1
|
Pompei G, Ganzorig N, Kotanidis CP, Alkhalil M, Collet C, Sinha A, Perera D, Beltrame J, Kunadian V. Novel diagnostic approaches and management of coronary microvascular dysfunction. Am J Prev Cardiol 2024; 19:100712. [PMID: 39161975 PMCID: PMC11332818 DOI: 10.1016/j.ajpc.2024.100712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/04/2024] [Accepted: 07/21/2024] [Indexed: 08/21/2024] Open
Abstract
The mechanism underlying ischaemic heart disease (IHD) has been primarily attributed to obstructive coronary artery disease (CAD). However, non-obstructive coronary arteries are identified in >50% of patients undergoing elective coronary angiography, recently leading to growing interest in the investigation and management of angina/ischaemia with non-obstructive coronary arteries (ANOCA/INOCA). INOCA is an umbrella term encompassing a multiple spectrum of possible pathogenetic entities, including coronary vasomotor disorders which consist of two major endotypes: coronary microvascular dysfunction (CMD) and vasospastic angina. Both conditions can coexist and be associated with concomitant obstructive CAD. Particularly, CMD refers to myocardial ischaemia due to reduced vasodilatory capacity of coronary microcirculation secondary to structural remodelling or impaired resting microvascular tone (functional) or a combination of both. CMD is not a benign condition and is more prevalent in women presenting with chronic coronary syndrome compared to men. In this setting, an impaired coronary flow reserve has been associated with increased risk of major adverse cardiovascular events. ANOCA/INOCA patients also experience impaired quality of life and associated increased healthcare costs. Therefore, research in this scenario has led to better definition, classification, and prognostic stratification based on the underlying pathophysiological mechanisms. The development and validation of non-invasive imaging modalities, invasive coronary vasomotor function testing and angiography-derived indices provide a comprehensive characterisation of CMD. The present narrative review aims to summarise current data relating to the diagnostic approach to CMD and provides details on the sequence that therapeutic management should follow.
Collapse
Affiliation(s)
- Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
| | - Christos P. Kotanidis
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Mohammad Alkhalil
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Aish Sinha
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital & The Queen Elizabeth Hospital, Adelaide, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, NewcastleUniversity, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| |
Collapse
|
2
|
Schipaanboord DJM, Woudstra J, Appelman Y, Rittersma SZH, van de Hoef TP, van Es R, Coronel R, Damman P, van der Harst P, Onland-Moret NC, den Ruijter HM. The Diagnostic Value of ECG Characteristics for Vasospastic and Microvascular Angina: A Systematic Review. Ann Noninvasive Electrocardiol 2024; 29:e70003. [PMID: 39206616 PMCID: PMC11358703 DOI: 10.1111/anec.70003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 04/14/2024] [Accepted: 07/20/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Coronary vascular dysfunction comprises VSA and/or MVA and is more common in women than in men with angina without obstructive coronary artery disease (ANOCA). Invasive coronary function testing is considered the reference test for diagnosis, but its burden on patients is large. We aimed to investigate the potential of electrocardiography (ECG) as noninvasive marker for vasospastic angina (VSA) and microvascular angina (MVA) diagnosis. METHODS We systematically screened Pubmed and EMBASE databases for studies reporting on ECG characteristics in ANOCA patients with (a suspicion of) coronary vascular dysfunction. We assessed study quality using QUADAS-2. We extracted data on diagnostic values of different ECG characteristics and analyzed whether the studies were sex-stratified. RESULTS Thirty publications met our criteria, 13 reported on VSA and 17 on MVA. The majority addressed repolarization-related ECG parameters. Only 1 of the 13 VSA papers and 4 of the 17 MVA papers showed diagnostic accuracy measures of the ECG characteristics. The presence of early repolarization, T-wave alternans, and inverted U waves showed of predictive value for VSA diagnosis. The QTc interval was predictive for MVA diagnosis in all six studies reporting on QTc interval. Sex-stratified results were reported in only 5 of the 30 studies and 3 of those observed sex-based differences. CONCLUSIONS ECG features are not widely evaluated in diagnostic studies for VSA and MVA. Those features predictive for VSA and MVA diagnosis mostly point to repolarization abnormalities and may contribute to noninvasive risk stratification.
