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Guevara-Bermudez LP, Toleva O. Worsening of Angina Following Nitroglycerin Administration: A Case Report of the Interplay With Undiagnosed Myocardial Bridge. Cureus 2023; 15:e40091. [PMID: 37425580 PMCID: PMC10328144 DOI: 10.7759/cureus.40091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
Myocardial bridge (MB) is a congenital abnormality where part of a coronary epicardial artery runs under the myocardium fibers and is compressed in systole; this becomes more pronounced when nitroglycerin (NTG) is administered. In this report, we describe the case of a 40-year-old African American man who presented with chest pain that did not respond to NTG or isosorbide mononitrate and was only partially relieved by narcotics. His past medical history was significant for coronary artery disease (CAD) with a stent into the left anterior descending artery (LAD) several months prior, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, sick sinus syndrome, permanent pacemaker, pulmonary embolism, and cerebral vascular accident. No explanation for his angina was found either in the previous outpatient left heart catheterization (LHC) procedures demonstrating LAD stent patency or initial chest pain workup upon admission. Functional LHC procedure with adenosine infusion and acetylcholine provocation demonstrated endothelial dysfunction with notable epicardial spasm and MB of the LAD that worsened with NTG. Cardiology advised dual antiplatelet therapy and a statin as part of treatment for CAD and a calcium channel blocker with a bradycardic effect (e.g., diltiazem, verapamil) for the MB and coronary vasospasm, and avoidance of NTG and long-acting nitrates (e.g., isosorbide mononitrate), which can cause reflex tachycardia and worsen angina from MB. A selective serotonin reuptake inhibitor was added for increased cardiac nociception. The patient's pain resolved, and he was discharged. MB is an important alternate etiology to consider when chest pain does not respond to NTG administration for adjustment of treatment modalities. The initial treatment for this patient's pain with NTG likely exacerbated symptoms by reducing intrinsic coronary wall tension and subsequently increasing reflex sympathetic stimulation of contractility of the left ventricular myocardium, which can, in turn, increase anginal symptoms and ischemia.
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Affiliation(s)
- Liliana P Guevara-Bermudez
- Department of Hospital Medicine, Emory Saint Joseph's Hospital, Atlanta, USA
- Department of Medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, USA
| | - Olga Toleva
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, USA
- Emory Women's Heart Center, Emory Saint Joseph's Hospital, Atlanta, USA
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Hao Z, Xinwei J, Ahmed Z, Huanjun P, Zhanqi W, Yanfei W, Chunhong C, Chan Z, Liqiang F. The Outcome of Percutaneous Coronary Intervention for Significant Atherosclerotic Lesions in Segment Proximal to Myocardial Bridge at Left Anterior Descending Coronary Artery. Int Heart J 2018; 59:467-473. [PMID: 29681571 DOI: 10.1536/ihj.17-179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aimed to evaluate the efficacy of percutaneous coronary intervention (PCI) for significant atherosclerosis lesions proximal to myocardial bridge (MB) at left anterior descending coronary artery (LAD).A total of 330 consecutive patients with LAD significant stenosis, diagnosed as acute coronary syndrome (ACS), were included. Based on whether combined with MB, the patients were divided into the MB group (MB, n = 48) and non-MB group (NMB, n = 282). Drug eluting stents (DES) were successfully implanted in the stenostic segments prior to MB. All patients were followed up during the hospital stay, 30 days and 12 months after PCI, to evaluate the major adverse cardiac events (MACEs).There was no difference in the incidence of MACEs between the two groups (6.2% versus 2.1%, P = 0.254) when in the hospital. During the follow-up of 30 days and 12 months after PCI, the rate of MACEs was significantly higher in the MB group than in the NMB group (18.2% versus 6.4% and 43.8% versus 17.0%, respectively, P < 0.001). Stent restenosis occurred in four patients in the MB group; whereas, in five patients in the NMB group, the rate of stent restenosis was higher in the MB group than in the NMB group (8.3% versus 1.8%, P = 0.036). Cox proportional hazards regression analysis revealed that the presence of MB was an independent predictor of MACEs (hazard ratio (HR) = 1.781, 95% confidence intervals (95% CI) = 1.108-2.863, P = 0.017).DES implantation for significant atherosclerosis stenosis in the segments proximal to MB have higher incidence of MACEs. MB appears to be associated with a higher incidence of stent restenosis after PCI and is a significant factor in the occurrence of MACEs.
