identification of structural and functional cardiac abnormalities using electrocardiographic data, these methods are data hungry, posing a challenge for critically important tasks where ground truth labels are relatively scarce. Impaired coronary microvascular and vasomotor function is difficult to identify with standard clinical methods of cardiovascular testing such as coronary angiography and noninvasive single photon emission tomography (SPECT) myocardial perfusion imaging (MPI). Gold standard data from positron emission tomography (PET) are gaining emphasis in clinical guidelines but are expensive and only available in relatively limited centers. We hypothesized that signals embedded within resting and stress electrocardiograms (ECGs) identify individuals with microvascular and vasomotor dysfunction. Methods: We developed and pretrained a self-supervised foundation vision transformer model using a large database of unlabeled ECG waveforms (N=800,035). We then fine-tuned the foundation model for two clinical tasks: the difficult problem of identifying patients with impaired myocardial flow reserve (AI-MFR), and the relatively easier problem of detecting impaired LVEF (AI-LVEF). A second ECG database was labeled with task-specific annotations derived from quantitative PET MPI (N=4167). Diagnostic accuracy of AI predictions was tested in a holdout set of patients undergoing PET MPI (N=1031). Prognostic evaluation was performed in the PET holdout cohort, as well as independent cohorts of patients undergoing pharmacologic or exercise stress SPECT MPI (N=6635). Results: The diagnostic accuracy of AI-MFR with SSL pretraining increased significantly compared to de novo supervised training (AUROC, sensitivity, specificity: 0.758, 70.1%, 69.4% vs. 0.632, 66.1%, 57.3%, p < 0.0001). SSL pretraining also produced a smaller increase in AI-LVEF accuracy (AUROC, sensitivity, specificity: 0.946, 89.4%, 85.9% vs. 0.918, 87.6%, 82.5%, p < 0.02). Abnormal AI-MFR was found to be significantly associated with mortality risk in all three test cohorts (Hazard Ratio (HR) 2.61 [95% CI 1.83, 3.71], p < 0.0001, PET cohort; HR 2.30 [2.03, 2.61], p < 0.0001, pharmacologic stress SPECT cohort; HR 3.76 [2.36, 5.99], p < 0.0001, exercise stress SPECT cohort). Conclusion: SSL pretraining of a vision transformer foundation model enabled identification of signals predictive of impaired MFR, a hallmark of microvascular and vasomotor dysfunction, and impaired LV function in resting and stress ECG waveforms. These signals are powerful predictors of prognosis in patients undergoing routine noninvasive stress testing and could enable more efficient diagnosis and management of these common conditions.
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Chitturi KR, Bhogal S, Kassaian SE, Merdler I, Abusnina W, Chaturvedi A, Ben-Dor I, Waksman R, Case BC, Barac A, Hashim HD. Coronary microvascular dysfunction and cancer therapy-related cardiovascular toxicity. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00459-7. [PMID: 38789343 DOI: 10.1016/j.carrev.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) has been implicated as a potential mechanism in the pathophysiology of different clinical presentations, including ischemia and no obstructive coronary artery disease (INOCA), myocardial infarction and nonobstructive coronary arteries (MINOCA), stress cardiomyopathy, heart failure, and myocarditis. There are limited data about the role of CMD in cancer therapy-related cardiovascular toxicities. CASE PRESENTATIONS Four women with a diagnosis of active cancer receiving treatment who developed subsequent MINOCA or INOCA presented for cardiac catheterization. Upon coronary angiography showing no obstructive coronary arteries, coronary function testing was performed to evaluate for CMD. METHODS Coronary physiology was assessed measuring non-hyperemic (resting full-cycle ratio [RFR]) and hyperemic (fractional flow reserve [FFR]) indices using a physiologic pressure wire. The wire also measured coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and RFR using thermodilution technology. CMD was confirmed if the CFR was <2.5 and the IMR was >25. RESULTS Among 4 patients with diagnosis of active cancer presenting with chest pain, there was no evidence of obstructive coronary artery disease, leading to separate diagnoses of INOCA, MINOCA, stress cardiomyopathy, and myocarditis. We found CMD in 2 patients (1 with INOCA and 1 with immune checkpoint inhibitor-related myocarditis). CONCLUSIONS CMD may play a role in cardiovascular toxicities. Further coronary physiology studies are needed to understand the mechanisms of cancer therapy-related cardiovascular toxicity and CMD, as well as optimal preventive and treatment options.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Sukhdeep Bhogal
- Section of Cardiology, Sovah Health, Martinsville, VA, United States of America
| | | | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Waiel Abusnina
- 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
| | - 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
| | - Ana Barac
- Section of Cardio-Oncology, Inova Schar Heart and Vascular, Falls Church, VA, 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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Countouris ME, Catov JM, Zhu J, de Jong N, Brands J, Chen X, Parks WT, Berlacher KL, Gandley RE, Straub AC, Villanueva FS. Association of Hypertensive Disorders of Pregnancy With Coronary Microvascular Dysfunction 8 to 10 Years After Delivery. Circ Cardiovasc Imaging 2024; 17:e016561. [PMID: 38771901 PMCID: PMC11115371 DOI: 10.1161/circimaging.124.016561] [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: 01/11/2024] [Accepted: 04/17/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are associated with subsequent adverse cardiac remodeling and cardiovascular disease. The role of myocardial microvascular disease among individuals with HDP and left ventricular (LV) remodeling as a potential link to cardiovascular disease is unknown. We aimed to determine whether individuals with HDP history have coronary microvascular dysfunction measured by coronary flow reserve 8 to 10 years after delivery and whether microvascular dysfunction correlates with LV remodeling. METHODS Individuals with pregnancies delivered from 2008 to 2010 underwent burst-replenishment myocardial contrast echocardiography (2017-2020) to quantify myocardial perfusion at rest and during dobutamine stress. Video intensity versus time data were used to derive β, the rate of rise of video intensity, a correlate for myocardial blood flow. Coronary flow reserve was calculated as the ratio of β at peak stress to β at rest, averaged across LV myocardial regions of interest. RESULTS We studied 91 individuals (aged 38±6 and 9.1±0.9 years postdelivery) and 19 with a history of HDP. Individuals with coronary microvascular dysfunction (coronary flow reserve <2.0; n=13) had a higher proportion of HDP (46.2% versus 16.7%; P=0.026) and higher prepregnancy body mass index, baseline heart rate, and hemoglobin A1c compared with those without microvascular dysfunction. The association of coronary flow reserve and HDP was attenuated after adjusting for cardiometabolic factors (P=0.133). In exploratory subgroup analyses, individuals with both LV remodeling (relative wall thickness >0.42) and HDP (n=12) had the highest proportion of microvascular dysfunction (41.7% versus +HDP-LV remodeling [n=7] 14.3%; -HDP+LV remodeling [n=26] 7.7%; P=0.0498). CONCLUSIONS In this small study, HDP history is associated with coronary microvascular dysfunction 1 decade after delivery, findings that may, in part, be driven by metabolic factors including obesity and diabetes. Microvascular dysfunction may contribute to cardiovascular disease among individuals with a history of HDP.
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Affiliation(s)
- Malamo E Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Janet M Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences (J.M.C., R.E.G.), University of Pittsburgh, PA
- Department of Epidemiology (J.M.C.), University of Pittsburgh, PA
| | - Jianhui Zhu
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Nikki de Jong
- Division of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (N.d.J.)
| | - Judith Brands
- Department of Library, Information and Communication Technologies Services and Archive, Enschede, the Netherlands (J.B.)
| | - Xucai Chen
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - W Tony Parks
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON, Canada (W.T.P.)
| | - Kathryn L Berlacher
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Robin E Gandley
- Department of Obstetrics, Gynecology, and Reproductive Sciences (J.M.C., R.E.G.), University of Pittsburgh, PA
| | - Adam C Straub
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
- Department of Pharmacology and Chemical Biology (A.C.S.), University of Pittsburgh, PA
| | - Flordeliza S Villanueva
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
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Michallek F, Nakamura S, Kurita T, Ota H, Nishimiya K, Ogawa R, Shizuka T, Nakashima H, Wang YN, Ito T, Sakuma H, Dewey M, Kitagawa K. Differentiating Macrovascular and Microvascular Ischemia Using Fractal Analysis of Dynamic Myocardial Perfusion Stress-CT. Invest Radiol 2024; 59:413-423. [PMID: 37812495 DOI: 10.1097/rli.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Fractal analysis of dynamic myocardial stress computed tomography perfusion imaging (4D-CTP) has shown potential to noninvasively differentiate obstructive coronary artery disease (CAD) and coronary microvascular disease (CMD). This study validates fractal analysis of 4D-CTP in a multicenter setting and assesses its diagnostic accuracy in subgroups with ischemia and nonobstructed coronary arteries (INOCA) and with mild to moderate stenosis. MATERIALS AND METHODS From the AMPLIFiED multicenter trial, patients with suspected or known chronic myocardial ischemia and an indication for invasive coronary angiography were included. Patients underwent dual-source CT angiography, 4D-CTP, and CT delayed-enhancement imaging. Coronary artery disease, CMD, and normal perfusion were defined by a combined reference standard comprising invasive coronary angiography with fractional flow reserve, and absolute or relative CT-derived myocardial blood flow. Nonobstructed coronary arteries were defined as ≤25% stenosis and mild to moderate stenosis as 26%-80%. RESULTS In 127 patients (27% female), fractal analysis accurately differentiated CAD (n = 61, 23% female), CMD (n = 23, 30% female), and normal perfusion (n = 34, 35% female) with a multiclass area under the receiver operating characteristic curve (AUC) of 0.92 and high agreement (multiclass κ = 0.89). In patients with ischemia (n = 84), fractal analysis detected CAD (n = 61) over CMD (n = 23) with sensitivity of 95%, specificity of 74%, accuracy of 89%, and AUC of 0.83. In patients with nonobstructed coronary arteries (n = 33), INOCA (n = 15) was detected with sensitivity of 100%, specificity of 78%, accuracy of 88%, and AUC of 0.94. In patients with mild to moderate stenosis (n = 27), fractal analysis detected CAD (n = 19) over CMD with sensitivity of 84%, specificity of 100%, accuracy of 89%, and AUC of 0.95. CONCLUSIONS In this multicenter study, fractal analysis of 4D-CTP accurately differentiated CAD and CMD including subgroups with INOCA and with mild to moderate stenosis.