Collapse
Affiliation(s)
- Diantha J M Schipaanboord
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Janneke Woudstra
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Amsterdam, The Netherlands
| | - Saskia Z H Rittersma
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ruben Coronel
- Department of Experimental Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - N Charlotte Onland-Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
3
|
Tudurachi A, Anghel L, Tudurachi BS, Zăvoi A, Ceasovschih A, Sascău RA, Stătescu C. Beyond the Obstructive Paradigm: Unveiling the Complex Landscape of Nonobstructive Coronary Artery Disease. J Clin Med 2024; 13:4613. [PMID: 39200755 PMCID: PMC11354865 DOI: 10.3390/jcm13164613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/03/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
Traditionally focused on obstructive atherosclerosis, contemporary research indicates that up to 70% of patients undergoing coronary angiography for angina and ischemic symptoms do not exhibit significant stenoses. Nonobstructive coronary artery disease (CAD) has emerged as a prevalent phenotype among these patients. This review emphasizes the emerging understanding that nonobstructive coronary artery disease, encompassing conditions such as ANOCA (Angina with No Obstructive Coronary Artery Disease), INOCA (Ischemia with No Obstructive Coronary Artery Disease), and MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries), represents the most prevalent phenotype in cardiac patients. It delves into the complex pathophysiology underlying these conditions, focusing on microvascular dysfunction and coronary vasoreactivity, which contribute to myocardial ischemia despite the absence of significant coronary obstructions. Additionally, the review critically examines the limitations of current treatments which primarily target obstructive lesions and underscores the necessity for tailored therapies that address the specific microvascular and immunoinflammatory pathways involved in nonobstructive CAD. The main focus of this review is to advocate for a shift in diagnostic and therapeutic strategies to better identify and manage this widely prevalent yet under-recognized subset of CAD.
Collapse
Affiliation(s)
- Andreea Tudurachi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
| | - Larisa Anghel
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Bogdan-Sorin Tudurachi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Alexandra Zăvoi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Alexandr Ceasovschih
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
- “St. Spiridon” Clinical Emergency Hospital, Independence Boulevard No. 1, 700111 Iasi, Romania
| | - Radu Andy Sascău
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Cristian Stătescu
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| |
Collapse
|
4
|
Jansen TPJ, Gietman O, Crooijmans C, Bourich J, Elias-Smale S, van Royen N, Thijssen D, Damman P, Dimitriu-Leen AC. The influence of sympathetic triggering by handgrip exercise on coronary vasoreactivity and complaints in patients with angina and non-obstructive coronary arteries: a proof-of-concept study. Eur J Prev Cardiol 2024:zwae207. [PMID: 38978208 DOI: 10.1093/eurjpc/zwae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/29/2024] [Accepted: 06/06/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Olaf Gietman
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Caïa Crooijmans
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Jihane Bourich
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Dick Thijssen
- Department of Cardiovascular Physiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Aukelien C Dimitriu-Leen
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| |
Collapse
|
5
|
Jansen TPJ, Crooijmans C, Pijls N, Paradies V, de Vos A, Dimitriu-Leen AC, Elias-Smale S, Rodwell L, van Royen N, Smits P, Damman P. Effects of age on microvascular function in patients with normal coronary arteries. EUROINTERVENTION 2024; 20:e690-e698. [PMID: 38840575 PMCID: PMC11145310 DOI: 10.4244/eij-d-23-00778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/02/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND It has been suggested that coronary microvascular function decreases with age, irrespective of the presence of epicardial atherosclerosis. AIMS Our aim is to quantitatively investigate the effects of age on microvascular function in patients with normal coronary arteries. METHODS In 314 patients with angina with no obstructive coronary artery disease (ANOCA), microcirculatory function was tested using the continuous thermodilution method. In 305 patients, the association between age and both resting and hyperaemic myocardial blood flow (Q), microvascular resistance (Rμ), absolute coronary flow reserve (CFR) and microvascular resistance reserve (MRR) was assessed. In addition, patients were divided into 3 groups to test for differences based on age quartiles (≤52 years [24.9%], 53-64 years [49.2%], ≥65 years [25.9%]). RESULTS The mean age was 59±9 years with a range from 22 to 79 years. The mean resting Q (Qrest) was not different in the 3 age groups (88±34 mL/min, 82±29 mL/min, and 86±38 mL/min, R2=0.001; p=0.62). A trend towards a decreasing mean hyperaemic Q (Qmax) was observed with increasing age (223±79 mL/min, 209±84 mL/min, 200±80 mL/min, R2=0.010; p=0.083). The mean resting Rμ (Rμ,rest) were 1,204±460 Wood units (WU), 1,260±411 WU, and 1,289±455 WU (p=0.23). The mean hyperaemic Rμ (Rμ,hyp) increased significantly with advancing age (429±149 WU, 464±164 WU, 503±162 WU, R2=0.026; p=0.005). Consequently, MRR decreased with age (3.2±1.2, 3.1±1.0, 2.9±0.9; p=0.038). This trend was present in both the patients with (n=121) and without (n=184) coronary microvascular dysfunction (CMD). CONCLUSIONS There is an age-dependent physiological increase in minimal microvascular resistance and decrease in microvascular function, which is represented by a decreased MRR and is independent of atherosclerosis. The age-dependent decrease in MRR was present in both patients with and without CMD and was most evident in patients with smooth coronary arteries.
