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Hikino K, Koyama S, Ito K, Koike Y, Koido M, Matsumura T, Kurosawa R, Tomizuka K, Ito S, Liu X, Ishikawa Y, Momozawa Y, Morisaki T, Kamatani Y, Mushiroda T, Terao C. RNF213 Variants, Vasospastic Angina, and Risk of Fatal Myocardial Infarction. JAMA Cardiol 2024; 9:723-731. [PMID: 38888930 PMCID: PMC11195602 DOI: 10.1001/jamacardio.2024.1483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/01/2024] [Indexed: 06/20/2024]
Abstract
Importance Vasospastic angina (VSA) is vasospasm of the coronary artery and is particularly prevalent in East Asian populations. However, the specific genetic architecture for VSA at genome-wide levels is not fully understood. Objective To identify genetic factors associated with VSA. Design, Setting, and Participants This was a case-control genome-wide association study of VSA. Data from Biobank Japan (BBJ; enrolled patients from 2002-2008 and 2013-2018) were used, and controls without coronary artery disease (CAD) were enrolled. Patients from the BBJ were genotyped using arrays or a set of arrays. Patients recruited between 2002 and 2005 were classified within the first dataset, and those recruited between 2006 and 2008 were classified within the second dataset. To replicate the genome-wide association study in the first and second datasets, VSA cases and control samples from the latest patients in the BBJ recruited between 2013 and 2018 were analyzed in a third dataset. Exposures Single-nucleotide variants associated with VSA. Main Outcomes and Measures Cases with VSA and controls without CAD. Results A total of 5720 cases (mean [SD] age, 67 [10] years; 3672 male [64.2%]) and 153 864 controls (mean [SD] age, 62 [15] years; 77 362 male [50.3%]) in 3 datasets were included in this study. The variants at the RNF213 locus showed the strongest association with VSA across the 3 datasets (odds ratio [OR], 2.34; 95% CI, 1.99-2.74; P = 4.4 × 10-25). Additionally, rs112735431, an Asian-specific rare deleterious variant (p.Arg4810Lys) experimentally shown to be associated with reduced angiogenesis and a well-known causal risk for Moyamoya disease was the most promising candidate for a causal variant explaining the association. The effect size of rs112735431 on VSA was distinct from that of other CADs. Furthermore, homozygous carriers of rs112735431 showed an association with VSA characterized by a large effect estimate (OR, 18.34; 95% CI, 5.15-65.22; P = 7.0 × 10-6), deviating from the additive model (OR, 4.35; 95% CI, 1.18-16.05; P = .03). Stratified analyses revealed that rs112735431 exhibited a stronger association in males (χ21 = 7.24; P = .007) and a younger age group (OR, 3.06; 95% CI, 2.24-4.19), corresponding to the epidemiologic features of VSA. In the registry, carriers without CAD of the risk allele rs112735431 had a strikingly high mortality rate due to acute myocardial infarction during the follow-up period (hazard ratio, 2.71; 95% CI, 1.57-4.65; P = 3.3 × 10-4). As previously reported, a possible overlap between VSA and Moyamoya disease was not found. Conclusions and Relevance Results of this study suggest that vascular cell dysfunction mediated by variants in the RNF213 locus may promote coronary vasospasm, and the presence of the risk allele could serve as a predictive factor for the prognosis.
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Affiliation(s)
- Keiko Hikino
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Satoshi Koyama
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Kaoru Ito
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Yoshinao Koike
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
- Department of Orthopedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaru Koido
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
- Division of Molecular Pathology, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Laboratory of Complex Trait Genomics, Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Takayoshi Matsumura
- Division of Human Genetics, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Kurosawa
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Kohei Tomizuka
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Shuji Ito
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
- Department of Orthopedic Surgery, Shimane University Faculty of Medicine, Izumo, Japan
| | - Xiaoxi Liu
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Yuki Ishikawa
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Yukihide Momozawa
- Laboratory for Genotyping Development, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Takayuki Morisaki
- Division of Molecular Pathology, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Yoichiro Kamatani
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
- Laboratory of Complex Trait Genomics, Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Taisei Mushiroda
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
| | - Chikashi Terao
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Japan
- Clinical Research Center, Shizuoka General Hospital, Shizuoka, Japan
- Department of Applied Genetics, The School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
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Kim JA, Kim SY, Virk HUH, Alam M, Sharma S, Johnson MR, Krittanawong C. Acute Myocardial Infarction in Pregnancy. Cardiol Rev 2024:00045415-990000000-00222. [PMID: 38411170 DOI: 10.1097/crd.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.
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Affiliation(s)
- Jitae A Kim
- From the Department of Cardiology, University of Buffalo, New York, NY
| | - Sophie Y Kim
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, El Paso, TX
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mahboob Alam
- Division of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Institute of Reproductive and Developmental Biology, Chelsea and Westminster Hospital, Imperial College London, London, UK; and
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Théberge ET, Vikulova DN, Pimstone SN, Brunham LR, Humphries KH, Sedlak TL. The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes. CJC Open 2024; 6:279-291. [PMID: 38487074 PMCID: PMC10935675 DOI: 10.1016/j.cjco.2023.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/26/2023] [Indexed: 03/17/2024] Open
Abstract
Background Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women. Methods This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD. Results A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD. Conclusions The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.