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Affiliation(s)
- Florian Michallek
- From the Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (F.M., M.D.); Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Japan (F.M., K.K.); Department of Radiology, Mie University Graduate School of Medicine, Tsu, Japan (S.N., H.S.); Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (T.K.); Department of Advanced MRI Collaborative Research, Tohoku University Graduate School of Medicine, Sendai, Japan (H.O.); Department of Cardiology, Tohoku University Graduate School of Medicine, Sendai, Japan (K.N.); Saiseikai Matsuyama Hospital, Matsuyama, Japan (R.O.); Takasaki General Medical Center, Takasaki, Japan (T.S.); National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan (H.N.); Peking Union Medical College Hospital, Beijing, China (Y.-N.W.); Kobe University Graduate School of Medicine, Kobe, Japan (T.I.); German Center for Cardiovascular Research, Berlin, Germany (M.D.); and Deutsches Herzzentrum der Charité (M.D.), Berlin, Germany
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10
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Lin X, Wu G, Wang S, Huang J. The prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF): a systematic review and meta-analysis. Heart Fail Rev 2024; 29:405-416. [PMID: 37870703 DOI: 10.1007/s10741-023-10362-x] [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] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
To date, studies on the prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF) have not been summarized and analyzed as a whole. We conducted this systematic review and meta-analysis to assess the prevalence of CMD in patients with HFpEF. The PubMed, Cochrane, and Embase databases were searched from dates of inception until May 1, 2023. The primary outcome was the prevalence of CMD in patients with HFpEF, and values of CMD prevalence were pooled using a random-effects model. In total, 10 studies involving 1267 patients, including 822 with HFpEF and 445 without HFpEF, were included. The pooled prevalence of CMD in patients with HFpEF was 71% (95% CI, 0.63-0.79). In the subgroup analysis, the prevalence of CMD was 79% (95% CI, 0.71-0.87) by invasive measurement and 66% (95% CI, 0.54-0.77) by noninvasive measurement and 67% (95% CI, 0.52-0.82) with CFR < 2.0 and 75.0% (95% CI, 0.71-0.79) with CFR < 2.5. The prevalence of endothelium-independent CMD and endothelium-dependent CMD was 62% (95% CI, 0.53-0.72) and 50% (95% CI, 0.19-0.81), respectively. The prevalence of CMD was 74% (95% CI = 0.69-0.79) and 66% (95% CI = 0.41-0.90) in prospective and retrospective studies, respectively. Compared with the control group, patients with HFpEF had a significantly lower CFR (MD = - 1.28, 95% CI = - 1.82 to - 0.74, P < 0.01) and a higher prevalence of CMD (RR = 2.21, 95% CI = 1.52 to 3.20, P < 0.01). Qualitative analysis demonstrated that CMD might be associated with poor clinical outcomes in patients with HFpEF. In conclusion, this is the first systematic review and meta-analysis of all studies reporting the prevalence of CMD in patients with HFpEF. Our study demonstrates that CMD is common in patients with HFpEF and might be associated with poor clinical outcomes in these patients. Clinicians should attach importance to CMD in the diagnosis and treatment of HFpEF. The number of studies in this field is relatively small. Therefore, more high-quality studies are needed to explore the diagnostic and prognostic value of CMD and the potential role of CMD as a therapeutic target in patients with HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Guomin Wu
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Shuai Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
| | - Jinyu Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
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11
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Bland A, Chuah E, Meere W, Ford TJ. Targeted Therapies for Microvascular Disease. Cardiol Clin 2024; 42:137-145. [PMID: 37949535 DOI: 10.1016/j.ccl.2023.07.002] [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] [Indexed: 11/12/2023]
Abstract
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.
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Affiliation(s)
- Adam Bland
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - William Meere
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia; University of Glasgow, ICAMS, G12 8QQ Glasgow, UK.
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12
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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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13
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Burgess SN, Mamas MA. The invasive investigation of INOCA in the coronary catheterization lab. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 38:100365. [PMID: 38510741 PMCID: PMC10945914 DOI: 10.1016/j.ahjo.2024.100365] [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: 11/22/2023] [Accepted: 01/17/2024] [Indexed: 03/22/2024]
Abstract
Over half of all patients with angina have no angiographically demonstratable obstructive coronary disease, with a significant proportion of these patients having undiagnosed microvascular dysfunction and/or vasospastic angina. In chronic coronary syndrome, ischemia with non-obstructive coronary artery disease (INOCA) often remains undiagnosed, or uninvestigated. INOCAmay occur due to vasospastic angina and microvascular dysfunction and require invasive assessment in the coronary catheterization lab. To evaluate INOCA coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) are used to assess microvascular dysfunction before acetylcholine provocation testing for coronary spasm. This review provides an overview of the invasive investigation of INOCA in the coronary catheterization lab for patients with angina to be optimally managed.
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Affiliation(s)
- Sonya N. Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia
- University of Sydney, NSW, Australia
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, UK
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14
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Bland A, Chuah E, Meere W, Ford TJ. Targeted Therapies for Microvascular Disease. Heart Fail Clin 2024; 20:91-99. [PMID: 37953025 DOI: 10.1016/j.hfc.2023.06.003] [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] [Indexed: 11/14/2023]
Abstract
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.
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Affiliation(s)
- Adam Bland
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - William Meere
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia; University of Glasgow, ICAMS, G12 8QQ Glasgow, UK.
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15
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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16
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Moody JB, Poitrasson-Rivière A, Renaud JM, Hagio T, Al-Mallah MH, Weinberg RL, Ficaro EP, Murthy VL. Integrated myocardial flow reserve (iMFR) assessment: diffuse atherosclerosis and microvascular dysfunction are more strongly associated with mortality than focally impaired perfusion. Eur J Nucl Med Mol Imaging 2023; 51:123-135. [PMID: 37787848 DOI: 10.1007/s00259-023-06448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND AIMS Although treatment of ischemia-causing epicardial stenoses may improve symptoms of ischemia, current evidence does not suggest that revascularization improves survival. Conventional myocardial ischemia imaging does not uniquely identify diffuse atherosclerosis, microvascular dysfunction, or nonobstructive epicardial stenoses. We sought to evaluate the prognostic value of integrated myocardial flow reserve (iMFR), a novel noninvasive approach to distinguish the perfusion impact of focal atherosclerosis from diffuse coronary disease. METHODS This study analyzed a large single-center registry of consecutive patients clinically referred for rest-stress myocardial perfusion positron emission tomography. Cox proportional hazards modeling was used to assess the association of two previously reported and two novel perfusion measures with mortality risk: global stress myocardial blood flow (MBF); global myocardial flow reserve (MFR); and two metrics derived from iMFR analysis: the extents of focal and diffusely impaired perfusion. RESULTS In total, 6867 patients were included with a median follow-up of 3.4 years [1st-3rd quartiles, 1.9-5.0] and 1444 deaths (21%). Although all evaluated perfusion measures were independently associated with death, diffusely impaired perfusion extent (hazard ratio 2.65, 95%C.I. [2.37-2.97]) and global MFR (HR 2.29, 95%C.I. [2.08-2.52]) were consistently stronger predictors than stress MBF (HR 1.62, 95%C.I. [1.46-1.79]). Focally impaired perfusion extent (HR 1.09, 95%C.I. [1.03-1.16]) was only moderately related to mortality. Diffusely impaired perfusion extent remained a significant independent predictor of death when combined with global MFR (p < 0.0001), providing improved risk stratification (overall net reclassification improvement 0.246, 95%C.I. [0.183-0.310]). CONCLUSIONS The extent of diffusely impaired perfusion is a strong independent and additive marker of mortality risk beyond traditional risk factors, standard perfusion imaging, and global MFR, while focally impaired perfusion is only moderately related to mortality.
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Affiliation(s)
| | | | | | | | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | - Richard L Weinberg
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Edward P Ficaro
- INVIA, LLC, Ann Arbor, MI, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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17
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Jensen SM, Prescott EIB, Abdulla J. The prognostic value of coronary flow reserve in patients with non-obstructive coronary artery disease and microvascular dysfunction: a systematic review and meta-analysis with focus on imaging modality and sex difference. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2545-2556. [PMID: 37716916 DOI: 10.1007/s10554-023-02948-1] [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: 04/07/2023] [Accepted: 08/30/2023] [Indexed: 09/18/2023]
Abstract
To clarify prognosis of patients with non-obstructive coronary artery disease (NOCAD) and coronary microvascular disease (CMD) assessed as low coronary flow reserve (CFR) according to imaging modalities and sex difference. Comprehensive systematic literature review and meta-analyses were conducted. Risk of death and major adverse cardiac events (MACE) were pooled and compared in patients with abnormally low versus normal CFR using cut-off limits 2.0-2.5. Random effects model used for estimation of odds ratios (OR) and hazard ratios (HR) with 95% confidence interval (CI). Nineteen eligible observational studies provided data for death and MACE, publication bias was insignificant, p = 0.62. Risk of death and MACE were significantly higher in patients with low (n = 4.612, 29%) than normal CFR (n = 11.367, 71%): using transthoracal echocardiography (TTE) (OR 4.25 (95% CI 2.94, 6.15) p < 0.001) and (OR 6.98 (95% CI 2.56, 19.01) p < 0.001), positron emission tomography (PET) (OR 2.51 (CI 95%: 1.40, 4..49) p = 0.002) and (OR 2.87 (95% CI 2.16, 3.81) p < 0.001), and invasive intracoronary assessment (OR 2.23 (95% CI 1.15, 4.34) p < 0.018), and (OR 4.61 (95% CI 2.51, 8.48) p < 0.001), respectively. Pooled adjusted HR for death and MACE were (HR 2.45(95% CI 1.37, 3.53) p < 0.001) and (HR 2.08 (95% CI 1.54, 2.63) p < 0.001) respectively. Studies comparing men and women with abnormally low CFR demonstrated similar worse prognosis in both sexes. Low CFR is associated with poorer prognosis in patients with NOCAD regardless of sex. TTE may overestimate risk of death and MACE, while PET seems to be more appropriate. Future studies are needed to consolidate the current evidence.
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Affiliation(s)
- Signe Miang Jensen
- Department of Medicine, Section of Cardiology, Glostrup University Hospital of Copenhagen, Valdemar Hansens vej 1, 2600, Glostrup, Denmark
| | - Eva Irene Bossano Prescott
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Jawdat Abdulla
- Department of Medicine, Section of Cardiology, Glostrup University Hospital of Copenhagen, Valdemar Hansens vej 1, 2600, Glostrup, Denmark.
