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Denby KJ, Zmaili M, Datta S, Das T, Ellis S, Ziada K, Lerman A, Raphael CE. Developments and Controversies in Invasive Diagnosis of Coronary Microvascular Dysfunction in Angina With Nonobstructive Coronary Arteries. Mayo Clin Proc 2024; 99:1469-1481. [PMID: 39232622 DOI: 10.1016/j.mayocp.2024.04.022] [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: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 09/06/2024]
Abstract
Approximately half of all coronary angiograms performed for angina do not show obstructive coronary artery disease, and many of these patients have coronary microvascular dysfunction (CMD). Invasive testing for CMD has increased with the advent and wider availability of thermodilution systems. We review CMD pathophysiology and invasive diagnostic testing using the Doppler and thermodilution systems. We report the results of a PubMed search of invasive microvascular testing and discuss limitations of current diagnostic algorithms in the diagnosis of CMD, including controversies regarding the optimal cutoff value for abnormal coronary flow reserve, use of microvascular resistance indices, and options for increasing sensitivity of testing.
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Affiliation(s)
- Kara J Denby
- Department of Cardiovascular Medicine, Saint Alphonsus Regional Medical Center, Boise, ID
| | - Mohammad Zmaili
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Sudarshana Datta
- Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston
| | - Thomas Das
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Stephen Ellis
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Khaled Ziada
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Feenstra RGT, Timmerman LS, Piek JJ, Beijk MAM. Do electrocardiographic changes induced during intracoronary vasospasm provocation testing reflect those during spontaneous angina episodes in patients with vasospastic angina?: a case series. Eur Heart J Case Rep 2024; 8:ytae386. [PMID: 39161720 PMCID: PMC11332263 DOI: 10.1093/ehjcr/ytae386] [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: 08/02/2023] [Revised: 02/01/2024] [Accepted: 07/17/2024] [Indexed: 08/21/2024]
Abstract
Background According to the Coronary Vasomotor Disorders International Study (COVADIS) group, the ECG criteria supporting the diagnosis of vasospastic angina (VSA) in spontaneous episodes or induced during intracoronary spasm testing are similar. However, it remains elusive whether acetylcholine-induced ECG changes during epicardial spasms reflect ECG changes that occur during the height of a spontaneous episode. Case summary We present four patients diagnosed with VSA during intracoronary spasm testing, of whom the ECG characteristics during spasm testing and a spontaneous angina episode are described. All patients have >90% coronary epicardial vasoconstriction in one or more vessels during acetylcholine provocation. ECGs at the height of a spontaneous episode and during acetylcholine-induced coronary spasm are found to be different in three out of four patients. Discussion In patients with VSA, the ECG at the height of a spontaneous episode and during acetylcholine-induced coronary artery spasm may differ substantially. In patients with symptoms suspicious of VSA, every effort should be undertaken to obtain ECGs during the height of a spontaneous episode of angina pectoris and there should be a low threshold to perform intracoronary function testing.
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Affiliation(s)
- Rutger G T Feenstra
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Lotte S Timmerman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
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Spiro J, Ford TJ, Yong A, Zeitz C, Beltrame JF. Protocol Variation in Functional Coronary Angiography Among Patients With Suspected Angina With Non-Obstructive Coronary Arteries: A Nationwide Snapshot of Current Practice Within Australia and New Zealand. Heart Lung Circ 2024:S1443-9506(24)00588-2. [PMID: 38951052 DOI: 10.1016/j.hlc.2024.04.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Functional coronary angiography (FCA) for endotype characterisation (vasospastic angina [VSA], coronary microvascular disease [CMD], or mixed) is recommended among patients with angina with non-obstructive coronary arteries. Whilst clear diagnostic criteria for VSA and CMD exist, there is no standardised FCA protocol. Variations in testing protocol may limit the widespread uptake of testing, generalisability of results, and expansion of collaborative research. At present, there are no data describing protocol variation across an entire geographic region. Therefore, we aimed to capture current practice variations in the approach to FCA to improve access and standardisation for diagnosis of coronary vasomotor disorders in Australia and New Zealand. METHOD Between July 2022 and July 2023, we conducted a national survey across all centres in Australia and New Zealand with an active FCA program. The survey captured attitudes towards FCA and protocols used for diagnosis of coronary vasomotor disorders at 33 hospitals across Australia and New Zealand. RESULTS Survey responses were received from 39 clinicians from 33 centres, with representation from centres within all Australian states and territories and both North and South Islands of New Zealand. A total of 21 centres were identified as having an active FCA program. In general, respondents agreed that comprehensive physiology testing helped inform clinical management. Barriers to program expansion included cost, additional catheter laboratory time, and the absence of an agreed-upon national protocol. Across the clinical sites, there were significant variations in testing protocol, including the technique used (Doppler vs thermodilution), order of testing (hyperaemia resistance indices first vs vasomotor function testing first), rate and dose of acetylcholine administration, routine use of temporary pacing wire, and routine single vs multivessel testing. Overall, testing was performed relatively infrequently, with very little follow-on FCA performed, despite nearly all respondents believing this would be clinically useful. CONCLUSIONS This survey demonstrates, for the first time, variations in FCA protocol among testing centres across two entire countries. Furthermore, whilst FCA was deemed clinically important, testing was performed relatively infrequently with little or no follow-on testing. Development and adoption of a standardised national FCA protocol may help improve patient access to testing and facilitate further collaborative research within Australia and New Zealand.