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Affiliation(s)
| | - Diana N. Vikulova
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Simon N. Pimstone
- University of British Columbia, Vancouver, British Columbia, Canada
- University of British Columbia Hospital, Vancouver, British Columbia, Canada
| | - Liam R. Brunham
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | | | - Tara L. Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis 2024; 18:17539447241230400. [PMID: 38343041 PMCID: PMC10860484 DOI: 10.1177/17539447241230400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
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Affiliation(s)
- Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Brown
- Cardiovascular Care Partnership, British Cardiovascular Society, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Medical School, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081124. [PMID: 36013303 PMCID: PMC9409871 DOI: 10.3390/life12081124] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 12/26/2022]
Abstract
Vasospastic angina (VSA) is an under-appreciated cause of chest pain. It is characterised by transient vasoconstriction of the coronary arteries and plays a significant role in the pathogenesis of stable angina and acute coronary syndromes. Complex mechanistic pathways characterised by endothelial dysfunction and smooth muscle hypercontractility lead to a broad spectrum of clinical manifestations ranging from recurrent angina to fatal arrhythmias. Invasive provocation testing using intracoronary acetylcholine or ergonovine is considered the current gold standard for diagnosis, but there is a wide variation in protocols amongst different institutions. Conventional pharmacological therapy relies on calcium channel blockers and nitrates; however, refractory VSA has limited options. This review evaluates the pathophysiology, diagnostic challenges, and management strategies for VSA. We believe global efforts to standardise diagnostic and therapeutic guidelines will improve the outcomes for affected patients.
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Meeder JG, Hartzema-Meijer MJ, Jansen TPJ, Konst RE, Damman P, Elias-Smale SE. Outpatient Management of Patients With Angina With No Obstructive Coronary Arteries: How to Come to a Proper Diagnosis and Therapy. Front Cardiovasc Med 2021; 8:716319. [PMID: 34796207 PMCID: PMC8592903 DOI: 10.3389/fcvm.2021.716319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/22/2021] [Indexed: 12/28/2022] Open
Abstract
Two-thirds of women and one-third of men who undergo a clinically indicated coronary angiography for stable angina, have no obstructive coronary artery disease (CAD). Coronary vascular dysfunction is a highly prevalent underlying cause of angina in these so called “Angina with No Obstructive Coronary Arteries (ANOCA)” patients, foremost in middle aged women. Coronary vascular dysfunction encompasses various endotypes, namely epicardial and microvascular coronary spasms, impaired vasodilatation, and increased microvascular resistance. ANOCA patients, especially those with underlying coronary vascular dysfunction, have an adverse cardiovascular prognosis, poor physical functioning, and a reduced quality of life. Since standard ischemia detection tests and coronary angiograms are not designed to diagnose coronary vascular dysfunction, this ischemic heart disease is often overlooked and hence undertreated. But adequate diagnosis is vital, so that treatment can be started to reduce symptoms, reduce healthcare costs and improve quality of life and cardiovascular prognosis. The purpose of this review is to give a contemporary overview of ANOCA with focus on coronary vascular dysfunction. We will provide a possible work-up of patients suspected of coronary vascular dysfunction in the outpatient clinical setting, based on the latest scientific insights and international consensus documents. We will discuss the value of ischemia detection testing, and non-invasive and invasive methods to diagnose coronary vascular dysfunction. Furthermore, we will go into pharmacological and non-pharmacological therapeutic options including anti-anginal regimens and lifestyle interventions.
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Affiliation(s)
- Joan G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, Netherlands
| | | | - Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
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Konst RE, Meeder JG, Wittekoek ME, Maas AHEM, Appelman Y, Piek JJ, van de Hoef TP, Damman P, Elias-Smale SE. Ischaemia with no obstructive coronary arteries. Neth Heart J 2020; 28:66-72. [PMID: 32780334 PMCID: PMC7419395 DOI: 10.1007/s12471-020-01451-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.
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Affiliation(s)
- R E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | | | - A H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Y Appelman
- Department of Cardiology, Amsterdam UMC, Location VUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Piek
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T P van de Hoef
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.
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Elhakeem RF, Lutfi MF, Ali ABM, Sukkar MY. Chest Pain Characteristics in Cardiac Syndrome X Compared to Coronary Artery Disease. Open Access Maced J Med Sci 2019; 7:2282-2286. [PMID: 31592275 PMCID: PMC6765080 DOI: 10.3889/oamjms.2019.609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 12/03/2022] Open
Abstract
AIM This study aimed to assess if clinical remarks gained by analysis of the present and past medical history of patients undergoing elective coronary angiography (ECA) due to typical chest pain can help to predict the outcome of ECA. MATERIAL AND METHODS One hundred and fifty-four ECA candidates with a history of typical chest were seen on the same day intended for ECA in the cardiac centre of AlShaab Teaching Hospital, Khartoum, Sudan. The details of the present complaints, characteristics of chest pain, past medical and socioeconomic history were recorded from each subject guided by a questionnaire. ECA confirmed CAD in 112 of the studied patients and were considered as the test group. The remaining patients (N = 42) were diagnosed as CSX after exclusion of significant narrowing of the coronary vessels and were considered as the control group. RESULTS Univariate analysis of pain characteristics among patients undergoing coronary angiography revealed that pain is less likely to radiate to the neck (OR = 0.44, 95% CI = 0.21 - 0.91, P = 0.027) and the back (OR = 0.48, 95% CI = 0.23 - 1.00, P = 0.049) in patients with CAD. Presence of shortness of breathing and/or dizziness significantly decrease the odds of having abnormal coronary angiography (OR = 0.30 and 0.48, 95% CI = 0.12 - 0.77 and 0.22 - 0.92, P = 0.013 and 0.030 respectively). Past history of diabetes mellitus significantly increases the odds of having abnormal coronary angiography (OR = 3.96, 95% CI = 1.68 - 9.30, P = 0.002). In contrast, past medical history of migraine decreases the odds of having positive finding in ECA (OR = 0.31, 95% CI = 0.13 - 0.72, P = 0.006). CONCLUSION Characteristics of chest pain are comparable in CAD and CSX. However, pain is less likely to radiate to the neck and/or the back in the first group. Presence of dyspnea and dizziness during angina attacks as well as the history of migraine significantly decreases the odds of having abnormal coronary angiography.