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18
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Ullrich-Daub H, Daub S, Olschewski M, Münzel T, Gori T. Diseases of the Coronary Microcirculation: Diagnosis and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:739-746. [PMID: 37721132 PMCID: PMC10722490 DOI: 10.3238/arztebl.m2023.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) comprises a variety of pathogenic mechanisms that impair the microcirculation of the heart. Clinical studies have shown that 30-50% of patients suffering from myocardial ischemia without significant coronary artery stenosis have CMD. The disease is associated with ele - vated mortality and poor quality of life. Whenever a patient presents with symptoms of angina pectoris and no underlying disease is detected by the usual methods, CMD should be considered a possible cause. METHODS This review is based on publications retrieved by a selective search in PubMed and on current international guidelines and recommendations of specialty societies. RESULTS The diagnosis of CMD is based on objective evidence of a microvascular origin of symptoms. The guidelines contain a class IIa recommendation for invasive coronary flow reserve and microvascular resistance measurements. Noninvasive tests such as positron emission tomography and cardiac magnetic resonance imaging are less accurate and are given a class IIb recommendation. No highquality therapeutic trials are available to date, and the treatment of CMD is thus based on that of chronic coronary syndrome. Lifestyle modification is performed to reduce risk factors. Patients with an abnormal coronary flow reserve or elevated microvascular resistance can be treated with an ACE inhibitor or angiotensin receptor blocker. Beta-blockers and calcium channel antagonists can relieve angina pectoris. Statins lower the LDL level and have positive pleiotropic effects. First-line treatment can be supplemented with further medications. CONCLUSION Approximately 25% of patients with CMD have symptoms that do not respond to intensive treatment with the currently available modalities. New treatments, including interventional therapies, are being studied. Their long-term benefit remains to be assessed and compared to that of the existing methods.
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Affiliation(s)
- Helen Ullrich-Daub
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Steffen Daub
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Maximilian Olschewski
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Thomas Münzel
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Tommaso Gori
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
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19
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Allbritton-King JD, García-Cardeña G. Endothelial cell dysfunction in cardiac disease: driver or consequence? Front Cell Dev Biol 2023; 11:1278166. [PMID: 37965580 PMCID: PMC10642230 DOI: 10.3389/fcell.2023.1278166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
The vascular endothelium is a multifunctional cellular system which directly influences blood components and cells within the vessel wall in a given tissue. Importantly, this cellular interface undergoes critical phenotypic changes in response to various biochemical and hemodynamic stimuli, driving several developmental and pathophysiological processes. Multiple studies have indicated a central role of the endothelium in the initiation, progression, and clinical outcomes of cardiac disease. In this review we synthesize the current understanding of endothelial function and dysfunction as mediators of the cardiomyocyte phenotype in the setting of distinct cardiac pathologies; outline existing in vivo and in vitro models where key features of endothelial cell dysfunction can be recapitulated; and discuss future directions for development of endothelium-targeted therapeutics for cardiac diseases with limited existing treatment options.
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Affiliation(s)
- Jules D. Allbritton-King
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Guillermo García-Cardeña
- Department of Pathology, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, United States
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20
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Mengozzi A, de Ciuceis C, Dell'oro R, Georgiopoulos G, Lazaridis A, Nosalski R, Pavlidis G, Tual-Chalot S, Agabiti-Rosei C, Anyfanti P, Camargo LL, Dąbrowska E, Quarti-Trevano F, Hellmann M, Masi S, Mavraganis G, Montezano AC, Rios FJ, Winklewski PJ, Wolf J, Costantino S, Gkaliagkousi E, Grassi G, Guzik TJ, Ikonomidis I, Narkiewicz K, Paneni F, Rizzoni D, Stamatelopoulos K, Stellos K, Taddei S, Touyz RM, Triantafyllou A, Virdis A. The importance of microvascular inflammation in ageing and age-related diseases: a position paper from the ESH working group on small arteries, section of microvascular inflammation. J Hypertens 2023; 41:1521-1543. [PMID: 37382158 DOI: 10.1097/hjh.0000000000003503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Microcirculation is pervasive and orchestrates a profound regulatory cross-talk with the surrounding tissue and organs. Similarly, it is one of the earliest biological systems targeted by environmental stressors and consequently involved in the development and progression of ageing and age-related disease. Microvascular dysfunction, if not targeted, leads to a steady derangement of the phenotype, which cumulates comorbidities and eventually results in a nonrescuable, very high-cardiovascular risk. Along the broad spectrum of pathologies, both shared and distinct molecular pathways and pathophysiological alteration are involved in the disruption of microvascular homeostasis, all pointing to microvascular inflammation as the putative primary culprit. This position paper explores the presence and the detrimental contribution of microvascular inflammation across the whole spectrum of chronic age-related diseases, which characterise the 21st-century healthcare landscape. The manuscript aims to strongly affirm the centrality of microvascular inflammation by recapitulating the current evidence and providing a clear synoptic view of the whole cardiometabolic derangement. Indeed, there is an urgent need for further mechanistic exploration to identify clear, very early or disease-specific molecular targets to provide an effective therapeutic strategy against the otherwise unstoppable rising prevalence of age-related diseases.
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Affiliation(s)
- Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa
| | - Carolina de Ciuceis
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Raffaella Dell'oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Georgios Georgiopoulos
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Antonios Lazaridis
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Ryszard Nosalski
- Centre for Cardiovascular Sciences; Queen's Medical Research Institute; University of Edinburgh, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine
- Center for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - George Pavlidis
- Preventive Cardiology Laboratory and Clinic of Cardiometabolic Diseases, 2 Cardiology Department, Attikon Hospital, Athens
- Medical School, National and Kapodistrian University of Athens, Greece
| | - Simon Tual-Chalot
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | | | - Panagiota Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Livia L Camargo
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Edyta Dąbrowska
- Department of Hypertension and Diabetology, Center of Translational Medicine
- Center of Translational Medicine
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marcin Hellmann
- Department of Cardiac Diagnostics, Medical University, Gdansk, Poland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Institute of Cardiovascular Science, University College London, London, UK
| | - Georgios Mavraganis
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Augusto C Montezano
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Francesco J Rios
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | | | - Jacek Wolf
- Department of Hypertension and Diabetology, Center of Translational Medicine
| | - Sarah Costantino
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- University Heart Center, Cardiology, University Hospital Zurich
| | - Eugenia Gkaliagkousi
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Tomasz J Guzik
- Centre for Cardiovascular Sciences; Queen's Medical Research Institute; University of Edinburgh, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine
- Center for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Ignatios Ikonomidis
- Preventive Cardiology Laboratory and Clinic of Cardiometabolic Diseases, 2 Cardiology Department, Attikon Hospital, Athens
- Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Francesco Paneni
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- University Heart Center, Cardiology, University Hospital Zurich
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Damiano Rizzoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
- Division of Medicine, Spedali Civili di Brescia, Montichiari, Brescia, Italy
| | - Kimon Stamatelopoulos
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Konstantinos Stellos
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Manheim, Germany
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Areti Triantafyllou
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Luo X, Liu Y, Liu J, Zhang J, Gao S, Zhang Y, Zhou Z, Xie H, Hou W, Gong YJ, Zheng B, Zhang Y, Li J. Impact of Isolated Coronary Microvascular Disease Diagnosed Using Various Measurement Modalities on Prognosis: An Updated Systematic Review and Meta-Analysis. Cardiology 2023; 149:78-92. [PMID: 37708863 DOI: 10.1159/000533670] [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: 05/31/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION The main aim of this study was to investigate the impact of isolated coronary microvascular disease (CMD) as diagnosed via various modalities on prognosis. METHODS A systematic literature review of PubMed, Embase, and Cochrane Library databases was conducted to identify relevant studies published up to March 2023. Included studies were required to measure coronary microvascular function and report outcomes in patients without obstructive coronary artery disease (CAD) or any other cardiac pathological characteristics. The primary endpoint was all-cause mortality, and the secondary endpoint was a major adverse cardiac event (MACE). Pooled effects were calculated using random effects models. RESULTS A total of 27 studies comprising 18,204 subjects were included in the meta-analysis. Indices of coronary microvascular function measurement included coronary angiography-derived index of microcirculatory resistance (caIMR), hyperemic microcirculatory resistance (HMR), coronary flow reserve (CFR), and so on. Patients with isolated CMD exhibited a significantly higher risk of mortality (OR: 2.97, 95% CI, 1.91-4.60, p < 0.0001; HR: 3.38, 95% CI, 1.77-6.47, p = 0.0002) and MACE (OR: 5.82, 95% CI, 3.65-9.29, p < 0.00001; HR: 4.01, 95% CI, 2.59-6.20, p < 0.00001) compared to those without CMD. Subgroup analysis by measurement modality demonstrated consistent and robust pooled effect estimates in various subgroups. CONCLUSION CMD is significantly associated with an elevated risk of mortality and MACE in patients without obstructive CAD or any other identifiable cardiac pathologies. The utilization of various measurement techniques may have potential advantages in the management of isolated CMD.
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Affiliation(s)
- Xingyu Luo
- Department of Cardiology, Peking University First Hospital, Beijing, China,
| | - Yaokun Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jiahui Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jin Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Songyuan Gao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yanyan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zuoyi Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Haotai Xie
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Weijie Hou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yan Jun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
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Xuan X, Zhang S. Exploring the active ingredients and mechanism of Shenzhi Tongxin capsule against microvascular angina based on network pharmacology and molecular docking. Medicine (Baltimore) 2023; 102:e34190. [PMID: 37390241 PMCID: PMC10313304 DOI: 10.1097/md.0000000000034190] [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: 03/07/2023] [Accepted: 06/13/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Microvascular angina (MVA) substantially threatens human health, and the Shenzhi Tongxin (SZTX) capsule demonstrates a remarkable cardioprotective effect, making it a potential treatment option for MVA. However, the precise mechanism of action for this medication remains unclear. This study utilized network pharmacology and molecular docking technology to investigate the active components and potential mechanisms underlying the efficacy of the SZTX capsule in alleviating MVA. METHODS The main ingredients of the SZTX capsule, along with their targets proteins and potential disease targets associated with MVA, were extracted from public available databases. This study utilized the STRING database and Cytoscape 3.7.2 software to establish a protein-protein interaction network and determine key signaling pathway targets. Subsequently, the DAVID database was utilized to conduct Gene Ontology and the Kyoto Encyclopedia of Genes and Genomes analyses on the intersection targets. To further investigate the molecular interactions, Autodock and PyMOL software were employed to perform molecular docking and visualize the resulting outcomes. RESULTS A total of 130 and 142 bioactive ingredients and intersection targets were identified respectively. Six core targets were obtained through protein-protein interaction network analysis. Gene Ontology enrichment analysis showed that 610 biological processes, 75 cellular components, and 92 molecular functions were involved. The results of Kyoto Encyclopedia of Genes and Genomes enrichment analyses indicated that SZTX capsule molecular mechanism in the treatment of MVA may be related to several pathways, including mitogen-activated protein kinases, PI3K-Akt, HIF-1, and others. The results of molecular docking showed that the 7 key active ingredients of SZTX capsule had good binding ability to 6 core proteins. CONCLUSION SZTX capsule potentially exerts its effects by targeting multiple signaling pathways, including the mitogen-activated protein kinases signaling pathway, PI3K-Akt signaling pathway, and HIF-1 signaling pathway. This multi-target approach enables SZTX capsule to inhibit inflammation, alleviate oxidative stress, regulate angiogenesis, and enhance endothelial function.