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Affiliation(s)
- Zhang Hao
- Physical Examination Center, Affiliated Hospital of Hebei University
| | - Jia Xinwei
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Zakarya Ahmed
- Physical Examination Center, Affiliated Hospital of Hebei University
| | - Pan Huanjun
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Wang Zhanqi
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Wang Yanfei
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Chen Chunhong
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Zhang Chan
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Fu Liqiang
- Division of Cardiology, Affiliated Hospital of Hebei University
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Jiang L, Zhang M, Zhang H, Shen L, Shao Q, Shen L, He B. A potential protective element of myocardial bridge against severe obstructive atherosclerosis in the whole coronary system. BMC Cardiovasc Disord 2018; 18:105. [PMID: 29843607 PMCID: PMC5975619 DOI: 10.1186/s12872-018-0847-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial bridge (MB) is generally described as a congenital benign variation. Previous studies have suggested that MB prevents atherosclerotic plaques from accumulating within the bridge segment but promotes coronary stenosis in the proximal segment adjacent to MB. However, it is still not clear whether MB has positive or negative effects on severe obstructive atherosclerosis in the whole coronary artery system. METHODS In this study, 6774 patients with symptoms of angina who were clinically diagnosed coronary artery disease (CAD) or suspected CAD underwent coronary angiography (CAG) in our center. The presence of MB was diagnosed, and a retrospective analysis was performed between MB and severe obstructive CAD requiring percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the whole coronary system. RESULTS Among 6774 patients, 3583 (52.89%) were diagnosed with severe obstructive CAD (SOCAD) requiring a treatment of PCI or CABG and enrolled into the SOCAD group; and 3191 (47.11%) without SOCAD into the non-SOCAD group. Non-SOCAD and SOCAD groups had 512(16.05%) and 66(1.84%) patients with MB, respectively (P < 0.0001). The rate of SOCAD requiring PCI or CABG in patients with MB was much lower than that in patients without MB (11.42% vs. 56.76%, P < 0.0001). After adjusting for sex, age, diabetes mellitus, hypertension, and other risk factors, MB still had some positive role in preventing severe obstructive CAD (log-OR = - 2.134, p-value < 0.0001) through logistic regression. CONCLUSIONS Our results provided a clue that MB might act as a potential protective element against severe obstructive atherosclerosis in the whole coronary artery system.
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Affiliation(s)
- Lisheng Jiang
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China. .,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Min Zhang
- Department of Clinical Medicine, Shanghai Medical School, Fudan University, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hong Zhang
- Institution of Biostatistics, School of Life Science, Fudan University, Shanghai, China
| | - Lan Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qin Shao
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Linghong Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China. .,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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Prinzmetal Angina in a Young Patient with Essential Thrombocythemia, After Anagrelide Initiation - Case Report and Literature Review. ARS MEDICA TOMITANA 2018. [DOI: 10.2478/arsm-2018-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
We report a case of Prinzmetal angina as inaugural manifestation of coronary disease, in a young adult male patient, recently started on anagrelide for essential thrombocythemia. Moderate proximal left anterior descendent coronary artery stenosis was documented by angiography, and interventional or surgical revascularization has been discussed. Patient’s option was for medical therapy alone. Anagrelide was temporarily withdrawn and rechallenged uneventfully after a couple of months and clinical evolution is good at four years follow-up. The mechanism by which anagrelide could induce coronary spasm and ischemia remains to be clarified.
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Late gadolinium enhancement on cardiac magnetic resonance imaging is associated with coronary endothelial dysfunction in patients with dilated cardiomyopathy. Heart Vessels 2017; 33:393-402. [DOI: 10.1007/s00380-017-1069-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
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Rogers IS, Tremmel JA, Schnittger I. Myocardial bridges: Overview of diagnosis and management. CONGENIT HEART DIS 2017; 12:619-623. [PMID: 28675696 DOI: 10.1111/chd.12499] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/20/2017] [Indexed: 12/30/2022]
Abstract
A myocardial bridge is a segment of a coronary artery that travels into the myocardium instead of the normal epicardial course. Although it is general perception that myocardial bridges are normal variants, patients with myocardial bridges can present with symptoms, such as exertional chest pain, that cannot be explained by a secondary etiology. Such patients may benefit from individualized medical/surgical therapy. This article describes the prevalence, clinical presentation, classification, evaluation, and management of children and adults with symptomatic myocardial bridges.