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Affiliation(s)
| | - Mohamed Faisal Lutfi
- College of Medicine, Qassim University, KSA, Buraydah, Qassim, Saudi Arabia
- Nile College of Medicine, Khartoum, Sudan
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Abstract
Heart disease is the leading cause of death among women in the industrialized world. However, women after myocardial infarctions (MIs) are less likely to receive preventive medications or revascularization and as many as 47% experience heart failure, stroke or die within 5 years. Premenopausal women with MIs frequently have coronary plaque erosions or dissections. Women under 50 years with angina and nonobstructive epicardial coronary artery disease often have coronary microvascular dysfunction (CMD) with reductions in coronary flow reserve that may require nontraditional therapies. In women with coronary artery disease treated with stents, the 3-year incidence of recurrent MI or death is 9.2%. Coronary bypass surgery operative mortality averages 4.6% for women compared with 2.4% in men. Addition of internal mammary artery and radial artery coronary grafts in women does not increase operative survival but improves 5-year outcome to greater than 80%.
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Gorski S, Bartnicka M, Citko A, Żelazowska-Rutkowska B, Jablonski K, Gorska A. Microangiopathy in Naifold Videocapillaroscopy and Its Relations to sE- Selectin, Endothelin-1, and hsCRP as Putative Endothelium Dysfunction Markers among Adolescents with Raynaud's Phenomenon. J Clin Med 2019; 8:jcm8050567. [PMID: 31027378 PMCID: PMC6572411 DOI: 10.3390/jcm8050567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/03/2023] Open
Abstract
The aim of this study was to analyze the relationship between the qualitative abnormalities on nailfold videocapillaroscopy (NVC), and the concentrations of selected biomarkers (sE-selectin, endothelin-1, high-sensitivity c-reactive protein (hsCRP)) and lipid metabolism parameters in children and adolescents with Raynaud’s phenomenon (RP). Raynaud’s phenomenon, to assess whether nailfold capillary changes may reflect the degree of systemic blood vessel abnormalities. The study group included 66 patients (34 undifferentiated—uRP and 32 secondary—sRP) aged 6–19 years and the control group. In both groups, NVC was performed and the selected biomarkers were measured (sE-selectin, endothelin-1, hsCRP) and lipid profile. Endothelin-1, sE-selectin and hsCRP concentrations in patients from both RP groups were significantly higher; concentration of HDL fraction was significantly lower compared with the control group. The analysis of multiple linear regression demonstrated that megacapillaries most strongly determine the sE-selectin value (p = 0.04) and hsCRP (p = 0.03). Both the total cholesterol and low-density lipoprotein (LDL) fraction concentrations were determined by the presence of avascular areas (p = 0.02). In conclusion, specific pathologic NVC changes were associated with higher endothelial damage biomarkers concentration and adverse changes in the lipid profile.
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Affiliation(s)
- Stanislaw Gorski
- Department of Medical Education, Jagiellonian University Medical College, 31-530 Krakow, Poland.
| | - Marta Bartnicka
- Department of Family Medicine, Medical University of Bialystok, 15-054 Bialystok, Poland.
| | - Anna Citko
- Outpatient Clinic, Bialystok Children's Clinical Hospital of L. Zamenhof, Medical University of Bialystok, 15-274 Bialystok, Poland.
| | - Beata Żelazowska-Rutkowska
- Department of Pediatric Laboratory Diagnostics, Medical University of Bialystok, 15-276 Bialystok, Poland.
| | - Konrad Jablonski
- Department of Medical Education, Jagiellonian University Medical College, 31-530 Krakow, Poland.
| | - Anna Gorska
- Department of Family Medicine, Medical University of Bialystok, 15-054 Bialystok, Poland.
- Department of Pediatrics, Rheumatology, Immunology, and Metabolic Bone Diseases, Rheumatology Outpatient Clinic, Medical University of Bialystok, 15-276 Bialystok, Poland.
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Picard F, Sayah N, Spagnoli V, Adjedj J, Varenne O. Vasospastic angina: A literature review of current evidence. Arch Cardiovasc Dis 2018; 112:44-55. [PMID: 30197243 DOI: 10.1016/j.acvd.2018.08.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/30/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
Vasospastic angina (VSA) is a variant form of angina pectoris, in which angina occurs at rest, with transient electrocardiogram modifications and preserved exercise capacity. VSA can be involved in many clinical scenarios, such as stable angina, sudden cardiac death, acute coronary syndrome, arrhythmia or syncope. Coronary vasospasm is a heterogeneous phenomenon that can occur in patients with or without coronary atherosclerosis, can be focal or diffuse, and can affect epicardial or microvasculature coronary arteries. This disease remains underdiagnosed, and provocative tests are rarely performed. VSA diagnosis involves three considerations: classical clinical manifestations of VSA; documentation of myocardial ischaemia during spontaneous episodes; and demonstration of coronary artery spasm. The gold standard diagnostic approach uses invasive coronary angiography to directly image coronary spasm using acetylcholine, ergonovine or methylergonovine as the provocative stimulus. Lifestyle changes, avoidance of vasospastic agents and pharmacotherapy, such as calcium channel blockers, nitrates, statins, aspirin, alpha1-adrenergic receptor antagonists, rho-kinase inhibitors or nicorandil, could be proposed to patients with VSA. This review discusses the pathophysiology, clinical spectrum and management of VSA for clinicians, as well as diagnostic criteria and the provocative tests available for use by interventional cardiologists.