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Affiliation(s)
- Xiaoyu Xuan
- First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shiliang Zhang
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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23
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Ilic I, Timcic S, Milosevic M, Boskovic S, Odanovic N, Furtula M, Dobric M, Aleksandric S, Otasevic P. The imPAct of Trimetazidine on MicrOcirculation after Stenting for stable coronary artery disease (PATMOS study). Front Cardiovasc Med 2023; 10:1112198. [PMID: 37456821 PMCID: PMC10348888 DOI: 10.3389/fcvm.2023.1112198] [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: 11/30/2022] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background Myocardial ischemia is caused by epicardial coronary artery stenosis or atherosclerotic disease affecting microcirculation. Trimetazidine (TMZ), promotes glucose oxidation which optimizes cellular energy processes in ischemic conditions. Small studies demonstrated protective effects of TMZ in terms of reducing myocardial injury after percutaneous coronary intervention (PCI), its effect on microcirculation using contemporary investigative methods has not been studied. The aim of the study was to examine effects of trimetazidine, given before elective PCI, on microcirculation using invasively measured index of microcirculatory resistance (IMR). Methods This was prospective, single blinded, randomized study performed in a single university hospital. It included consecutive patients with an indication for PCI of a single, de novo, native coronary artery lesion. Patients were randomly assigned to receive either TMZ plus standard therapy (TMZ group) or just standard therapy. Coronary physiology indices fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were measured before and after PCI using coronary pressure wire. Results We randomized 71 patients with similar clinical characteristics and risk profile, previous medications and coronary angiograms. Patientshad similar values of Pd/Pa, FFR and CFR prior to PCI procedure. After PCI, FFR values were higher in TMZ group, while IMR values were lower in this group respectively (FFR TMZ + 0.89 ± 0.05 vs. TMZ - 0.85 ± 0.06, p = 0.007; CFR TMZ + 2.1 ± 0.8 vs. TMZ- 2.3 ± 1.3, p = 0.469; IMR TMZ + 18 ± 9 vs. TMZ- 24 ± 12, p = 0.028). In two-way repeated measures ANOVA PCI was associated with change in FFR values (TMZ p = 0.050; PCI p < 0.001; p for interaction 0.577) and TMZ with change in IMR values (TMZ p = 0.034, PCI p = 0.129, p for interaction 0.344). Conclusion Adding trimetazidine on top of medical treatment prior to elective PCI reduces microvascular dysfunction by lowering postprocedural IMR values when compared to standard therapy alone.
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Affiliation(s)
- Ivan Ilic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Timcic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Maja Milosevic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Srdjan Boskovic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Natalija Odanovic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Matija Furtula
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milan Dobric
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Petar Otasevic
- Cardiology Clinic, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Yang Z, Liu Y, Li Z, Feng S, Lin S, Ge Z, Fan Y, Wang Y, Wang X, Mao J. Coronary microvascular dysfunction and cardiovascular disease: Pathogenesis, associations and treatment strategies. Biomed Pharmacother 2023; 164:115011. [PMID: 37321056 DOI: 10.1016/j.biopha.2023.115011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is a high-risk factor for a variety of cardiovascular events. Due to its complex aetiology and concealability, knowledge of the pathophysiological mechanism of CMD is still limited at present, which greatly restricts its clinical diagnosis and treatment. Studies have shown that CMD is closely related to a variety of cardiovascular diseases, can aggravate the occurrence and development of cardiovascular diseases, and is closely related to a poor prognosis in patients with cardiovascular diseases. Improving coronary microvascular remodelling and increasing myocardial perfusion might be promising strategies for the treatment of cardiovascular diseases. In this paper, the pathogenesis and functional assessment of CMD are reviewed first, along with the relationship of CMD with cardiovascular diseases. Then, the latest strategies for the treatment of CMD and cardiovascular diseases are summarized. Finally, urgent scientific problems in CMD and cardiovascular diseases are highlighted and future research directions are proposed to provide prospective insights for the prevention and treatment of CMD and cardiovascular diseases in the future.
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Affiliation(s)
- Zhihua Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China; Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Yangxi Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhenzhen Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Shaoling Feng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Shanshan Lin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhao Ge
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yujian Fan
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yi Wang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Xianliang Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Jingyuan Mao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
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25
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Yang Z, Liu Y, Song Z, Fan Y, Lin S, Ge Z, Feng S, Liu Y, Bi Y, Wang Y, Wang X, Mao J. Chinese patent medicines for coronary microvascular disease: clinical evidence and potential mechanisms. Int J Med Sci 2023; 20:1024-1037. [PMID: 37484810 PMCID: PMC10357442 DOI: 10.7150/ijms.85789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 07/25/2023] Open
Abstract
Coronary microvascular disease (CMVD) is a high risk factor for many cardiovascular events. Due to the limited understanding of its pathophysiological mechanism, modern medicine still lacks therapeutic drugs for CMVD. Existing clinical studies have shown that traditional Chinese medicine (TCM) can effectively improve the clinical symptoms and quality of life of CMVD patients. As an indispensable part of TCM, Chinese patent medicines (CPMs) are widely used in clinical practice. In the face of numerous oral CPMs for treatment of CMVD, how to choose a reasonable medication regimen is one of the important issues in clinic. Based on this, this paper reviewed the clinical efficacy and recommended level of 12 CPMs in the treatment of CMVD, which are recommended by expert consensus on diagnosis and treatment of coronary microvascular disease with integrated Chinese and Western medicine (WM). In addition, this study also systematically summarized the possible mechanisms of CPMs in the treatment of CMVD by protecting coronary microvascular endothelial cells, improving vascular endothelial function, inhibiting inflammation, reducing oxidative stress, promoting angiogenesis, and improving hemorheology, aiming to provide meaningful information for its clinical application.
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Affiliation(s)
- Zhihua Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Yangxi Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Zhihui Song
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Yujian Fan
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Shanshan Lin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Zhao Ge
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Shaoling Feng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Yu Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Yingfei Bi
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Yi Wang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Xianliang Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Jingyuan Mao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
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26
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Akhiyat N, Lasho TL, Ganji M, Toya T, Shi CX, Chen X, Braggio E, Ahmad A, Corban MT, Stewart K, Fernandez J, Xie Z, Finke C, Lerman LO, Patnaik MM, Lerman A. Clonal Hematopoiesis of Indeterminate Potential Is Associated With Coronary Microvascular Dysfunction In Early Nonobstructive Coronary Artery Disease. Arterioscler Thromb Vasc Biol 2023; 43:774-783. [PMID: 36951061 PMCID: PMC10133092 DOI: 10.1161/atvbaha.122.318928] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/23/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Clonal hematopoiesis (CH) of indeterminate potential (CHIP) is a risk factor for cardiovascular disease. The relationship between CHIP and coronary microvascular dysfunction (CMD) is unknown. The current study examines the association between CHIP and CH with CMD and the potential relationships in risk for adverse cardiovascular outcomes. METHODS In this retrospective observational study, targeted next-generation sequencing was performed for 177 participants with no coronary artery disease who presented with chest pain and underwent routine coronary functional angiogram. Patients with somatic mutations in leukemia-associated driver genes in hematopoietic stem and progenitor cells were examined; CHIP was considered at a variant allele fraction ≥2%; CH was considered at a variant allele fraction ≥1%. CMD was defined as coronary flow reserve to intracoronary adenosine of ≤2. Major adverse cardiovascular events considered were myocardial infarction, coronary revascularization, or stroke. RESULTS A total of 177 participants were examined. Mean follow-up was 12±7 years. A total of 17 patients had CHIP and 28 had CH. Cases with CMD (n=19) were compared with controls with no CMD (n=158). Cases were 56±9 years, were 68% women, and had more CHIP (27%; P=0.028) and CH (42%; P=0.001) than controls. CMD was associated with independent risk for major adverse cardiovascular events (hazard ratio, 3.89 [95% CI, 1.21-12.56]; P=0.023), and 32% of this risk was mediated by CH. The risk mediated by CH was ≈0.5× as large as the direct effect of CMD on major adverse cardiovascular events. CONCLUSIONS In humans, we observe patients with CMD are more likely to have CHIP, and nearly one-third of major adverse cardiovascular events in CMD are mediated by CH.
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Affiliation(s)
- Nadia Akhiyat
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terra L Lasho
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Morsaleh Ganji
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Takumi Toya
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chang-Xin Shi
- Division of Hematology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Xianfeng Chen
- Department of Health Sciences Research & Center for Individualized Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Esteban Braggio
- Division of Hematology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Ali Ahmad
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michel T. Corban
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Keith Stewart
- Division of Hematology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
- Center for Individualized Medicine, Mayo Clinic, Rochester, USA
| | - Jenna Fernandez
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zhuoer Xie
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christy Finke
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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27
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Godo S, Takahashi J, Shiroto T, Yasuda S, Shimokawa H. Coronary Microvascular Spasm: Clinical Presentation and Diagnosis. Eur Cardiol 2023; 18:e07. [PMID: 37377449 PMCID: PMC10291603 DOI: 10.15420/ecr.2022.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/13/2022] [Indexed: 06/29/2023] Open
Abstract
Professor Maseri pioneered the research and treatment of coronary vasomotion abnormalities represented by coronary vasospasm and coronary microvascular dysfunction (CMD). These mechanisms can cause myocardial ischaemia even in the absence of obstructive coronary artery disease, and have been appreciated as an important aetiology and therapeutic target with major clinical implications in patients with ischaemia with non-obstructive coronary artery disease (INOCA). Coronary microvascular spasm is one of the key mechanisms responsible for myocardial ischaemia in patients with INOCA. Comprehensive assessment of coronary vasomotor reactivity by invasive functional coronary angiography or interventional diagnostic procedure is recommended to identify the underlying mechanisms of myocardial ischaemia and to tailor the best treatment and management based on the endotype of INOCA. This review highlights the pioneering works of Professor Maseri and contemporary research on coronary vasospasm and CMD with reference to endothelial dysfunction, Rho-kinase activation and inflammation.