Collapse
Affiliation(s)
- Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Caïa Crooijmans
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nico Pijls
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Annemiek de Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Suzette Elias-Smale
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pieter Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
6
|
Schipaanboord DJ, Jansen TP, Crooijmans C, Onland-Moret NC, Elias-Smale SE, Dimitriu-Leen AC, van der Harst P, van de Hoef TP, van Es R, Damman P, den Ruijter HM. ANOCA patients with and without coronary vasomotor dysfunction present with limited electrocardiographic remodeling. IJC HEART & VASCULATURE 2024; 50:101347. [PMID: 38322017 PMCID: PMC10844962 DOI: 10.1016/j.ijcha.2024.101347] [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: 12/15/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/08/2024]
Abstract
Background Coronary vasomotor dysfunction (CVDys) comprises coronary vasospasm (CVS) and/or coronary microvascular dysfunction (CMD) and is highly prevalent in patients with angina and non-obstructive coronary artery disease (ANOCA). Invasive coronary function testing (CFT) to diagnose CVDys is becoming more common, enabling pathophysiologic research of CVDys. This study aims to explore the electrophysiological characteristics of ANOCA patients with CVDys. Methods We collected pre-procedural 12-lead electrocardiograms of ANOCA patients with CVS (n = 35), CMD (n = 24), CVS/CMD (n = 26) and patients without CVDys (CFT-, n = 23) who participated in the NL-CFT registry and underwent CFT. Heart axis and conduction times were compared between patients with CVS, CMD or CVS/CMD and patients without CVDys. Results Heart axis, heart rate, PQ interval and QRS duration were comparable between the groups. A small prolongation of the QT-interval corrected with Bazett (QTcB) and Fridericia (QTcF) was observed in patients with CVDys compared to patients without CVDys (CVS vs CFT-: QTcB = 422 ± 18 vs 414 ± 18 ms (p = 0.14), QTcF = 410 ± 14 vs 406 ± 12 ms (p = 0.21); CMD vs CFT-: QTcB = 426 ± 17 vs 414 ± 18 ms (p = 0.03), QTcF = 413 ± 11 vs 406 ± 12 ms (p = 0.04); CVS/CMD vs CFT-: QTcB = 424 ± 17 vs 414 ± 18 ms (p = 0.05), QTcF = 414 ± 14 vs 406 ± 12 ms (p = 0.04)). Conclusions Pre-procedural 12-lead electrocardiograms were comparable between patients with and without CVDys undergoing CFT except for a slightly longer QTc interval in patients with CVDys compared to patients without CVDys, suggesting limited cardiac remodeling in patients with CVDys.