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Affiliation(s)
- Fabien Picard
- Cardiology department, hôpital Cochin, AP-HP, 75014 Paris, France; Faculté de médecine, université Paris Descartes, 75006 Paris, France.
| | - Neila Sayah
- Cardiology department, hôpital Cochin, AP-HP, 75014 Paris, France
| | - Vincent Spagnoli
- Cardiology department, centre hospitalier affilié universitaire régional (CHAUR) de Trois-Rivières, QC G8Z 3R9 Tois-Rivières, Canada
| | - Julien Adjedj
- Cardiology department, centre hospitalier universitaire Vaudois, 1011 Lausanne, Switzerland
| | - Olivier Varenne
- Cardiology department, hôpital Cochin, AP-HP, 75014 Paris, France; Faculté de médecine, université Paris Descartes, 75006 Paris, France
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Beltrame JF, Crea F, Kaski JC, Ogawa H, Ong P, Sechtem U, Shimokawa H, Bairey Merz CN. International standardization of diagnostic criteria for vasospastic angina. Eur Heart J 2018; 38:2565-2568. [PMID: 26245334 DOI: 10.1093/eurheartj/ehv351] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/24/2015] [Indexed: 02/07/2023] Open
Abstract
The Coronary Vasomotion Disorders International Study Group (COVADIS) was established to develop international standards for the diagnostic criteria of coronary vasomotor disorders. The first symposium held on the 4-5 September 2013 addressed the criteria for vasospastic angina, which included the following (i) nitrate-responsive angina, (ii) transient ischaemic electrocardiogram changes, and (iii) documented coronary artery spasm. Adoption of these diagnostic criteria will improve the clinical diagnosis of this condition and facilitate research in this field.
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Affiliation(s)
- John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, London, UK
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,National Cerebral and Cardiovascular Center, Suita, Japan
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd Suite A3206, Los Angeles, CA, USA
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13
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Ahmed B, Creager MA. Alternative causes of myocardial ischemia in women: An update on spontaneous coronary artery dissection, vasospastic angina and coronary microvascular dysfunction. Vasc Med 2017; 22:146-160. [DOI: 10.1177/1358863x16686410] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Bina Ahmed
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Mark A Creager
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Lutfi MF. QT Interval Derived Measurements in Patients with Cardiac Syndrome X Compared to Coronary Artery Disease. Front Physiol 2016; 7:422. [PMID: 27708590 PMCID: PMC5030246 DOI: 10.3389/fphys.2016.00422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/06/2016] [Indexed: 11/18/2022] Open
Abstract
Previous studies assessing effect of ischemia on ventricular repolarization are mostly directed toward patients with coronary artery disease (CAD); however, similar reports on cardiac syndrome X (CSX) are scarce. Whether microvascular dysfunction of CSX and ischemia induced by CAD produce comparable effect on ventricular repolarization is unclear and deserve further studies. In the present study, ECG measures of ventricular repolarization were compared between CAD and CSX patients (40 subjects in each group). Following evaluation of sociodemographic characteristics, medical and past medical history, a resting ECG was used to assess measurements of ventricular repolarization in each patient, namely, QT interval (QT), corrected QT interval (QTc), QT dispersion (QTd), corrected QT dispersion (QTcd), adjacent QT dispersion (AdQTd), QT dispersion ratio (QTdR), JT dispersion (JTd), and Corrected JT dispersion (JTcd). Results showed comparable QT intervals and QTd in CAD and CSX patients even after adjustment for the possible variations in gender, age and body mass index of the studied groups. Although JTd was increased in CSX subjects (26.6 ± 7.2 ms) compared with CAD patients (22.7 ± 6.5 ms, p = 0.019), statistical significance disappeared after correcting JT for variations in heart rate. QT and QTc were significantly below 440 ms in CAD as well as CSX patients (p < 0.001). In contrast, maximum QTd, maximum QTcd and AdQTd of CAD and CSX patients were significantly above 440 ms (p < 0.001). The means of JTd and JTcd were significantly above 22 ms and 24 ms respectively (p < 0.001, p = 0.001) in CSX but not CAD patients (p = 0.529, p = 0.281). The present findings clearly demonstrate comparable measures of ventricular repolarization in CAD and CSX patients and consequently an equal risk of cardiac events in both groups.
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Affiliation(s)
- Mohamed F Lutfi
- Department of Physiology, Faculty of Medicine and Health Sciences, Al-Neelain University Khartoum, Sudan
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15
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Beltrame JF, Crea F, Kaski JC, Ogawa H, Ong P, Sechtem U, Shimokawa H, Bairey Merz CN. The Who, What, Why, When, How and Where of Vasospastic Angina. Circ J 2016; 80:289-298. [DOI: 10.1253/circj.cj-15-1202] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- John F. Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George’s, University of London
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center
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16
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Scantlebury DC, Prasad A, Rabinstein AA, Best PJM. Prevalence of migraine and Raynaud phenomenon in women with apical ballooning syndrome (Takotsubo or stress cardiomyopathy). Am J Cardiol 2013; 111:1284-8. [PMID: 23415512 DOI: 10.1016/j.amjcard.2013.01.269] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 11/16/2022]
Abstract
Apical ballooning syndrome (ABS), migraine, and Raynaud phenomenon are characterized by female predominance, identifiable triggers, and, likely, vascular dysfunction. Estrogen deficiency, such as in menopause, is considered to be a predisposing factor for ABS. We investigated the association of ABS with migraine, Raynaud phenomenon, and hormonal factors. We compared 25 consecutive residents (all women) of Olmsted County, Minnesota, presenting with ABS, to 2 age-matched control groups from the same community: 25 women presenting with ST-segment elevation myocardial infarction (STEMI), matched for the index ABS event date, and 50 women with neither diagnosis. The patients with ABS were more likely to have a migraine history (11 [44%] vs 4 [16%] STEMI controls, p = 0.031, and vs 6 [12%] population controls, p = 0.003), and "possible migraine" (including other headache syndromes suggestive of migraine; 15 [60%] vs 6 [24%] STEMI controls, p = 0.012; and vs 12 [24%] population controls, p = 0.003). Of the patients with ABS, 4 (16%) had Raynaud phenomenon compared to no STEMI controls and 1 (2%) population control (p = 0.038). No differences were present in parity, menopausal status, years since the onset of menopause, and frequency of oophorectomy. Current hormonal replacement therapy use was greater in those with ABS than in the population controls: 4 (16%) versus none (p = 0.002). In conclusion, the association of ABS with migraine and Raynaud phenomenon supports a role of vasomotor dysfunction in the pathogenesis of ABS. The absence of an association with reproductive characteristics and the finding that ABS occurred despite exogenous hormonal use in some patients suggests that estrogen deficiency per se is not the primary factor in the pathophysiology.