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Affiliation(s)
- Ian S Rogers
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA.,Division of Pediatric Cardiology, Stanford University, Stanford, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
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Uemura T, Yamamuro M, Kaikita K, Takashio S, Utsunomiya D, Hirakawa K, Nakayama M, Sakamoto K, Yamamoto E, Tsujita K, Kojima S, Hokimoto S, Yamashita Y, Ogawa H. Late gadolinium enhancement on cardiac magnetic resonance predicts coronary vasomotor abnormality and myocardial lactate production in patients with chronic heart failure. Heart Vessels 2016; 31:1969-1979. [PMID: 26892530 PMCID: PMC5122619 DOI: 10.1007/s00380-016-0816-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
Myocardial fibrosis and microvascular dysfunction are key determinants of outcome in heart failure (HF); we examined their relationship in patients with HF. Our study included 61 consecutive patients with HF but without coronary stenosis. All underwent gadolinium-enhanced cardiac magnetic resonance to evaluate late gadolinium enhancement (LGE) and an acetylcholine (ACh) provocation test to evaluate microvascular dysfunction. During the ACh provocation test, we sampled blood simultaneously from the coronary sinus and aortic root to compare lactate concentrations. We quantified coronary blood flow volume using an intracoronary Doppler-tipped guidewire. We detected LGE in 34 patients (LGE-positive); 27 were LGE-negative. Coronary blood flow volume increased significantly after the ACh provocation test only in LGE-negative patients (before vs. after ACh, 47.5 ± 36.8 vs. 69.2 ± 48.0 ml/min, respectively; p = 0.004). The myocardial lactate extraction ratio (LER) significantly decreased after the ACh test in both groups (LGE-negative, p = 0.001; LGE-positive, p < 0.001), significantly more so in the LGE-positive group (p = 0.017). Multivariate logistic regression analysis showed that a post-ACh LER < 0 (indicating myocardial lactate production) was a significant predictor of LGE-positivity (odds ratio 4.54; 95 % confidence interval 1.38-14.93; p = 0.013). In the LGE-positive group, an LGE volume greater than the median significantly predicted a post-ACh LER of <0 (p = 0.042; odds ratio 6.02; 95 % confidence interval 1.07-33.86). ACh-provoked coronary vasomotor abnormality is closely correlated with myocardial fibrosis in patients with HF but without organic coronary stenosis. Coronary vasomotor abnormalities in fibrotic myocardium may worsen HF.
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Affiliation(s)
- Tomoaki Uemura
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Megumi Yamamuro
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.
| | - Koichi Kaikita
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Daisuke Utsunomiya
- Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kyoko Hirakawa
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Mina Nakayama
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kenji Sakamoto
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Eiichiro Yamamoto
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kenichi Tsujita
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Sunao Kojima
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Seiji Hokimoto
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Yasuyuki Yamashita
- Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Departments of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Im SI, Choi WG, Rha SW, Choi BG, Choi SY, Kim SW, Na JO, Choi CU, Lim HE, Kim JW, Kim EJ, Park CG, Seo HS, Oh DJ. Significant Response to Lower Acetylcholine Dose Is Associated with Worse Clinical and Angiographic Characteristics in Patients with Vasospastic Angina. Korean Circ J 2013; 43:468-73. [PMID: 23964293 PMCID: PMC3744734 DOI: 10.4070/kcj.2013.43.7.468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/08/2013] [Accepted: 07/10/2013] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives Subjects and Methods Results Conclusion
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Affiliation(s)
- Sung Il Im
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Woong Gil Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
- Cardiology Department, Konkuk University Chungju Hospital, Chungju, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Byoung Geol Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Se Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sun Won Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Hong Euy Lim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Jin Won Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dong Joo Oh
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
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