Collapse
Affiliation(s)
- Diantha J.M. Schipaanboord
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tijn P.J. Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Caïa Crooijmans
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N. Charlotte Onland-Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - Pim van der Harst
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tim P. van de Hoef
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester M. den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - on behalf of the IMPRESS consortium
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Cardiology, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
7
|
Hasdemir H, Taş A, Cevik E, Alan Y, Broyd CJ, Ozcan A, Sonsoz MR, Kara I, Demirtakan ZG, Parker K, Perera D, Umman S, Sezer M. Primary versus iatrogenic (post-PCI) coronary microvascular dysfunction: a wire-based multimodal comparison. Open Heart 2023; 10:e002437. [PMID: 38011991 PMCID: PMC10685972 DOI: 10.1136/openhrt-2023-002437] [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: 07/28/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Although there are studies examining each one separately, there are no data in the literature comparing the magnitudes of the iatrogenic, percutaneous coronary intervention (PCI)-induced, microvascular dysfunction (Type-4 CMD) and coronary microvascular dysfunction (CMD) in the setting of ischaemia in non-obstructed coronary arteries (INOCA) (Type-1 CMD). OBJECTIVES We aimed to compare the characteristics of Type-1 and Type-4 CMD subtypes using coronary haemodynamic (resistance and flow-related parameters), thermodynamic (wave energy-related parameters) and hyperemic ECG changes. METHODS Coronary flow reserve (CFR) value of <2.5 was defined as CMD in both groups. Wire-based multimodal perfusion markers were comparatively analysed in 35 patients (21 INOCA/CMD and 14 CCS/PCI) enrolled in NCT05471739 study. RESULTS Both groups had comparably blunted CFR values per definition (2.03±0.22 vs 2.11±0.37; p: 0.518) and similar hyperemic ST shift in intracoronary ECG (0.16±0.09 vs 0.18±0.07 mV; p: 0.537). While the Type-1 CMD was characterised with impaired hyperemic blood flow acceleration (46.52+12.83 vs 68.20+28.63 cm/s; p: 0.017) and attenuated diastolic microvascular decompression wave magnitudes (p=0.042) with higher hyperemic microvascular resistance (p<0.001), Type-4 CMD had blunted CFR mainly due to higher baseline flow velocity due to post-occlusive reactive hyperemia (33.6±13.7 vs 22.24±5.3 cm/s; p=0.003). CONCLUSIONS The perturbations in the microvascular milieu seen in CMD in INOCA setting (Type-1 CMD) seem to be more prominent than that of seen following elective PCI (Type-4 CMD), although resulting reversible ischaemia is equally severe in the downstream myocardium.
Collapse
Affiliation(s)
- Hakan Hasdemir
- Department of Cardiology, Acibadem Atakent Hospital, Istanbul, Turkey
| | - Ahmet Taş
- Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Asklepios Harzklinik Goslar, Goslar, Germany
| | - Erdem Cevik
- Department of Cardiology, Istanbul University, Fatih, Turkey
| | - Yaren Alan
- Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Christopher J Broyd
- Department of Cardiology, The Prince Charles Hospital, Chermside, Brisbane, Queensland, Australia
| | - Alp Ozcan
- Department of Cardiology, Istanbul University, Fatih, Turkey
| | - Mehmet R Sonsoz
- Department of Cardiology, Başakşehir Çam & Sakura City Hospital, Istanbul, Turkey
| | - Ilke Kara
- Asklepios Harzklinik Goslar, Goslar, Germany
- Bahcesehir Faculty of Medicine, Istanbul, Turkey
| | | | | | - Divaka Perera
- Department of Cardiology, King's College London, London, UK
| | | | - Murat Sezer
- Department of Cardiology, Acibadem International Hospital, Istanbul, Turkey
| |
Collapse
|
8
|
Civieri G, Kerkhof PLM, Montisci R, Iliceto S, Tona F. Sex differences in diagnostic modalities of coronary artery disease: Evidence from coronary microcirculation. Atherosclerosis 2023; 384:117276. [PMID: 37775426 DOI: 10.1016/j.atherosclerosis.2023.117276] [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: 03/24/2023] [Revised: 06/16/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
Although atherosclerosis is usually considered a disease of the large arteries, risk factors for atherosclerosis also trigger structural and functional abnormalities at a microvascular level. In cardiac disease, microvascular dysfunction is especially relevant in women, among whom the manifestation of ischemic disease due to impaired coronary microcirculation is more common than in men. This sex-specific clinical phenotype has important clinical implications and, given the higher pre-test probability of coronary microvascular dysfunction in females, different diagnostic modalities should be used in women compared to men. In this review, we summarize invasive and non-invasive diagnostic modalities to assess coronary microvascular function, ranging from catheter-based evaluation of endothelial function to Doppler echocardiography and positron emission tomography. Moreover, we discuss different clinical settings in which microvascular disease plays an important role, underlining the importance of choosing the right diagnostic modality depending on the sex of the patients.