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Affiliation(s)
- Dawn C Scantlebury
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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17
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Jiménez Caballero PE, Muñoz Escudero F. Peripheral endothelial function and arterial stiffness in patients with chronic migraine: a case-control study. J Headache Pain 2013; 14:8. [PMID: 23565915 PMCID: PMC3619990 DOI: 10.1186/1129-2377-14-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Migraine is a complex and disabilitating neurovascular disorder predominantly affecting women. There is strong evidence that nitric oxide is critically involved in migraine pathophysiology. The aim of the present study was to test the hypothesis that chronic migraine is associated with ultrasonographic endothelial dysfunction and increase in arterial stiffness. These parameters were assessed using a novel plethysmograph by peripheral arterial tonometry. METHODS Twenty-one patients with chronic migraine and twenty-one healthy controls matched by sex and gender were recruited. Measurement of the ultrasonographic endothelial function and augmentation index were made according to manufacturer's protocol. RESULTS The mean of patient's peripheral arterial tonometry ratios was 1.93 ± 0.39 and for healthy control 2.21 ± 0.44 (p=0.040). The median of patients' augmentation index was -6,0 (IQR: 6.5 to -15) in healthy controls and 9.0 (IQR: 4 to 12) in chronic migraine, (p=0.002). CONCLUSIONS Patients with chronic migraine have ultrasonographic endothelial dysfunction and increase in the arterial stiffness. An improved understanding of the role in the endothelial system of migraine may provide a basis for preventive drugs in migraine and restore the endothelial function.
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Affiliation(s)
| | - Francisco Muñoz Escudero
- Department of Neurology, Virgen de la Salud Hospital, Avenida de Barber 32, Toledo, 45005, Spain
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18
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Basuray A, Chamie D, Asher E, Jozic J, Parikh SA. A shocking front nine: cardiac arrest on the golf course. Circulation 2012; 126:2526-32. [PMID: 23169254 DOI: 10.1161/circulationaha.111.084129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anupam Basuray
- Division of Cardiovascular Medicine, Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106, USA
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19
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Dresen WF, Wells QS, Maron DJ, McPherson JA. Therapeutic procedures for coronary vasospasm-induced polymorphic ventricular tachycardia. Ther Adv Cardiovasc Dis 2012; 6:115-21. [PMID: 22547691 DOI: 10.1177/1753944712446303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Coronary vasospasm is an unusual cause of angina and myocardial ischemia, with the potential to provoke acute myocardial infarction, malignant cardiac arrhythmias, and sudden cardiac death. The diagnosis is largely clinical and requires a high index of suspicion. Provocation studies are rarely performed due to the risks of the procedure and the relatively low incidence of disease. A subset of patients does not respond to conventional medical therapy and a paucity of evidence exists to guide therapy. While generally believed a multifocal phenomenon, there have been reports of successful treatment of focal, refractory vasospasm with coronary stent implantation. Furthermore, consideration of an implantable cardioverter defibrillator is warranted when vasospasm is complicated by lethal ventricular arrhythmias.
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Affiliation(s)
- William F Dresen
- Vanderbilt University Medical Center, 905 Derby Trace, Nashville, TN 37211, USA.
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20
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The Vanishing Stenosis: ST Elevation Myocardial Infarction and Rhythm Disturbance due to Coronary Artery Spasm-Case Report and Review of the Literature. Case Rep Med 2010; 2010:132902. [PMID: 20368774 PMCID: PMC2846340 DOI: 10.1155/2010/132902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2009] [Accepted: 02/08/2010] [Indexed: 12/03/2022] Open
Abstract
A 62-year-old lady was admitted with clinical and electrocardiograph features of acute myocardial infarction. Urgent coronary arteriography was performed, demonstrating a single discrete stenosis of one coronary artery. Following intracoronary injection of GTN, this stenosis completely resolved, as the symptoms did. The causes of acute myocardial infarction with normal coronary arteries are reviewed.
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Abstract
Migraine attacks with auras are sometimes associated with underlying hereditary or acquired cerebrovascular disorders. A unifying pathophysiological explanation linking migraine to these conditions has been difficult to identify. On the basis of genetic and epidemiological evidence, we suggest that changes in blood vessels, hypoperfusion disorders, and microembolisation can cause neurovascular dysfunction and evoke cortical spreading depression, an event that is widely thought to underlie aura symptoms. In fact, recent experimental data have indicated that focal, mild, and transient ischaemia can trigger cortical spreading depression without an enduring tissue signature. Although migraine with aura has many causes (eg, neuronal network excitability), it seems that migraine and stroke might both be triggered by hypoperfusion and could therefore exist on a continuum of vascular complications in a subset of patients who have these hereditary or acquired comorbid vascular conditions.