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Affiliation(s)
- Jon Spiro
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia.
| | - Thomas J Ford
- Department of Cardiology, Gosford Hospital, Central Coast Local Health District, Gosford, NSW, Australia
| | - Andy Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Chris Zeitz
- Department of Cardiology, Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia; University of Adelaide, Basil Hetzel Institute, Adelaide, SA, Australia
| | - John F Beltrame
- Department of Cardiology, Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia; University of Adelaide, Basil Hetzel Institute, Adelaide, SA, Australia
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Rehan R, Wong CCY, Cooke C, Weaver J, Jain P, Adams M, Ng MKC, Yong ASC. Prevalence of Coronary Vasomotor Disorders in Patients With Angina and Nonobstructive Coronary Arteries: A Sydney Experience. Heart Lung Circ 2024:S1443-9506(24)00161-6. [PMID: 38925996 DOI: 10.1016/j.hlc.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes. METHOD Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing. RESULTS This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007). CONCLUSIONS Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, University of Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. https://twitter.com/RajanRehan23
| | - Christopher C Y Wong
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, University of Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Charlie Cooke
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - James Weaver
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pankaj Jain
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Mark Adams
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Martin K C Ng
- Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Andy S C Yong
- Department of Cardiology, Concord Hospital, University of Sydney, NSW, Australia; Faculty of Medicine, Health, and Human Sciences, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.
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5
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Rehan R, Wong CCY, Weaver J, Chan W, Tremmel JA, Fearon WF, Ng MKC, Yong ASC. Multivessel Coronary Function Testing Increases Diagnostic Yield in Patients With Angina and Nonobstructive Coronary Arteries. JACC Cardiovasc Interv 2024; 17:1091-1102. [PMID: 38749588 DOI: 10.1016/j.jcin.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield. OBJECTIVES The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA). METHODS Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 μg) and right (20 to 80μg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels. RESULTS This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486). CONCLUSIONS Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.
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Affiliation(s)
- Rajan Rehan
- Royal Prince Alfred Hospital, Sydney, Australia
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Teragawa H, Oshita C, Uchimura Y. Do changes in intracoronary pressure aid coronary spasm diagnosis using the spasm provocation test? World J Cardiol 2024; 16:16-26. [PMID: 38313387 PMCID: PMC10835468 DOI: 10.4330/wjc.v16.i1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Although the spasm provocation test (SPT) can diagnose coronary spasms, it would be helpful if it could also predict their occurrence. AIM To investigate whether coronary spasms can be predicted using changes in intracoronary artery pressure measured using a pressure wire during the SPT. METHODS Seventy patients underwent SPTs with pressure-wire measurement of intracoronary artery pressure. During each SPT, the pressure wire was advanced into the distal portion of the right coronary artery (RCA) and left anterior descending coronary artery, and the ratio of intracoronary pressure to aortic pressure (Pd/Pa) was monitored. Coronary spasm was defined as an arterial narrowing of > 90% in response to the administration of acetylcholine (ACh), with chest symptoms and/or ischemic electrocardiographic changes. ACh was administered to the RCA at low, moderate, or high doses of 20, 50, or 80 µg, respectively, and to the left coronary artery (LCA) at low, moderate, or high doses of 50, 100, or 200 µg, respectively. Coronary arteries with coronary spasms at low doses of ACh were defined as group L, and those with coronary spasms at moderate or high doses were defined as group MH. Those who did not occur coronary spasms at any ACh dose were designated as group N. RESULTS Among the 132 coronary arteries assessed using a pressure wire, there were 49 in group N, 25 in group L, and 58 in group MH. Baseline Pd/Pa was the lowest in group L (P = 0.001). The decrease in the Pd/Pa between baseline to low doses of ACh was lower in group MH than in group N (P < 0.001). A receiver-operating characteristics analysis showed that the cutoff baseline Pd/Pa value for predicting group L was 0.95, with a sensitivity of 0.600 (15/25) and a specificity of 0.713 (76/107) and that the cutoff value of Pd/Pa from baseline to low doses of ACh for predicting group MH was -0.04, with a sensitivity of 0.741 (43/58) and a specificity of 0.694 (34/49). CONCLUSION These findings suggest that indices of intracoronary pressure during SPT may be useful means for predicting the occurrence of coronary spasms.