Collapse
Affiliation(s)
- Giovanni Civieri
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Peter L M Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, the Netherlands
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, Italy
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| |
Collapse
|
9
|
Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
| | | |
Collapse
|
10
|
Taha YK, Dungan JR, Weaver MT, Xu K, Handberg EM, Pepine CJ, Bairey Merz CN. Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA). J Clin Med 2023; 12:5836. [PMID: 37762777 PMCID: PMC10531826 DOI: 10.3390/jcm12185836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/23/2023] [Accepted: 09/02/2023] [Indexed: 09/29/2023] Open
Abstract
Identifying ischemic heart disease (IHD) in women based on symptoms is challenging. Women are more likely to endorse non-cardiac symptoms. More than 50% of women with suspected ischemia have no obstructive coronary disease (and thus, INOCA) and impaired outcomes during follow-up. We aimed to identify symptoms having predictive capacity for INOCA in women with clinical evidence of coronary ischemia. We included 916 women from the original WISE cohort (NCT00000554) who had coronary angiography performed for suspected ischemia and completed a 65-item WISE symptom questionnaire. Sixty-two percent (n = 567) had suspected INOCA. Logistic regression models using a best subsets approach were examined to identify the best predictive model for INOCA based on Score χ2 and AICc. A 10-variable, best-fit model accurately predicted INOCA (AUC 0.72, 95% CI 0.68, 0.75). The model indicated that age ≤ 55 years, left side chest pain, chest discomfort, neck pain, and palpitations had independent, positive relationship (OR > 1) to INOCA (p < 0.001 to 0.008). An inverse relationship (OR < 1) was observed for impending doom, and pain in the jaw, left or bilateral arm, and right hand, interpreted as INOCA associated with the absence of these symptoms (p ≤ 0.001 to 0.023). Our best-fit model accurately predicted INOCA based on age and symptom presentation ~72% of the time. While the heterogeneity of symptom presentation limits the utility of this unvalidated 10-variable model, it has promise for consideration of symptom inclusion in future INOCA prediction risk modeling for women with evidence of symptomatic ischemia.
Collapse
Affiliation(s)
- Yasmeen K. Taha
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - Jennifer R. Dungan
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
- College of Nursing, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA;
| | - Michael T. Weaver
- College of Nursing, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA;
| | - Ke Xu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL 32611, USA;
| | - Eileen M. Handberg
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - Carl J. Pepine
- College of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610, USA; (Y.K.T.); (E.M.H.); (C.J.P.)
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| |
Collapse
|
11
|
Ranasinghe S, Merz CNB, Khan N, Wei J, George M, Berry C, Chieffo A, Camici PG, Crea F, Kaski JC, Marzilli M, Gulati M. Sex Differences in Quality of Life in Patients with Ischemia with No Obstructive Coronary Artery Disease (INOCA): A Patient Self-Report Retrospective Survey from INOCA International. J Clin Med 2023; 12:5646. [PMID: 37685713 PMCID: PMC10488627 DOI: 10.3390/jcm12175646] [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: 07/03/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Women with obstructive coronary artery disease (CAD) have a relatively lower quality of life (QoL) compared to men, but our understanding of sex differences in QoL in ischemia with no obstructive coronary artery disease (INOCA) is limited. We conducted a survey of patient members of INOCA International with an assessment of self-reported health measures. Functional capacity was retrospectively estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed before and after INOCA symptom onset. Of the 1579 patient members, the overall survey completion rate was 21%. Women represented 91% of the respondents. Estimated functional capacity, expressed as metabolic equivalents (METs), was higher before compared to after INOCA diagnosis comparably for both women and men. For every one MET decline in functional capacity, there was a significantly greater decline in QoL for men compared with women in physical health (4.0 ± 1.1 vs. 2.9 ± 0.3 days/month, p < 0.001), mental health (2.4 ± 1.2 vs. 1.8 ± 0.3 days/month, p = 0.001), and social health/recreational activities (4.1 ± 1.0 vs. 2.9 ± 0.3 days/month, p = 0.0001), respectively. In an international survey of patients living with INOCA, despite similar diagnoses, clinical comorbidities, and symptoms, INOCA-related functional capacity declines are associated with a greater adverse impact on QoL in men compared to women.
Collapse
Affiliation(s)
- Sachini Ranasinghe
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Najah Khan
- Houston Methodist Hospital, Houston, TX 77030, USA
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, UK
| | - Alaide Chieffo
- IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Department of Medicine, Vita Salute San Raffaele University, 20132 Milan, Italy
| | | | - Filippo Crea
- Department of Cardiology, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George’s University of London, London SW17 0RE, UK
| | - Mario Marzilli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University of Pisa, 56126 Pisa, Italy
| | - Martha Gulati
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| |
Collapse
|
12
|
Kalkman DN, Couturier EGM, El Bouziani A, Dahdal J, Neefs J, Woudstra J, Vogel B, Trabattoni D, MaassenVanDenBrink A, Mehran R, de Winter RJ, Appelman Y. Migraine and cardiovascular disease: what cardiologists should know. Eur Heart J 2023; 44:2815-2828. [PMID: 37345664 DOI: 10.1093/eurheartj/ehad363] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/06/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.