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22
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Modin B, Vågerö D, Hallqvist J, Koupil I. The contribution of parental and grandparental childhood social disadvantage to circulatory disease diagnosis in young Swedish men. Soc Sci Med 2007; 66:822-34. [PMID: 18155818 DOI: 10.1016/j.socscimed.2007.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Indexed: 01/21/2023]
Abstract
Men born out of wedlock in early twentieth century Sweden who never married have previously been shown to have a doubled mortality risk from ischaemic heart disease compared to the corresponding group of men born to married parents. This study further explores the question of childhood social disadvantage and its long-term consequences for cardiovascular health by examining the two subsequent generations. The question posed is whether the sons and grandsons of men and women born out of wedlock in early twentieth century Sweden have an increased risk of circulatory disease compared with the corresponding descendants of those born inside marriage. We examined this by use of military conscription data. The material used is the Uppsala Birth Cohort Multigenerational database consisting of individuals born at Uppsala University Hospital between 1915 and 1929 (UG1), their children (UG2) and grandchildren (UG3). Conscription data were available for UG2s born between 1950 and 1982 (n=5,231) and UG3s born between 1953 and 1985 (n=10,074) corresponding to 72.1% and 73.6%, respectively, of all males born in each time-period. Logistic regression showed that significant excess risk of circulatory disease diagnoses was present only among descendants of men born outside marriage, with sons and grandsons demonstrating odds ratios of 1.64 and 1.83, respectively, when BMI and height at the time of conscription, father's social class in mid-life and father's or grandfather's history of circulatory disease had been adjusted for. Separate analyses showed that the effect of the maternal and paternal grandfather was of approximately the same magnitude. Further analyses revealed an interaction between the father's social class and the grandfather's legitimacy status at birth on UG3-men's likelihood of having a circulatory disease, with elevated odds only among those whose fathers were either manual workers or self-employed. The results of this study suggest that social disadvantage in one generation can be linked to health disadvantage in the subsequent two generations.
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Affiliation(s)
- Bitte Modin
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, 106 91 Stockholm, Sweden.
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23
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Bernatsky S, Pineau CA, Lee JL, Clarke AE. Headache, Raynaud's syndrome and serotonin receptor agonists in systemic lupus erythematosus. Lupus 2007; 15:671-4. [PMID: 17120594 DOI: 10.1177/0961203306069997] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are potential concerns regarding serotonin receptor agonists in SLE patients with migraine, particularly patients with concomitant Raynaud's syndrome. We estimated the prevalence of lupus-related headache and Raynaud's syndrome in the Montreal General Hospital SLE clinic cohort and evaluated the relationship between these two variables in multivariable logistic regression models, controlling for age, sex, race, SLE duration and the presence of lupus anticoagulant and antibodies to cardiolipin and beta2 glycoprotein I. We also assessed, through chart review in those individuals with both Raynaud's syndrome and migraine, a history of serotonin receptor agonist use, and any associated worsening vasospasm. Based on Systemic Lupus Activity Measure (SLAM) scores, the cumulative incidence of lupus-related headache in our sample (n = 391) was 46.1%; the prevalence of Raynaud's syndrome was 49.4%. The adjusted odds ratio (OR) for lupus-related headache and Raynaud's syndrome was 1.7 (95% CI 1.1, 2.5). In addition, there was a strong independent relationship between headache and anti-beta2 glycoprotein I antibodies (adjusted OR 5.6 [95% CI 1.8, 17.0]). The data from our chart review suggest that careful use of serotonin receptor agonists in patients with both Raynaud's syndrome and migraines may be undertaken, although caution would necessitate that these agents not be used in individuals with very severe Raynaud's (eg, digital ulcerations, and so on).
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Affiliation(s)
- S Bernatsky
- Division of Clinical Epidemiology, Montreal General Hospital, Montreal, PQ, Canada
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Abstract
Coronary artery spasm is an important cause of chest pain and myocardial ischaemia. It can be defined as an exaggerated contractile response of epicardial coronary artery smooth muscle to various stimuli but the underlying mechanism is not well understood. Recent studies have shown that the loss of endothelial vasodilatory function in conjunction with an increase in vascular smooth muscle constrictor sensitivity to calcium are the likely predisposing conditions for coronary spasm. This review highlights current understanding of the pathophysiology, predisposing factors, diagnostic and therapeutic approaches for coronary spasm.
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Affiliation(s)
- Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.
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25
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Yetkin E, Ozisik H, Ozcan C, Aksoy Y, Turhan H. Decreased endothelium-dependent vasodilatation in patients with migraine: a new aspect to vascular pathophysiology of migraine. Coron Artery Dis 2006; 17:29-33. [PMID: 16374138 DOI: 10.1097/00019501-200602000-00005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Migraine is a common neurovascular disorder characterized by attacks of severe headache, autonomic and neurological symptoms. We hypothesized that patients with migraine had abnormal endothelial function. The vascular theory of migraine assumes that the major pathophysiological events that initiate the migraine attack occur in the perivascular nerves of the major cerebral vessels. Accordingly, we aimed to measure endothelium-dependent vasodilatation in migraineurs by means of flow-mediated dilatation, which reflects endothelium-dependent vasodilatation capacity. MATERIALS AND METHODS Forty-five patients who fulfilled the diagnostic criteria for migraine and 45 age and sex-matched healthy participants were enrolled in the study. Flow-mediated dilatation of the brachial artery was determined using a high-resolution B-mode ultrasonographic system. Flow-mediated vasodilatation was expressed as the change in post-stimulus diameter as a percentage of the baseline diameter. RESULTS Mean ages of the patients were 33+/-10 years in migraineurs (range: 18-52 years, 36 female, 9 male) and 33+/-9 years in non-migraineurs (range: 17-50 years, 36 female and 9 male). Flow-mediated dilatation of patients with migraine is significantly lower than that of the controls (8.02+/-4.095% vs. 10.72+/-3.52%, respectively, P=0.001). CONCLUSION We have shown that migraineurs have decreased endothelium-dependent vasodilatation capacity compared with non-migraineurs. Migraine may be a local manifestation of systemic vascular vasomotion abnormalities.