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Affiliation(s)
- Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
- Graduate School, International University of Health and WelfareNarita, Japan
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28
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Kitada R, Otsuka K, Fukuda D. Role of plaque imaging for identification of vulnerable patients beyond the stage of myocardial ischemia. Front Cardiovasc Med 2023; 10:1095806. [PMID: 37008333 PMCID: PMC10063905 DOI: 10.3389/fcvm.2023.1095806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/21/2023] [Indexed: 03/19/2023] Open
Abstract
Chronic coronary syndrome (CCS) is a progressive disease, which often first manifests as acute coronary syndrome (ACS). Imaging modalities are clinically useful in making decisions about the management of patients with CCS. Accumulating evidence has demonstrated that myocardial ischemia is a surrogate marker for CCS management; however, its ability to predict cardiovascular death or nonfatal myocardial infarction is limited. Herein, we present a review that highlights the latest knowledge available on coronary syndromes and discuss the role and limitations of imaging modalities in the diagnosis and management of patients with coronary artery disease. This review covers the essential aspects of the role of imaging in assessing myocardial ischemia and coronary plaque burden and composition. Furthermore, recent clinical trials on lipid-lowering and anti-inflammatory therapies have been discussed. Additionally, it provides a comprehensive overview of intracoronary and noninvasive cardiovascular imaging modalities and an understanding of ACS and CCS, with a focus on histopathology and pathophysiology.
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van Schalkwijk DL, Widdershoven J, Magro M, Smaardijk V, Bekendam M, Vermeltfoort I, Mommersteeg P. Clinical and psychological characteristics of patients with ischemia and non-obstructive coronary arteries (INOCA) and obstructive coronary artery disease. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100282. [PMID: 38511098 PMCID: PMC10945986 DOI: 10.1016/j.ahjo.2023.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/22/2024]
Abstract
Study objective Ischemia with non-obstructive coronary arteries (INOCA) is caused by vascular dysfunctions and predominantly seen in women. For better recognition and prevention more insight is needed on risk factors and well-being. We aimed to explore differences in psychological distress, quality of life, risk factors, and medication use between women with INOCA and obstructive coronary artery disease (CAD). Methods Patients from two separate studies (n = 373, 57 % women) completed a questionnaire assessing psychological and clinical factors. Analyses were performed for women only who were categorized into three groups: non-ischemic chest pain (n = 115), INOCA (n = 68), and obstructive CAD (n = 30). Secondary analyses were performed for men only, and sex differences within INOCA patients were explored. Results and conclusion Compared to obstructive CAD patients, INOCA patients reported better physical functioning (p = 0.041). Furthermore, INOCA patients had less often hypercholesterolemia (p < 0.001), were less often active smokers (p = 0.062), had a lower mean BMI (p = 0.022), and reported more often a familial history of CAD (p = 0.004). Patients with INOCA used antithrombotic, cholesterol lowering medications, and beta-blockers less often than patients with obstructive CAD. No differences between patients with INOCA and obstructive CAD were found for psychological distress, well-being, and for women-specific risk factors. The results suggest that women with INOCA experience similar levels of psychological distress and seem to have different risk factor profiles and are less optimally treated as compared to obstructive CAD patients. Further research on risk factors is needed for better prevention and treatment.
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Affiliation(s)
- Dinah L. van Schalkwijk
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, the Netherlands
| | - Jos Widdershoven
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, the Netherlands
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Veerle Smaardijk
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, the Netherlands
| | - Maria Bekendam
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, the Netherlands
| | - Ilse Vermeltfoort
- Department of Nuclear Medicine, Institute Verbeeten, Tilburg, the Netherlands
| | - Paula Mommersteeg
- Center of Research on Psychology in Somatic Diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg University, the Netherlands
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Madeira S. Unrevealing what is beyond our glance. Rev Port Cardiol 2023; 42:467-469. [PMID: 36828178 DOI: 10.1016/j.repc.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- Sérgio Madeira
- Unidade de Intervenção Cardiovascular do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal.
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Jin K. Does coronary microvascular dysfunction have a role in cardiovascular oncology? Eur J Prev Cardiol 2023; 30:206-208. [PMID: 36200324 DOI: 10.1093/eurjpc/zwac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Kai Jin
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, Kepple Street, London WC1E 7HT, UK
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Rajai N, Ahmad A, Toya T, Sara JD, Herrmann J, Lerman LO, Lerman A. Coronary microvascular dysfunction is an independent predictor of developing cancer in patients with non-obstructive coronary artery disease. Eur J Prev Cardiol 2023; 30:209-216. [PMID: 35989450 PMCID: PMC10787540 DOI: 10.1093/eurjpc/zwac184] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 01/21/2023]
Abstract
AIMS Cardiovascular disease and cancer share common pathogenesis and risk factors. Coronary microvascular dysfunction (CMD), reflecting impaired coronary microvascular dilation in response to stress, is related to a higher risk of major cardiovascular events; however, its association with cancer has not been explored. METHODS AND RESULTS A retrospective study on 1042 patients with non-obstructive coronary artery diseases (NOCADs) was performed. Data regarding demographic, clinical history, diagnostic coronary reactivity test, and cancer occurrence were collected. Coronary microvascular dysfunction was defined as coronary flow reserve (the ratio of hyperaemic blood flow to resting blood flow) ≤2.5. Thirty-four per cent had CMD (67.4% female and the average age was 52.4 ± 12.2 years). Of 917 patients with no history of cancer, 15.5% developed cancer during follow-up [median of 9 (4, 16) years]. Kaplan-Meier analysis showed that CMD patients had lower cancer-free survival compared with those without CMD (log-rank P = 0.005). Cox proportional hazard analyses showed that after adjusting for age, sex, hypertension, diabetes, smoking, and glomerular filtration rate, CMD is independently associated with cancer [hazard ratio, 1.4; 95% confidence interval (CI), 1.09-2.04; P = 0.04]. The rate of major adverse cardiovascular events (MACE) was significantly higher in CMD patients compared with that in non-CMD patients who had a previous history of cancer [odds ratio (OR), 2.5; 95% CI, 1-6.2; P = 0.04] and those with no history of cancer (OR, 1.4; 95% CI, 1.01-1.9; P = 0.044). CONCLUSION Coronary microvascular dysfunction is associated with cancer incidence in patients presenting with NOCADs. This study emphasizes follow-up in patients with CMD to evaluate the risk of MACE as well as potential malignant diseases.
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Affiliation(s)
- Nazanin Rajai
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
- Division of Cardiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Jaskanwal D. Sara
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
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Zhou W, Sin J, Yan AT, Wang H, Lu J, Li Y, Kim P, Patel AR, Ng MY. Qualitative and Quantitative Stress Perfusion Cardiac Magnetic Resonance in Clinical Practice: A Comprehensive Review. Diagnostics (Basel) 2023; 13:diagnostics13030524. [PMID: 36766629 PMCID: PMC9914769 DOI: 10.3390/diagnostics13030524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
Stress cardiovascular magnetic resonance (CMR) imaging is a well-validated non-invasive stress test to diagnose significant coronary artery disease (CAD), with higher diagnostic accuracy than other common functional imaging modalities. One-stop assessment of myocardial ischemia, cardiac function, and myocardial viability qualitatively and quantitatively has been proven to be a cost-effective method in clinical practice for CAD evaluation. Beyond diagnosis, stress CMR also provides prognostic information and guides coronary revascularisation. In addition to CAD, there is a large body of literature demonstrating CMR's diagnostic performance and prognostic value in other common cardiovascular diseases (CVDs), especially coronary microvascular dysfunction (CMD). This review focuses on the clinical applications of stress CMR, including stress CMR scanning methods, practical interpretation of stress CMR images, and clinical utility of stress CMR in a setting of CVDs with possible myocardial ischemia.
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Affiliation(s)
- Wenli Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Jason Sin
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong SAR, China
| | - Andrew T. Yan
- St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| | | | - Jing Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, Shanghai 200233, China
| | - Paul Kim
- Department of Medicine, University of California San Diego, San Diego, CA 92093, USA
| | - Amit R. Patel
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ming-Yen Ng
- Department of Medical Imaging, HKU-Shenzhen Hospital, Shenzhen 518009, China
- Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
- Correspondence:
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Ueng KC, Chiang CE, Chao TH, Wu YW, Lee WL, Li YH, Ting KH, Su CH, Lin HJ, Su TC, Liu TJ, Lin TH, Hsu PC, Wang YC, Chen ZC, Jen HL, Lin PL, Ko FY, Yen HW, Chen WJ, Hou CJY. 2023 Guidelines of the Taiwan Society of Cardiology on the Diagnosis and Management of Chronic Coronary Syndrome. ACTA CARDIOLOGICA SINICA 2023; 39:4-96. [PMID: 36685161 PMCID: PMC9829849 DOI: 10.6515/acs.202301_39(1).20221103a] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 01/24/2023]
Abstract
Coronary artery disease (CAD) covers a wide spectrum from persons who are asymptomatic to those presenting with acute coronary syndromes (ACS) and sudden cardiac death. Coronary atherosclerotic disease is a chronic, progressive process that leads to atherosclerotic plaque development and progression within the epicardial coronary arteries. Being a dynamic process, CAD generally presents with a prolonged stable phase, which may then suddenly become unstable and lead to an acute coronary event. Thus, the concept of "stable CAD" may be misleading, as the risk for acute events continues to exist, despite the use of pharmacological therapies and revascularization. Many advances in coronary care have been made, and guidelines from other international societies have been updated. The 2023 guidelines of the Taiwan Society of Cardiology for CAD introduce a new concept that categorizes the disease entity according to its clinical presentation into acute or chronic coronary syndromes (ACS and CCS, respectively). Previously defined as stable CAD, CCS include a heterogeneous population with or without chest pain, with or without prior ACS, and with or without previous coronary revascularization procedures. As cardiologists, we now face the complexity of CAD, which involves not only the epicardial but also the microcirculatory domains of the coronary circulation and the myocardium. New findings about the development and progression of coronary atherosclerosis have changed the clinical landscape. After a nearly 50-year ischemia-centric paradigm of coronary stenosis, growing evidence indicates that coronary atherosclerosis and its features are both diagnostic and therapeutic targets beyond obstructive CAD. Taken together, these factors have shifted the clinicians' focus from the functional evaluation of coronary ischemia to the anatomic burden of disease. Research over the past decades has strengthened the case for prevention and optimal medical therapy as central interventions in patients with CCS. Even though functional capacity has clear prognostic implications, it does not include the evaluation of non-obstructive lesions, plaque burden or additional risk-modifying factors beyond epicardial coronary stenosis-driven ischemia. The recommended first-line diagnostic tests for CCS now include coronary computed tomographic angiography, an increasingly used anatomic imaging modality capable of detecting not only obstructive but also non-obstructive coronary plaques that may be missed with stress testing. This non-invasive anatomical modality improves risk assessment and potentially allows for the appropriate allocation of preventive therapies. Initial invasive strategies cannot improve mortality or the risk of myocardial infarction. Emphasis should be placed on optimizing the control of risk factors through preventive measures, and invasive strategies should be reserved for highly selected patients with refractory symptoms, high ischemic burden, high-risk anatomies, and hemodynamically significant lesions. These guidelines provide current evidence-based diagnosis and treatment recommendations. However, the guidelines are not mandatory, and members of the Task Force fully realize that the treatment of CCS should be individualized to address each patient's circumstances. Ultimately, the decision of healthcare professionals is most important in clinical practice.