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Affiliation(s)
- Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan.
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan
| | - Yuko Uchimura
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima 732-0057, Japan
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7
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Yaker ZS, Lincoff AM, Cho L, Ellis SG, Ziada KM, Zieminski JJ, Gulati R, Gersh BJ, Holmes D, Raphael CE. Coronary spasm and vasomotor dysfunction as a cause of MINOCA. EUROINTERVENTION 2024; 20:e123-e134. [PMID: 38224252 PMCID: PMC10786177 DOI: 10.4244/eij-d-23-00448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
Increasing evidence has shown that coronary spasm and vasomotor dysfunction may be the underlying cause in more than half of myocardial infarctions with non-obstructive coronary arteries (MINOCA) as well as an important cause of chronic chest pain in the outpatient setting. We review the contemporary understanding of coronary spasm and related vasomotor dysfunction of the coronary arteries, the pathophysiology and prognosis, and current and emerging approaches to diagnosis and evidence-based treatment.
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Affiliation(s)
- Zachary S Yaker
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Picard F, Adjedj J, Collet JP, Van Belle E, Monsegu J, Karsenty B, Dupouy P, Quillot M, Bonnet G, Gautier A, Cayla G, Benamer H. Pharmacological coronary spasm provocative testing in clinical practice: A French Coronary Atheroma and Interventional Cardiology Group (GACI) position paper. Arch Cardiovasc Dis 2023; 116:590-596. [PMID: 37891058 DOI: 10.1016/j.acvd.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023]
Abstract
Vasospastic angina, also described as Prinzmetal angina, was first described as a variant form of angina at rest with transient ST-segment elevation; it is common and present in many clinical scenarios, including chronic and acute coronary syndromes, sudden cardiac death, arrhythmia and syncope. However, vasospastic angina remains underdiagnosed, and provocative tests are rarely performed. The gold-standard diagnostic approach uses invasive coronary angiography to induce coronary spasm using ergonovine, methylergonovine or acetylcholine as provocative stimuli. The lack of uniform protocol decreases the use and performance of these tests, accounting for vasospastic angina underestimation. This position paper from the French Coronary Atheroma and Interventional Cardiology Group (GACI) aims to review the indications for provocative tests, the testing conditions, drug protocols and positivity criteria.
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Affiliation(s)
- Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France.