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Affiliation(s)
- Ertan Yetkin
- Department of Cardiology, Inonu University School of Medicine, Malatya, Turkey.
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Park SM, Shim WJ, Ahn JC, Lim DS, Kim YH, Ro YM. Changes of coronary blood flow in vasospastic angina under cold stimulation by transthoracic Doppler echocardiography. J Korean Med Sci 2005; 20:204-8. [PMID: 15831987 PMCID: PMC2808592 DOI: 10.3346/jkms.2005.20.2.204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This study was done to evaluate changes of microvascular function under cold stimulation by measuring coronary flow velocities (CFVs) in vasospastic angina (VA) patients using transthoracic Doppler echocardiography (TTDE). 14 patients with VA and 15 healthy controls were included. CFVs were measured at the distal left anterior descending coronary artery by TTDE at baseline and under cold stimulation. Hyperemia was induced by intravenous adenosine infusion (140 microg/kg/min). At baseline, CFVs and coronary flow reserve (CFR) were not different between controls and VA patients. Under cold stimulation, the degree of increment of CFV with adenosine was lower in VA patients than in controls. Comparing baseline with cold stimulation, coronary flow reserve (CFR) increased (3.1+/-0.7 to 3.8 +/-1.0, p=0.06) in controls. In contrast, in VA patients, CFR was decreased (2.8 +/-0.9 to 2.6 +/-0.7, p=0.05) and coronary vascular resistance index markedly increased (0.35 to 0.43, p=0.01). Throughout the study, no patient experienced chest pain or ECG changes. In VA patients, CFR was preserved at baseline, but coronary blood flow increase in response to cold stimulation was blunted and CFR was decreased. These findings suggest that endothelial dependent vasodilation is impaired at the coronary microvascular and the epicardial artery level in VA under cold stimulation.
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Affiliation(s)
- Seong Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Wan Joo Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Jung Cheon Ahn
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Do Sun Lim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Young Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Young Moo Ro
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
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27
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Williams FMK, Cherkas LF, Spector TD, MacGregor AJ. A common genetic factor underlies hypertension and other cardiovascular disorders. BMC Cardiovasc Disord 2004; 4:20. [PMID: 15518590 PMCID: PMC529445 DOI: 10.1186/1471-2261-4-20] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2004] [Accepted: 11/01/2004] [Indexed: 11/18/2022] Open
Abstract
Background Certain conditions characterised by blood vessel occlusion or vascular spasm have been found to cluster together in epidemiological studies. However the biological causes for these associations remain controversial. This study used a classical twin design to examine whether these conditions are linked through shared environmental exposures or by a common underlying genetic propensity to vasospasm. Methods We investigated the association between hypertension, migraine, Raynaud's phenomenon and coronary artery disease in twins from a national register. Phenotype status was determined using a questionnaire and the genetic and environmental association between phenotypes was estimated through variance components analysis. Results Responses were obtained from 2,204 individuals comprising 525 monozygotic and 577 dizygotic pairs. There was a significant genetic contribution to all four traits with heritabilities ranging from 0.34 to 0.64. Multivariate model-fitting demonstrated that a single common genetic factor underlies the four conditions. Conclusions We have confirmed an association between hypertension, migraine, Raynaud's phenomenon and coronary artery disease, and shown that a single genetic factor underlies them. The demonstration of a shared genetic factor explains the association between them and adds weight to the theory of an inherited predisposition to vasospasm.
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Affiliation(s)
- Frances MK Williams
- Twin Research and Genetic Epidemiology Unit, St Thomas' Hospital, London SE1 7EH, UK
| | - Lynn F Cherkas
- Twin Research and Genetic Epidemiology Unit, St Thomas' Hospital, London SE1 7EH, UK
| | - Tim D Spector
- Twin Research and Genetic Epidemiology Unit, St Thomas' Hospital, London SE1 7EH, UK
| | - Alex J MacGregor
- Twin Research and Genetic Epidemiology Unit, St Thomas' Hospital, London SE1 7EH, UK
- Department of Medicine, University of East Anglia, Norwich NR4 7TJ, UK
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28
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Abstract
Under physiologic conditions, epicardial arteries contribute minimally to coronary vascular resistance. However, in the presence of endothelial dysfunction, stimuli that normally produce vasodilation may instead cause constriction. Examples include neural release of acetylcholine or norepinephrine, platelet activation and production of serotonin and thrombin, and release of local factors such as bradykinin. This shift from a primary endothelial-mediated vasodilator influence to one of endothelial dysfunction and unchecked vasoconstriction is precisely the milieu in which coronary vasospasm is observed. This condition, which typically occurs during periods of relatively sedentary activity, is associated with focal and transient obstruction of an epicardial arterial segment resulting in characteristic echocardiographic changes and symptoms of myocardial ischemia. This review highlights the current understanding of mechanisms regulating the coronary circulation during health and examines the pathophysiologic changes that occur with coronary spasm. Genetic and other predisposing conditions are addressed, as well as novel therapies based on recent mechanistic insights of the coronary contractile dysfunction associated with coronary spasm.