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Affiliation(s)
- Kwo-Chang Ueng
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University, Taichung
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University, Tainan
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Wen-Lieng Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University, Tainan
| | - Ke-Hsin Ting
- Division of Cardiology, Department of Internal Medicine, Yunlin Christian Hospital, Yunlin
| | - Chun-Hung Su
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University, Taichung
| | - Hung-Ju Lin
- Cardiovascular Center, Department of Internal Medicine, National Taiwan University Hospital
| | - Ta-Chen Su
- Cardiovascular Center, Department of Internal Medicine, National Taiwan University Hospital
- Department of Environmental and Occupational Medicine, National Taiwan University College of Medicine, Taipei
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Yu-Chen Wang
- Division of Cardiology, Asia University Hospital, Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
| | - Hsu-Lung Jen
- Division of Cardiology, Cheng Hsin Rehabilitation Medical Center, Taipei
| | - Po-Lin Lin
- Division of Cardiology, Hsinchu MacKay Memorial Hospital, Hsinchu
| | - Feng-You Ko
- Cardiovascular Center, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, Min Sheng General Hospital, Taoyuan
| | - Charles Jia-Yin Hou
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
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Liu Q, Li Q, Wan X, Xu M, Pan J, Zhang Y, Li M, Zhang M. The value of myocardial work in the estimation of left ventricular systolic function in patients with coronary microvascular disease: A study based on adenosine stress echocardiography. Front Cardiovasc Med 2023; 10:1119785. [PMID: 37113699 PMCID: PMC10126338 DOI: 10.3389/fcvm.2023.1119785] [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: 12/09/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is associated with increased cardiovascular events in patients with angina with non-obstructive coronary (ANOCA), especially heart failure. Conventional echocardiography is difficult to identify early alterations in cardiac function due to CMD. Methods We recruited 78 ANOCA patients. All patients underwent conventional echocardiography examination, adenosine stress echocardiography and examination of coronary flow reserve (CFR) by transthoracic echocardiography. Based on the CFR results, patients were divided into the CMD group (CFR < 2.5) and the non-CMD group (CFVR ≥ 2.5). Demographic data, conventional echocardiographic parameters, two-dimensional speckle-tracking echocardiography (2D-STE) parameters and myocardial work (MW) were compared between the two groups at rest and at stress. Logistic regression was used to analyze the factors associated with CMD. Results There was no significant difference in conventional echocardiography parameters, 2D-STE related indices or MW at rest between the two groups. Global work index (GWI), global contractive work (GCW), and global work efficiency (GWE) were lower in the CMD group than in the non-CMD group at stress (p = 0.040, 0.044, <0.001, respectively), but global waste work (GWW) and peak strain dispersion (PSD) were higher (both p < 0.001). GWI and GCW were associated with systolic blood pressure, diastolic blood pressure, product of heart rate and blood pressure, GLS and coronary flow velocity. While GWW was mainly correlated with PSD, GWE was correlated with PSD and GLS. In the non-CMD group, the responses to adenosine was mainly manifested as an increase in GWI, GCW and GWE (p = 0.001, 0.001, 0.009, respectively) and a decrease in PSD and GWW (p = 0.001, 0.015, respectively). In the CMD group, the response to adenosine was mainly manifested as an increase in GWW and a decrease in GWE (p = 0.002, and 0.006, respectively). In the multivariate regression analysis, we found that ΔGWW (difference in GWW before vs. after adenosine stress) and ΔPSD (difference in PSD before vs. after adenosine stress) were independent factors associated with CMD. The ROC curves showed that the composite prediction model consisting of ΔGWW and ΔPSD had excellent diagnostic value for CMD (area under the curve = 0.913). Conclusion In the present study, we found that CMD caused deterioration of myocardial work in ANOCA patients under adenosine stress, and that increased cardiac contraction asynchrony and wasted work may be the main changes caused by CMD.
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Affiliation(s)
| | | | | | | | | | - Yu Zhang
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
| | - Mengmeng Li
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
| | - Mei Zhang
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Interv Cardiol Clin 2023; 12:119-129. [PMID: 36372455 PMCID: PMC10019932 DOI: 10.1016/j.iccl.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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Hahad O, Schmitt VH, Arnold N, Keller K, Prochaska JH, Wild PS, Schulz A, Lackner KJ, Pfeiffer N, Schmidtmann I, Michal M, Schattenberg JM, Tüscher O, Daiber A, Münzel T. Chronic cigarette smoking is associated with increased arterial stiffness in men and women: evidence from a large population-based cohort. Clin Res Cardiol 2023; 112:270-284. [PMID: 36068365 PMCID: PMC9898409 DOI: 10.1007/s00392-022-02092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/24/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cigarette smoking is a threat to global human health and a leading cause of the cardiovascular disease (CVD) morbidity and mortality. Importantly, sex-specific differences in smoking-induced arterial stiffness, an early key event in the development of atherosclerotic CVD, remain still elusive. Thus, this study sought out to investigate sex-specific associations between smoking and measures of arterial stiffness. METHODS AND RESULTS Overall, 15,010 participants (7584 men and 7426 women aged 35-74 years) of the Gutenberg Health Study were examined at baseline during 2007-2012. Smoking status, pack-years of smoking, and years since quitting smoking were assessed by a standardized computer-assisted interview. Arterial stiffness and wave reflection were determined by stiffness index (SI) and augmentation index (AI). In the total sample, 45.8% had never smoked, 34.7% were former smokers, and 19.4% were current smokers. Median cumulative smoking exposure was 22.0 pack-years in current male smokers and 16.0 in current female smokers. In general, multivariable linear regression models adjusted for a comprehensive set of confounders revealed that smoking status, pack-years of smoking, and years since quitting smoking were dose-dependently associated with markers of arterial stiffness. In sex-specific analyses, these associations were overall more pronounced in men and SI was stronger related to the male sex, whereas differences between men and women in the case of AI appeared to be less substantial. DISCUSSION The present results indicate that chronic smoking is strongly and dose-dependently associated with increased arterial stiffness in a large population-based cohort regardless of sex but with a stronger association in men.
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Affiliation(s)
- Omar Hahad
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany.
| | - Volker H. Schmitt
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Natalie Arnold
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany ,Department of Cardiology, German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Karsten Keller
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany ,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany ,Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen H. Prochaska
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany ,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany ,Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Philipp S. Wild
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany ,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany ,Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Karl J. Lackner
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany ,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Matthias Michal
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jörn M. Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Oliver Tüscher
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andreas Daiber
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany ,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany.
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Bland A, Chuah E, Meere W, Ford TJ. Targeted Therapies for Microvascular Disease. Interv Cardiol Clin 2023; 12:131-139. [PMID: 36372457 DOI: 10.1016/j.iccl.2022.09.011] [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: 05/14/2023]
Abstract
Coronary microvascular dysfunction (CMD) is a common cause of ischemia but no obstructive coronary artery disease that results in an inability of the coronary microvasculature to meet myocardial oxygen demand. CMD is challenging to diagnose and manage due to a lack of mechanistic research and targeted therapy. Recent evidence suggests we can improved patient outcomes by stratifying antianginal therapies according to the diagnosis revealed by invasive assessment of the coronary microcirculation. This review article appraises the evidence for management of CMD, which includes treatment of cardiovascular risk, antianginal therapy and therapy for atherosclerosis.
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Affiliation(s)
- Adam Bland
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - William Meere
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital - Central Coast LHD, 75 Holden Street, Gosford, New South Wales 2250, Australia; The University of Newcastle, University Dr, Callaghan, New South Wales 2308, Australia; University of Glasgow, ICAMS, G12 8QQ Glasgow, UK.
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Tu Y, Li Q, Zhou Y, Ye Z, Wu C, Xie E, Li Y, Li P, Wu Y, Guo Z, Yu C, Zheng J, Gao Y. Empagliflozin inhibits coronary microvascular dysfunction and reduces cardiac pericyte loss in db/db mice. Front Cardiovasc Med 2022; 9:995216. [PMID: 36588571 PMCID: PMC9800791 DOI: 10.3389/fcvm.2022.995216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is a pathophysiological feature of diabetic heart disease. However, whether sodium-glucose cotransporter 2 (SGLT2) inhibitors protect the cardiovascular system by alleviating CMD is not known. Objective We observed the protective effects of empagliflozin (EMPA) on diabetic CMD. Materials and methods The mice were randomly divided into a db/db group and a db/db + EMPA group, and db/m mice served as controls. At 8 weeks of age, the db/db + EMPA group was given empagliflozin 10 mg/(kg⋅d) by gavage for 8 weeks. Body weight, fasting blood glucose and blood pressure were dynamically observed. Cardiac systolic and diastolic function and coronary flow reserve (CFR) were detected using echocardiography. The coronary microvascular structure and distribution of cardiac pericytes were observed using immunofluorescence staining. Picrosirius red staining was performed to evaluate cardiac fibrosis. Results Empagliflozin lowered the increased fasting blood glucose levels of the db/db group. The left ventricular ejection fraction, left ventricular fractional shortening, E/A ratio and E/e' ratio were not significantly different between the three groups. CFR was decreased in the db/db group, but EMPA significantly improved CFR. In contrast to the sparse and abnormal expansion of coronary microvessels observed in the db/db group, the number of coronary microvessels was increased, and the capillary diameter was decreased in the db/db + EMPA group. The number and microvascular coverage of cardiac pericytes were reduced in the db/db mice but were improved by EMPA. The cardiac fibrosis was increased in db/db group and may alleviate by EMPA. Conclusion Empagliflozin inhibited CMD and reduced cardiac pericyte loss in diabetic mice.