| | - Julien Adjedj
- Department of Cardiology, Institut Arnault-Tzanck, 06700 Saint-Laurent-du-Var, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, AP-HP, 75013 Paris, France
| | - Eric Van Belle
- CHU Lille, Department of Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, INSERM U1011, Institut Pasteur de Lille, EGID, Université de Lille, 59000 Lille, France
| | - Jacques Monsegu
- Department of Interventional Cardiology, Institut Cardio-Vasculaire, Groupe Hospitalier Mutualiste Grenoble, 38000 Grenoble, France
| | | | - Patrick Dupouy
- Pôle Cardio-Vasculaire Interventionnel, Clinique les Fontaines, 77000 Melun, France
| | - Marine Quillot
- Department of Interventional Cardiology, Centre Hospitalier Henri-Duffaut, 84000 Avignon, France
| | - Guillaume Bonnet
- Haut-Lévêque Cardiology Hospital, Bordeaux University, 33600 Pessac, France
| | - Alexandre Gautier
- Department of Cardiology, Hôpital Bichat, AP-HP, 75018 Paris, France
| | - Guillaume Cayla
- Cardiology Department, Nîmes University Hospital, Montpellier University, 30900 Nîmes, France
| | - Hakim Benamer
- ICPS Jacques Cartier, Ramsay Générale de Santé, 91300 Massy, France; ICV-GVM La Roseraie, 93300 Aubervilliers, France; Hôpital Foch, 92150 Suresnes, France
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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
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Boerhout C, Feenstra R, van de Hoef T, Piek J, Beijk M. Pharmacotherapy in patients with vasomotor disorders. IJC HEART & VASCULATURE 2023; 48:101267. [PMID: 37727753 PMCID: PMC10505589 DOI: 10.1016/j.ijcha.2023.101267] [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: 07/20/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Abstract
Background Anginal symptoms in patients with non-obstructive coronary artery disease are frequently related to vasomotor disorders of the coronary circulation. Although frequently overlooked, a distinct diagnosis of different vasomotor disorders can be made by intracoronary function testing. Early detection and treatment seems beneficial, but little evidence is available for the medical treatment of these disorders. Nevertheless, there are several pharmacotherapeutic options available to treat these patients and improve quality of life. Methods & findings We performed an extensive yet non-systematic literature search to explore available pharmacotherapeutic strategies for addressing vasomotor disorders in individuals experiencing angina and non-obstructive coronary artery disease. This article presents a comprehensive overview of therapeutic possibilities for patients exhibiting abnormal vasoconstriction (such as spasm) and abnormal vasodilation (like coronary microvascular dysfunction). Conclusion Treatment of vasomotor disorders can be very challenging, but a general treatment algorithm based on the existing evidence and the best available current practice is feasible.
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Affiliation(s)
| | | | - T.P. van de Hoef
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J.J. Piek
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - M.A.M. Beijk
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
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11
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Seitz A, Martínez Pereyra V, Froebel S, Hubert A, McChord J, Bekeredjian R, Sechtem U, Ong P. Characterization and implications of intracoronary hemodynamic assessment during coronary spasm provocation testing. Clin Res Cardiol 2023; 112:1312-1321. [PMID: 37195455 DOI: 10.1007/s00392-023-02224-1] [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: 03/22/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Current diagnostic criteria for coronary spasm are based on patient's symptoms, ECG shifts and epicardial vasoconstriction during acetylcholine (ACh) spasm testing. AIMS To assess the feasibility and diagnostic value of coronary blood flow (CBF) and resistance (CR) assessment as objective parameters during ACh testing. METHODS Eighty-nine patients who underwent intracoronary reactivity testing including ACh testing with synchronous Doppler wire-based measurements of CBF and CR were included. Coronary microvascular and epicardial spasm, respectively, were diagnosed based on COVADIS criteria. RESULTS Patients were 63 ± 13 years old, predominantly female (69%) and had preserved LV ejection fraction (64 ± 8%). Overall, assessment of CBF and CR during ACh testing revealed a decrease in CBF of 0.62 (0.17-1.53)-fold and an increase of CR of 1.45 [0.67-4.02]-fold in spasm patients compared to 2.08 (1.73-4.76) for CBF and 0.45 (0.44-0.63) for CR in patients without coronary spasm (both p < 0.01). Receiver operating characteristic revealed a high diagnostic ability of CBF and CR (AUC 0.86, p < 0.001, respectively) in identifying patients with coronary spasm. However, in 21% of patients with epicardial spasm and 42% of patients with microvascular spasm a paradoxical response was observed. CONCLUSIONS This study demonstrates feasibility and potential diagnostic value of intracoronary physiology assessments during ACh testing. We observed opposite responses of CBF and CR to ACh in patients with positive vs. negative spasm test. While a decrease in CBF and an increase in CR during ACh seem pathognomonic for spasm, some patients with coronary spasm demonstrate paradoxical ACh response demanding further scientific investigations.
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Affiliation(s)
- Andreas Seitz
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany.