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Affiliation(s)
- Srilakshmi Konidala
- Department of Medicine, Cardiovascular Center, General Clinical Research Center, Milwaukee, WI 53226, USA
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Cook NR, Benseñor IM, Lotufo PA, Lee IM, Skerrett PJ, Chown MJ, Ajani UA, Manson JE, Buring JE. Migraine and coronary heart disease in women and men. Headache 2002; 42:715-27. [PMID: 12390634 DOI: 10.1046/j.1526-4610.2002.02173.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We evaluated migraine as an independent risk factor for subsequent coronary heart disease (CHD) events among women in the Women's Health Study (WHS) and men in the Physicians' Health Study (PHS). BACKGROUND Although several studies have suggested that migraine is associated with increased risk of stroke, there are few and conflicting data on whether migraine predicts risk of future CHD events. METHODS The WHS is an ongoing randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer in 39876 women health professionals aged > or =45 years in 1993, and the PHS is a completed randomized, double-blind, placebo-controlled trial of aspirin and beta-carotene in the primary prevention of cardiovascular disease and cancer in 22071 men physicians aged 40 to 84 years in 1982. Primary endpoints were defined as major CHD (nonfatal myocardial infarction [MI] or fatal CHD) and total CHD (major CHD plus angina and coronary revascularization). RESULTS After adjusting for other CHD risk factors, female health professionals and male physicians reporting migraine were not at increased risk for subsequent major CHD (women: relative risk [RR], 0.83; 95% confidence interval [CI], 0.53 to 1.29; men: RR, 1.02; 95% Cl, 0.79 to 1.31) or total CHD (women: RR, 1.01; 95% Cl, 0.76 to 1.34; men: RR, 0.98; 95% Cl, 0.82 to 1.18). When considered separately, there was also no increase in risk of MI or angina. CONCLUSION These prospective data suggest that migraine is not associated with increased risk of subsequent CHD events in women or men.
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Affiliation(s)
- Nancy R Cook
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
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Flammer J, Orgül S, Costa VP, Orzalesi N, Krieglstein GK, Serra LM, Renard JP, Stefánsson E. The impact of ocular blood flow in glaucoma. Prog Retin Eye Res 2002; 21:359-93. [PMID: 12150988 DOI: 10.1016/s1350-9462(02)00008-3] [Citation(s) in RCA: 1115] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Two principal theories for the pathogenesis of glaucomatous optic neuropathy (GON) have been described--a mechanical and a vascular theory. Both have been defended by various research groups over the past 150 years. According to the mechanical theory, increased intraocular pressure (IOP) causes stretching of the laminar beams and damage to retinal ganglion cell axons. The vascular theory of glaucoma considers GON as a consequence of insufficient blood supply due to either increased IOP or other risk factors reducing ocular blood flow (OBF). A number of conditions such as congenital glaucoma, angle-closure glaucoma or secondary glaucomas clearly show that increased IOP is sufficient to lead to GON. However, a number of observations such as the existence of normal-tension glaucoma cannot be satisfactorily explained by a pressure theory alone. Indeed, the vast majority of published studies dealing with blood flow report a reduced ocular perfusion in glaucoma patients compared with normal subjects. The fact that the reduction of OBF often precedes the damage and blood flow can also be reduced in other parts of the body of glaucoma patients, indicate that the hemodynamic alterations may at least partially be primary. The major cause of this reduction is not atherosclerosis, but rather a vascular dysregulation, leading to both low perfusion pressure and insufficient autoregulation. This in turn may lead to unstable ocular perfusion and thereby to ischemia and reperfusion damage. This review discusses the potential role of OBF in glaucoma and how a disturbance of OBF could increase the optic nerve's sensitivity to IOP.
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Sun H, Mohri M, Shimokawa H, Usui M, Urakami L, Takeshita A. Coronary microvascular spasm causes myocardial ischemia in patients with vasospastic angina. J Am Coll Cardiol 2002; 39:847-51. [PMID: 11869851 DOI: 10.1016/s0735-1097(02)01690-x] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We aimed to test the hypothesis that coronary microvascular spasm (MVS) alone causes myocardial ischemia in patients with angina attributable to epicardial coronary spasm, and to determine whether there is a difference in clinical characteristics between those with and without microvascular spasm. BACKGROUND Patients with "vasospastic angina" have epicardial coronary artery spasm, but it is unknown whether coronary microvessel disease also contributes to the occurrence of angina in these patients. METHODS We studied 55 consecutive patients with angina in whom epicardial coronary spasm was provoked by intracoronary acetylcholine (ACH). RESULTS In 14 patients (25.5%, Group 1), submaximal dose of ACH induced myocardial ischemia (chest pain, ischemic electrocardiogram changes, lactate production) without large epicardial spasm, suggesting the occurrence of coronary microvascular spasm. By contrast, the remaining 41 patients (Group 2) had evidence of myocardial ischemia only when epicardial spasm was angiographically demonstrated. The Group 1 patients were predominantly women (p < 0.05) and had a history of prolonged (>30 min) chest pain (p < 0.05), whereas the Group 2 patients were more likely men and smokers (p < 0.01). CONCLUSIONS Myocardial ischemia most probably due to coronary MVS was demonstrated in a sizable portion of patients with epicardial vasospasm, preferentially in women having both typical and prolonged anginal pain. The result suggests that coronary microvascular disease may also contribute to angina in patients with "vasospastic angina."
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Affiliation(s)
- Hongtao Sun
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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