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Affiliation(s)
- Yimin Tu
- Department of Cardiology, China-Japan Friendship School of Clinical Medicine, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qing Li
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yuanchen Zhou
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Zixiang Ye
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chao Wu
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Enmin Xie
- Department of Cardiology, China-Japan Friendship School of Clinical Medicine, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yike Li
- Department of Cardiology, China-Japan Friendship School of Clinical Medicine, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Peizhao Li
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yaxin Wu
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Ziyu Guo
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Changan Yu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship School of Clinical Medicine, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship School of Clinical Medicine, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
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SenthilKumar G, Gutierrez-Huerta CA, Freed JK, Beyer AM, Fancher IS, LeBlanc AJ. New developments in translational microcirculatory research. Am J Physiol Heart Circ Physiol 2022; 323:H1167-H1175. [PMID: 36306213 PMCID: PMC9678417 DOI: 10.1152/ajpheart.00566.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
Microvascular disease plays a critical role in systemic end-organ dysfunction, and treatment of microvascular pathologies may greatly reduce cardiovascular morbidity and mortality. The Call for Papers collection: New Developments in Translational Microcirculatory Research highlights key advances in our understanding of the role of microvessels in the development of chronic diseases as well as therapeutic strategies to enhance microvascular function. This Mini Review provides a concise summary of these advances and draws from other relevant research to provide the most up-to-date information on the influence of cutaneous, cerebrovascular, coronary, and peripheral microcirculation on the pathophysiology of obesity, hypertension, cardiovascular aging, peripheral artery disease, and cognitive impairment. In addition to these disease- and location-dependent research articles, this Call for Papers includes state-of-the-art reviews on coronary endothelial function and assessment of microvascular health in different organ systems, with an additional focus on establishing rigor and new advances in clinical trial design. These articles, combined with original research evaluating cellular, exosomal, pharmaceutical, exercise, heat, and dietary interventional therapies, establish the groundwork for translating microcirculatory research from bench to bedside. Although numerous studies in this collection are focused on human microcirculation, most used robust preclinical models to probe mechanisms of pathophysiology and interventional benefits. Future work focused on translating these findings to humans are necessary for finding clinical strategies to prevent and treat microvascular dysfunction.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cristhian A Gutierrez-Huerta
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Julie K Freed
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreas M Beyer
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ibra S Fancher
- Department of Kinesiology and Applied Physiology, College of Health Sciences, University of Delaware, Newark, Delaware
| | - Amanda Jo LeBlanc
- Department of Cardiovascular and Thoracic Surgery, School of Medicine, University of Louisville, Louisville, Kentucky
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky
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Gao J, Meng T, Li M, Du R, Ding J, Li A, Yu S, Li Y, He Q. Global trends and frontiers in research on coronary microvascular dysfunction: a bibliometric analysis from 2002 to 2022. Eur J Med Res 2022; 27:233. [PMID: 36335406 PMCID: PMC9636644 DOI: 10.1186/s40001-022-00869-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is a leading cause of ischemic heart disease. Over the past few decades, considerable progress has been made with respect to research on CMD. The present study summarized the current research hotspots and trends on CMD by applying a bibliometric approach. METHODS Relevant publications between 2002 and 2022 were extracted from the Web of Science Core Collection. Visualization network maps of countries, institutions, authors, and co-cited authors were built using VOSviewer. CiteSpace was used for keyword analysis and the construction of a dual-map overlay of journals and a timeline view of co-cited references. RESULTS 1539 CMD-related publications were extracted for bibliometric analysis. The annual publications generally showed an upward trend. The United States of America was the most prolific country, with 515 publications (33.5%). Camici P. G. was the most influential author, whereas the European Heart Journal, Circulation, and Journal of the American College of Cardiology were the most authoritative journals. Research hotspot analysis revealed that endothelial dysfunction as well as reduced nitric oxide production or bioavailability played critical roles in CMD development. Positron emission tomography was the most widely used imaging method for diagnosis. In addition, microvascular angina, hypertrophic cardiomyopathy, and heart failure have attracted much attention as the main clinical implications. Furthermore, international standards for CMD diagnosis and management may be the future research directions. CONCLUSIONS This study offers a comprehensive view about the hotspots and development trends of CMD, which can assist subsequent researchers and guide future directions.
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Affiliation(s)
- Jing Gao
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Tiantian Meng
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Li
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruolin Du
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jingyi Ding
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anqi Li
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shanshan Yu
- Graduate School, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yixiang Li
- Graduate School, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Qingyong He
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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Kentoffio K, Temu TM, Shakil SS, Zanni MV, Longenecker CT. Cardiovascular disease risk in women living with HIV. Curr Opin HIV AIDS 2022; 17:270-278. [PMID: 35938460 PMCID: PMC9370828 DOI: 10.1097/coh.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To synthesize current evidence on the impact of cardiovascular disease among women living with HIV (WLWH) with a particular focus on disease prevalence, mechanisms and prevention. RECENT FINDINGS HIV-related cardiovascular disease risk is 1.5-fold to 2-fold higher for women than for men. Mechanisms of enhanced risk are multifactorial and include reinforcing pathways between traditional risk factors, metabolic dysregulation, early reproductive aging and chronic immune activation. These pathways influence both the presentation of overt syndromes of myocardial infarction, stroke and heart failure, as well as subclinical disease, such as microvascular dysfunction and cardiac fibrosis. Cardiovascular disease, therefore, remains a consistent threat to healthy aging among WLWH. SUMMARY Although no specific prevention strategies exist, patient-centered risk mitigation approaches that are adaptable to the needs of aging individuals are essential to combat disparities in cardiovascular outcomes among WLWH. Further research into the optimal prevention approach for CVD among WLWH, particularly for women living in under-resourced health systems, is needed.
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Affiliation(s)
- Katherine Kentoffio
- Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Tecla M Temu
- Department of Global Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Saate S Shakil
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Markella V. Zanni
- Department of Medicine, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Chris T. Longenecker
- Department of Global Health, University of Washington School of Medicine, Seattle, WA, USA
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
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Yang Z, Lin S, Liu Y, Ren Q, Ge Z, Wang C, Bi Y, Wang X, Mao J. Traditional chinese medicine in coronary microvascular disease. Front Pharmacol 2022; 13:929159. [PMID: 36003524 PMCID: PMC9393228 DOI: 10.3389/fphar.2022.929159] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary microvascular disease (CMVD) is common in patients with cardiovascular risk factors and is associated with an increased risk of adverse cardiovascular events. Although the study of CMVD in modern medicine is ongoing, there is still no effective treatment for it. Traditional Chinese medicine (TCM) has some clinical advantages based on syndrome differentiation and individualized treatment. In this review, we review the clinical significance, pathogenesis, and current treatments of CMVD and systematically summarize the clinical efficacy and potential action mechanisms of TCM for CMVD. In addition, the scientific problems that need to be solved urgently and the research strategy of TCM for CMVD are described. CMVD has great clinical significance, but there are still many gaps in the related research. This review aims to attract the attention of clinicians to CMVD and promote research on CMVD in TCM.
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Affiliation(s)
- Zhihua Yang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shanshan Lin
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangxi Liu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qiuan Ren
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhao Ge
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ci Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingfei Bi
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xianliang Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingyuan Mao
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Abstract
PURPOSE OF REVIEW Obstructive coronary artery disease is a major cause of ischemia in both men and women; however, women are more likely to present with ischemia in the setting of no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA), conditions that are associated with adverse cardiovascular prognosis despite absence of coronary stenosis. In this review, we focus on mechanisms of coronary ischemia that should be considered in the differential diagnosis when routine anatomic clinical investigation leads to the finding of non-obstructive coronary artery disease on coronary angiography in the setting of acute myocardial infarction. RECENT FINDINGS There are multiple mechanisms that contribute to MINOCA, including atherosclerotic plaque disruption, coronary artery spasm, coronary microvascular dysfunction (CMD), coronary embolism and/or thrombosis, and spontaneous coronary artery dissection. Non-coronary causes such as myocarditis or supply-demand mismatch should also be considered on the differential when there is an unexplained troponin elevation. Use of advanced imaging and diagnostic techniques to determine the underlying etiology of MINOCA is feasible and helpful, as this has the potential to guide management and secondary prevention. Failure to identify the underlying cause(s) may result in inappropriate treatment and inaccurate counseling to patients. MINOCA predominates in young women and is associated with a guarded prognosis. The diagnosis of MINOCA should prompt further investigation to determine the underlying cause of troponin elevation. Patients with INOCA and MINOCA are heterogeneous, and response to treatments can be variable. Large randomized controlled trials to determine longer-term optimal medical therapy for management of these conditions are under investigation.
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Affiliation(s)
- Jingwen Huang
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sonali Kumar
- Department of Medicine, Emory Cardiovascular Disease Fellowship Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Olga Toleva
- Andreas Gruentzig Cardiovascular Center, Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Puja K Mehta
- Division of Cardiology, Emory Women's Heart Center, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Rd, Suite 505, GA, 30322, Atlanta, USA.
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Common Shared Pathogenic Aspects of Small Vessels in Heart and Brain Disease. Biomedicines 2022; 10:biomedicines10051009. [PMID: 35625746 PMCID: PMC9138783 DOI: 10.3390/biomedicines10051009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 12/24/2022] Open
Abstract
Small-vessel disease (SVD), also known as microvascular endothelial dysfunction, is a disorder with negative consequences for various organs such as the heart and brain. Impaired dilatation and constriction of small vessels in the heart lead to reduced blood flow and ischemia independently of coronary artery disease (CAD) and are associated with major cardiac events. SVD is usually a silent form of subcortical vascular burden in the brain with various clinical manifestations, such as silent-lacunar-ischemic events and confluent white-matter hyperintensities. Imaging techniques are the main help for clinicians to diagnose cardiac and brain SVD correctly. Markers of inflammation, such as C-reactive protein, tumor-necrosis-factor α, and interleukin 6, provide insight into the disease and markers that negatively influence nitric-oxide bioavailability and promote oxidative stress. Unfortunately, the therapeutic approach against SVD is still not well-defined. In the last decades, various antioxidants, oxidative stress inhibitors, and superoxide scavengers have been the target of extensive investigations due to their potential therapeutic effect, but with unsatisfactory results. In clinical practice, traditional anti-ischemic and risk-reduction therapies for CAD are currently in use for SVD treatment.
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Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, Rajkumar CA, Shun-Shin MJ, Ahmad Y, Sen S, Al-Lamee R, Petraco R. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J 2022; 43:1582-1593. [PMID: 34849697 PMCID: PMC9020988 DOI: 10.1093/eurheartj/ehab775] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
AIMS This meta-analysis aims to quantify the association of reduced coronary flow with all-cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. METHODS AND RESULTS We systematically identified all studies between 1 January 2000 and 1 August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios (HRs) using a random-effects model. Seventy-nine studies with a total of 59 740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality [HR: 3.78, 95% confidence interval (CI): 2.39-5.97] and a higher incidence of MACE (HR 3.42, 95% CI: 2.92-3.99). Each 0.1 unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR: 1.16, 95% CI: 1.04-1.29) and MACE (per 0.1 CFR unit HR: 1.08, 95% CI: 1.04-1.11). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR: 5.44, 95% CI: 3.78-7.83) and MACE (HR: 3.56, 95% CI: 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR: 3.76, 95% CI: 2.35-6.00), heart failure (HR: 6.38, 95% CI: 1.95-20.90), heart transplant (HR: 3.32, 95% CI: 2.34-4.71), and diabetes mellitus (HR: 7.47, 95% CI: 3.37-16.55). CONCLUSION Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice, to target aggressive vascular risk modification for individuals at higher risk.