| | - Valeria Martínez Pereyra
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Sarah Froebel
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Johanna McChord
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert Bosch Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
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12
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Feenstra RG, Jansen TP, Matthijs Boekholdt S, Brouwer JE, Klees MI, Appelman Y, Wittekoek ME, van de Hoef TP, de Winter RJ, Piek JJ, Damman P, Beijk MA. Efficacy and safety of the endothelin-1 receptor antagonist macitentan in epicardial and microvascular vasospasm; a proof-of-concept study. IJC HEART & VASCULATURE 2023; 47:101238. [PMID: 37576078 PMCID: PMC10422675 DOI: 10.1016/j.ijcha.2023.101238] [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: 05/15/2023] [Revised: 06/05/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
Background Treatment of patients diagnosed with angina due to epicardial or microvascular coronary artery spasm (CAS) is challenging because patients often remain symptomatic despite conventional pharmacological therapy. In this prospective, randomized, double-blind, placebo-controlled, sequential cross-over proof-of-concept study, we compared the efficacy and safety of macitentan, a potent inhibitor of the endothelin-1 receptor, to placebo in symptomatic patients with CAS despite background pharmacological treatment. Methods Patients with CAS diagnosed by invasive spasm provocation testing with >3 anginal attacks per week despite pharmacological treatment were considered for participation. Participants received either 10 mg of macitentan or placebo daily for 28 days as add-on treatment. After a wash-out period patients were crossed over to the alternate treatment arm. The primary endpoint was the difference in anginal burden calculated as [1] the duration (in minutes) * severity (on a Visual Analogue Scale (VAS) pain scale 1-10); and [2] the frequency of angina attacks * severity during medication use compared to the run-in phase. Results 28 patients of whom 22 females (79%) and a mean age of 55.3 ± 7.6 completed the entire study protocol (epicardial CAS n = 19 (68), microvascular CAS n = 9 (32)). Change in both indices of anginal burden were not different during treatment with add-on macitentan as compared to add-on placebo (duration*severity: -9 [-134 78] vs -45 [-353 11], p = 0.136 and frequency*severity: -1.7 [-5.8 1.2] vs -1.8 [-6.2 0.3], p = 0.767). The occurrence and nature of self-reported adverse events were closely similar between the treatment phase with macitentan and placebo. Conclusion In patients with angina due to epicardial or microvascular CAS despite background pharmacological treatment, 28 days of add-on treatment with the ET-1 receptor antagonist, macitentan 10 mg daily, did not reduce anginal burden compared to add-on treatment with placebo.Trial Registrationhttps://trialsearch.who.int/, Identifier: EUCTR2018-002623-42-NL. Registration date: 20 February 2019.
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Affiliation(s)
- Rutger G.T. Feenstra
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Tijn P.J. Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S. Matthijs Boekholdt
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Janet E. Brouwer
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Margriet I. Klees
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Yolande Appelman
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Tim P. van de Hoef
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robbert J. de Winter
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jan J. Piek
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel A.M. Beijk
- Amsterdam UMC, Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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13
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Boerhout CKM, Beijk MAM, Damman P, Piek JJ, van de Hoef TP. Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review. Korean Circ J 2023; 53:519-534. [PMID: 37525496 PMCID: PMC10435829 DOI: 10.4070/kcj.2023.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 08/02/2023] Open
Abstract
Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.
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Affiliation(s)
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medica Centre, Nijmegen, The Netherlands
| | - Jan J Piek
- Heart Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Division Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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14
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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.
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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
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15
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Grigorian-Shamagian L, Oteo JF, Gutiérrez-Barrios A, Abdul-Jawad Altisent O, Amat-Santos I, Cisnal AF, Roa J, Arellano Serrano C, Fadeuilhe E, Cortés C, Sanz-Ruiz R, Vázquez-Alvarez ME, Díez Delhoyo F, Tamargo M, Soriano J, Elízaga J, Fernández-Avilés F, Gutiérrez E. Endothelial dysfunction in patients with angina and non-obstructed coronary arteries is associated with an increased risk of mayor cardiovascular events. Results of the Spanish ENDOCOR registry. Int J Cardiol 2023; 370:18-25. [PMID: 36328111 DOI: 10.1016/j.ijcard.2022.10.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/16/2022] [Accepted: 10/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Coronary endothelial dysfunction and vasospasm are potential causes of ischemia in patients without obstructive coronary stenoses (INOCA). OBJECTIVE To evaluate the prevalence of endothelial dysfunction and the clinical profile of patients with INOCA in Spain, as well as to identify the predictors and the prognostic impact of endothelial dysfunction in this scenario. METHODS A total of 438 consecutive patients with INOCA in whom the acetylcholine test was performed were prospectively enrolled. Patients were followed up at 1 and 2 years. RESULTS Mean age was 62 ± 11 years with 60% female. Clinical presentation comprised 52.6% angina at rest, 61.2% exertional angina, and 31.7% dyspnea. There were no major complications of the acetylcholine test. Endothelial dysfunction was observed in 198 (45%) of patients, with severe vasoconstriction (defined as over 70% constriction), being observed in 101 (23%). Multivariable regression analysis showed that endothelial dysfunction was predicted by the presence of exertional angina (OR 2.2; CI95%1.01-2.55; p = 0.02), prior coronary disease (OR 2.46; CI95% 1.57-3.89; p < 0.01), and coronary intramyocardial bridging (2.35; CI95% 1.02-5.60; p = 0.04). Patients with endothelial dysfunction presented with worsening angina compared to those without endothelial dysfunction (25.6% vs. 12.8%) and also presented with increased levels of minimal effort angina (40% vs. 26,7%, p = 0.03) more frequently during the follow up than those without endothelial dysfunction. Endothelial dysfunction was also an independent predictor of the occurrence of myocardial infarction or unstable angina at one year (OR 2.85, CI 95% 1.01-9.25; p = 0.03). CONCLUSIONS Endothelial dysfunction is present in almost half of patients with INOCA and is associated with worsening symptoms, as well as with a higher rate of adverse events.