Collapse
Affiliation(s)
- Deborah N Kalkman
- Department of Clinical and Experimental Cardiology, Heart Center; Amsterdam Cardiovascular Sciences, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Emile G M Couturier
- Department of Neurology, Boerhaave Medisch Centrum, Amsterdam, The Netherlands
| | - Abdelhak El Bouziani
- Department of Clinical and Experimental Cardiology, Heart Center; Amsterdam Cardiovascular Sciences, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Jorge Dahdal
- Department of Cardiology, Heart Center, Amsterdam UMC-Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jolien Neefs
- Department of Clinical and Experimental Cardiology, Heart Center; Amsterdam Cardiovascular Sciences, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke Woudstra
- Department of Cardiology, Heart Center, Amsterdam UMC-Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robbert J de Winter
- Department of Clinical and Experimental Cardiology, Heart Center; Amsterdam Cardiovascular Sciences, Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Heart Center, Amsterdam UMC-Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Favorini S, Perrin T, Hellige G, Arenja N. Sudden cardiac arrest due to recurrent coronary spasm in a young woman: a case report. Eur Heart J Case Rep 2023; 7:ytad253. [PMID: 37378054 PMCID: PMC10291570 DOI: 10.1093/ehjcr/ytad253] [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: 11/29/2022] [Revised: 01/10/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023]
Abstract
Background Coronary artery spasm (CAS) is a pathological condition resulting from transient functional narrowing of the coronary arteries leading to myocardial ischaemia and in some rare cases even to sudden cardiac arrest (SCA). The most important preventable risk factor is use of tobacco, whereas possible precipitating factors include some medications and psychological stress. Case summary A 32-year-old woman was hospitalized with burning chest pain. The immediate investigations revealed the diagnosis of non-ST-segment elevation myocardial infarction, because of ST elevations in one single lead and increased high-sensitivity troponin. Due to ongoing chest pain and a severe impaired left ventricular ejection fraction (LVEF) of 30% with apical akinesia, a prompt coronary angiography (CAG) was scheduled. After aspirin administration, she developed anaphylaxis with pulseless electrical activity (PEA). She could be resuscitated successfully. CAG revealed multi-vessel CAS for which she received calcium channel blockers. Five days after, she suffered from a second SCA due to ventricular fibrillation and was resuscitated again. Repeated CAG showed no critical coronary artery occlusion. LVEF improved progressively during hospitalization. Drug therapy was increased, and a subcutaneous implantable cardioverter defibrillator (ICD) was implanted for secondary prevention. Discussion CAS may in some instances lead to SCA, especially in case of multi-vessel involvement. Allergic and anaphylactic events can trigger CAS, which are frequently underestimated. Regardless of the cause, cornerstone of CAS prophylaxes remains optimal medical therapy as in the avoidance of predisposing risk factors. In case of life-threatening arrhythmia, the implantation of an ICD should be considered.