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Affiliation(s)
- Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Haseeb Rahman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, Connecticut 06510, USA
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
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Spione F, Arevalos V, Gabani R, Sabaté M, Brugaletta S. Coronary Microvascular Angina: A State-of-the-Art Review. Front Cardiovasc Med 2022; 9:800918. [PMID: 35433857 PMCID: PMC9005807 DOI: 10.3389/fcvm.2022.800918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/08/2022] [Indexed: 12/28/2022] Open
Abstract
Up to 60–70% of patients, undergoing invasive coronary angiography due to angina and demonstrable myocardial ischemia with provocative tests, do not have any obstructive coronary disease. Coronary microvascular angina due to a dysfunction of the coronary microcirculation is the underlying cause in almost 50% of these patients, associated with a bad prognosis and poor quality of life. In recent years, progress has been made in the diagnosis and management of this condition. The aim of this review is to provide an insight into current knowledge of this condition, from current diagnostic methods to the latest treatments.
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Affiliation(s)
- Francesco Spione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Victor Arevalos
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rami Gabani
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- *Correspondence: Salvatore Brugaletta,
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Akhiyat N, Vasile V, Ahmad A, Sara JD, Nardi V, Lerman LO, Jaffe A, Lerman A. Plasma Ceramide Levels Are Elevated in Patients With Early Coronary Atherosclerosis and Endothelial Dysfunction. J Am Heart Assoc 2022; 11:e022852. [PMID: 35301857 PMCID: PMC9075496 DOI: 10.1161/jaha.121.022852] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Elevated plasma ceramides are independent predictors of cardiovascular disease and mortality in patients with advanced epicardial coronary artery disease. Our understanding of plasma ceramides in early epicardial coronary artery disease, however, remains limited. We examined the role of plasma ceramides in early coronary atherosclerosis characterized by coronary endothelial dysfunction. Methods and Results Participants presenting with chest pain and nonobstructive epicardial coronary artery disease underwent coronary endothelial function. Patients (n=90) demonstrated abnormal coronary endothelial function with acetylcholine (≥20% decrease in coronary artery diameter or ≤50% increase in coronary blood flow). A total of 30 controls had normal coronary endothelial function. Concentrations of plasma ceramide 18:0 (P=0.038), 16:0 (P=0.021), and 24:0 (P=0.019) differed between participants with normal and abnormal coronary endothelial function. Ceramide 24:0 (odds ratio [OR], 2.23 [95% CI, 1.07–4.66]; P=0.033) and 16:0 (OR, 1.91×106 [95% CI, 11.93–3.07×1011]; P=0.018) were independently associated with coronary endothelial dysfunction. Among participants with endothelium‐dependent coronary dysfunction (n=78), ceramides 16:0 (OR, 5.17×105 [95% CI, 2.83–9.44×1010]; P=0.033), 24:0 (OR, 2.98 [95% CI, 1.27–7.00]; P=0.012), and 24:1/24:0 (OR, 4.39×10−4 [95% CI, 4×10−7–0.48]; P=0.030) were more likely to be elevated. Conclusions The current study demonstrated an association between increased circulating ceramide levels and coronary endothelial dysfunction in the absence of epicardial coronary artery disease. This study supports the role of plasma ceramides as a potential biomarker or a therapeutic target for early coronary atherosclerosis in humans.
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Affiliation(s)
- Nadia Akhiyat
- Division of Internal Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Vlad Vasile
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
| | - Ali Ahmad
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
| | - Jaskanwal Deep Sara
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
| | - Valentina Nardi
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
| | - Lilach O Lerman
- Division of Nephrology and Hypertension Department of Medicine Mayo Clinic Rochester MN
| | - Allan Jaffe
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
| | - Amir Lerman
- Division of Cardiovascular Disease Department of Medicine Mayo Clinic Rochester MN
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Mileva N, Nagumo S, Mizukami T, Sonck J, Berry C, Gallinoro E, Monizzi G, Candreva A, Munhoz D, Vassilev D, Penicka M, Barbato E, De Bruyne B, Collet C. Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e023207. [PMID: 35301851 PMCID: PMC9075440 DOI: 10.1161/jaha.121.023207] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background A relevant proportion of patients with suspected coronary artery disease undergo invasive coronary angiography showing normal or nonobstructive coronary arteries. However, the prevalence of coronary microvascular disease (CMD) and coronary spasm in patients with nonobstructive coronary artery disease remains to be determined. The objective of this study was to determine the prevalence of coronary CMD and coronary vasospastic angina in patients with no obstructive coronary artery disease. Methods and Results A systematic review and meta‐analysis of studies assessing the prevalence of CMD and vasospastic angina in patients with no obstructive coronary artery disease was performed. Random‐effects models were used to determine the prevalence of these 2 disease entities. Fifty‐six studies comprising 14 427 patients were included. The pooled prevalence of CMD was 0.41 (95% CI, 0.36–0.47), epicardial vasospasm 0.40 (95% CI, 0.34–0.46) and microvascular spasm 24% (95% CI, 0.21–0.28). The prevalence of combined CMD and vasospastic angina was 0.23 (95% CI, 0.17–0.31). Female patients had a higher risk of presenting with CMD compared with male patients (risk ratio, 1.45 [95% CI, 1.11–1.90]). CMD prevalence was similar when assessed using noninvasive or invasive diagnostic methods. Conclusions In patients with no obstructive coronary artery disease, approximately half of the cases were reported to have CMD and/or coronary spasm. CMD was more prevalent among female patients. Greater awareness among physicians of ischemia with no obstructive coronary arteries is urgently needed for accurate diagnosis and patient‐tailored management.
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Affiliation(s)
- Niya Mileva
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Cardiology Clinic Alexandrovska University Hospital Sofia Bulgaria
| | - Sakura Nagumo
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Division of Cardiology Department of Internal Medicine Showa UniversityFujigaoka Hospital Kanagawa Japan
| | - Takuya Mizukami
- Division of Cardiology Department of Internal Medicine Showa UniversityFujigaoka Hospital Kanagawa Japan
| | - Jeroen Sonck
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre Institute of Cardiovascular and Medical Sciences University of Glasgow Glasgow United Kingdom
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Translational Medical Sciences University of Campania "Luigi Vanvitelli" Naples Italy
| | | | | | - Daniel Munhoz
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Clinical Medicine Discipline of Cardiology University of Campinas UNICAMP Campinas Brazil.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Dobrin Vassilev
- Cardiology Clinic Alexandrovska University Hospital Sofia Bulgaria
| | | | - Emanuele Barbato
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Advanced Biomedical Sciences University of Naples, Federico II Naples Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium.,Department of Cardiology Lausanne University Hospital Lausanne Switzerland
| | - Carlos Collet
- Cardiovascular Center Aalst OLV Hospital Aalst Belgium
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50
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Henry TD, Bairey Merz CN, Wei J, Corban MT, Quesada O, Joung S, Kotynski CL, Wang J, Lewis M, Schumacher AM, Bartel RL, Takagi H, Shah V, Lee A, Sietsema WK, Losordo DW, Lerman A. Autologous CD34+ Stem Cell Therapy Increases Coronary Flow Reserve and Reduces Angina in Patients With Coronary Microvascular Dysfunction. Circ Cardiovasc Interv 2022; 15:e010802. [PMID: 35067072 PMCID: PMC8843403 DOI: 10.1161/circinterventions.121.010802] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 11/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction results in angina and adverse outcomes in patients with evidence of ischemia and nonobstructive coronary artery disease; however, no specific therapy exists. CD34+ cell therapy increases microvasculature in preclinical models and improves symptoms, exercise tolerance, and mortality in refractory angina patients with obstructive coronary artery disease. The objective of this research was to evaluate the safety, tolerability, and efficacy of intracoronary CD34+ cell therapy in patients with coronary microvascular dysfunction. METHODS We conducted a 2-center, 20-participant trial of autologous CD34+ cell therapy (protocol CLBS16-P01; NCT03508609) in patients with ischemia and nonobstructive coronary artery disease with persistent angina and coronary flow reserve ≤2.5. Efficacy measures included coronary flow reserve, angina frequency, Canadian Cardiovascular Society angina class, Seattle Angina Questionnaire, SF-36, and modified Bruce exercise treadmill test obtained at baseline and 6 months after treatment. Autologous CD34+ cells (CLBS16) were mobilized by administration of granulocyte-colony stimulating factor 5µg/kg/day for 5 days and collected by leukapheresis. Participants received a single intracoronary left anterior descending infusion of isolated CD34+ cells in medium that enhances cell function. RESULTS Coronary flow reserve improved from 2.08±0.32 at baseline to 2.68±0.79 at 6 months after treatment (P<0.005). Angina frequency decreased (P<0.004), Canadian Cardiovascular Society class improved (P<0.001), and quality of life improved as assessed by the Seattle Angina Questionnaire (P≤0.03, all scales) and SF-36 (P≤0.04, all scales). There were no cell-related serious adverse events. CONCLUSIONS In this pilot clinical trial of microvascular angina, patients with ischemia and nonobstructive coronary artery disease receiving intracoronary infusion of CD34+ cell therapy had higher coronary flow reserve, less severe angina, and better quality of life at 6 months. The current study supports a potential therapeutic role for CD34+ cells in patients with microvascular angina. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03508609.
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Affiliation(s)
- Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH (O.Q., T.D.H.)
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.N.B.M., J.W., S.J.)
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.N.B.M., J.W., S.J.)
| | | | - Odayme Quesada
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH (O.Q., T.D.H.)
| | - Sandy Joung
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.N.B.M., J.W., S.J.)
| | - Christine L. Kotynski
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Jian Wang
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Michelle Lewis
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Ann M. Schumacher
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Ronnda L. Bartel
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Hiroshi Takagi
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Vishal Shah
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Anna Lee
- Mayo Clinic, Rochester, MN (M.T.C., A.L.)
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - William K. Sietsema
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Douglas W. Losordo
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
| | - Amir Lerman
- Caladrius Biosciences, Basking Ridge, NJ (C.L.K., J.W., M.L., A.M.S., R.L.B., H.T., V.S., A.L., W.K.S., D.W.L.)
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