Collapse
Affiliation(s)
- Serena Favorini
- Department of Cardiology, Spital Uster, Brunnenstrasse 42, 8610 Uster, Switzerland
| | - Tilman Perrin
- Department of Cardiology, Kantonsspital Olten and Bürgerspital Solothurn, Schöngrünstrasse 36A, 4500 Solothurn, Switzerland
| | - Gerrit Hellige
- Department of Cardiology, Kantonsspital Olten and Bürgerspital Solothurn, Schöngrünstrasse 36A, 4500 Solothurn, Switzerland
| | | |
Collapse
|
14
|
Woudstra J, Vink CEM, Schipaanboord DJM, Eringa EC, den Ruijter HM, Feenstra RGT, Boerhout CKM, Beijk MAM, de Waard GA, Ong P, Seitz A, Sechtem U, Piek JJ, van de Hoef TP, Appelman Y. Meta-analysis and systematic review of coronary vasospasm in ANOCA patients: Prevalence, clinical features and prognosis. Front Cardiovasc Med 2023; 10:1129159. [PMID: 36993994 PMCID: PMC10041338 DOI: 10.3389/fcvm.2023.1129159] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Background Coronary artery spasm (CAS), encompassing epicardial and microvascular spasm, is increasingly recognized as cause of angina in patients with non-obstructive coronary artery disease (ANOCA). However, various spasm provocation testing protocols and diagnostic criteria are used, making diagnosis and characterization of these patients difficult and interpretation of study results cumbersome. This review provides a structured overview of the prevalence, characterization and prognosis of CAS worldwide in men and women. Methods A systematic review identifying studies describing ANOCA patients with CAS was performed. Multiple outcomes (prevalence, clinical features, and prognosis) were assessed. Data, except for prognosis were pooled and analysed using random effects meta-analysis models. Results Twenty-five publications (N = 14.554) were included (58.2 years; 44.2% women). Percentages of epicardial constriction to define epicardial spasm ranged from >50% to >90%. Epicardial spasm was prevalent in 43% (range 16-73%), with a higher prevalence in Asian vs. Western World population (52% vs. 33%, p = 0.014). Microvascular spasm was prevalent in 25% (range 7-39%). Men were more likely to have epicardial spasm (61%), women were more likely to have microvascular spasm (64%). Recurrent angina is frequently reported during follow-up ranging from 10 to 53%. Conclusion CAS is highly prevalent in ANOCA patients, where men more often have epicardial spasm, women more often have microvascular spasm. A higher prevalence of epicardial spasm is demonstrated in the Asian population compared to the Western World. The prevalence of CAS is high, emphasizing the use of unambiguous study protocols and diagnostic criteria and highlights the importance of routine evaluation of CAS in men and women with ANOCA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272100.
Collapse
Affiliation(s)
- Janneke Woudstra
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Diantha J M Schipaanboord
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Rutger G T Feenstra
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Coen K M Boerhout
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Marcel A M Beijk
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Guus A de Waard
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Peter Ong
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Andreas Seitz
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Tim P van de Hoef
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
15
|
Initial single-center experience of a standardized protocol for invasive assessment of ischemia and no obstructive coronary artery disease. Rev Port Cardiol 2023; 42:455-465. [PMID: 36828182 DOI: 10.1016/j.repc.2022.05.011] [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: 02/06/2022] [Accepted: 05/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Coronary vasomotion disorders (CVDs), including microvascular angina (MVA) and vasospastic angina (VSA), account for significant morbidity among patients with non-obstructive coronary artery disease (NOCAD). However, protocols for CVD assessment in clinical practice are seldom standardized and may be difficult to implement. PURPOSE To assess the safety and feasibility of a comprehensive coronary function test (CFT) protocol for assessment of CVD and the prevalence of different phenotypes of CVD in patients with angina and NOCAD (ANOCA). METHODS Patients with persistent angina referred for invasive coronary angiogram and found to have NOCAD were prospectively recruited and underwent a CFT. Functional parameters (fractional flow reserve, coronary flow reserve and index of myocardial resistance) and coronary vasoreactivity were assessed in all patients. RESULTS Of the 20 patients included, the mean age was 63±13 years and 50% were females. Most patients had persistent typical angina and evidence of ischemia in noninvasive tests (75%). The CFT was successfully performed in all subjects without serious complications. Isolated MVA was found in 25%, isolated VSA in 40%, both MVA and VSA in 10% and noncardiac chest pain in 25% of patients. Antianginal therapy was modified after the results of CFT in 70% of patients. CONCLUSION A coronary function test was feasible and safe in a cohort of patients with ANOCA. CVD were prevalent in this selected group of patients, and some presented mixed CVD phenotypes. CFT may provide a definitive diagnosis in patients with persistent angina and prompt the stratification of pharmacological therapy.
Collapse
|
16
|
Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
Collapse
Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
| |
Collapse
|
17
|
Maas AHEM, Damman P. Some endotypes of microvascular dysfunction may be more worrisome than others. EUROINTERVENTION 2022; 18:703-704. [PMID: 36269210 PMCID: PMC10241298 DOI: 10.4244/eij-e-22-00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
18
|
Abouelnour A, Gori T. Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies. Biomedicines 2021; 9:biomedicines9121774. [PMID: 34944590 PMCID: PMC8698648 DOI: 10.3390/biomedicines9121774] [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: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.
Collapse
Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Cardiovascular Institute, Assiut University, Assiut 71515, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Correspondence:
| |
Collapse
|