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Affiliation(s)
- Lilian Grigorian-Shamagian
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | | | | | | | - Ignacio Amat-Santos
- Departamento de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Jessica Roa
- Hospital Juan Ramón Jiménez de Huelva, Spain
| | | | | | - Carlos Cortés
- Departamento de Cardiología, Hospital Clínico Universitario, Valladolid, Spain
| | - Ricardo Sanz-Ruiz
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - María Eugenia Vázquez-Alvarez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - Felipe Díez Delhoyo
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - María Tamargo
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - Javier Soriano
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - Jaime Elízaga
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain
| | - Enrique Gutiérrez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Spain; Universidad Complutense de Madrid, Spain; Centro de investigación biomédica en red - Enfermedades cardiovasculares (CIBERCV, Instituto de Salud Carlos III, Madrid), Spain.
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16
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Mehta PK, Huang J, Levit RD, Malas W, Waheed N, Bairey Merz CN. Ischemia and no obstructive coronary arteries (INOCA): A narrative review. Atherosclerosis 2022; 363:8-21. [PMID: 36423427 PMCID: PMC9840845 DOI: 10.1016/j.atherosclerosis.2022.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/30/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Myocardial ischemia with no obstructive coronary arteries (INOCA) is a chronic coronary syndrome condition that is increasingly being recognized as a substantial contributor to adverse cardiovascular mortality and outcomes, including myocardial infarction and heart failure with preserved ejection fraction (HFpEF). While INOCA occurs in both women and men, women are more likely to have the finding of INOCA and are more adversely impacted by angina, with recurrent hospitalizations and a lower quality of life with this condition. Abnormal epicardial coronary vascular function and coronary microvascular dysfunction (CMD) have been identified in a majority of INOCA patients on invasive coronary function testing. CMD can co-exist with obstructive epicardial coronary artery disease (CAD), diffuse non-obstructive epicardial CAD, and with coronary vasospasm. Epicardial vasospasm can also occur with normal coronary arteries that have no atherosclerotic plaque on intravascular imaging. While all predisposing factors are not clearly understood, cardiometabolic risk factors, and endothelium dependent and independent mechanisms that increase oxidative stress and inflammation are associated with microvascular injury, CMD and INOCA. Cardiac autonomic dysfunction has also been implicated in abnormal vasoreactivity and persistent symptoms. INOCA is under-recognized and under-diagnosed, partly due to the heterogenous patient populations and mechanisms. However, diagnostic testing methods are available to guide INOCA management. Treatment of INOCA is evolving, and focuses on cardiac risk factor control, improving ischemia, reducing atherosclerosis progression, and improving angina and quality of life. This review focuses on INOCA, relations to HFpEF, available diagnostics, current and investigational therapeutic strategies, and knowledge gaps in this condition.
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Affiliation(s)
- Puja K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jingwen Huang
- J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca D Levit
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Waddah Malas
- Cardiovascular Disease Fellowship Training Program, Loyola Medical Center, Chicago, IL, USA
| | - Nida Waheed
- Cardiovascular Disease Fellowship Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
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17
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Bockus L, Kim F. Coronary endothelial dysfunction: from pathogenesis to clinical implications. Open Heart 2022; 9:e002200. [PMID: 36600608 PMCID: PMC9743399 DOI: 10.1136/openhrt-2022-002200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Endothelial dysfunction (ED) has a substantial role in the pathogenesis of atherosclerosis and other vascular diseases. Multiple risk factors, including smoking, hyperlipiadaemia and diabetes, can have associated ED, which is correlated with cardiac events. Measurement of coronary artery endothelial function requires the use of invasive techniques to assess both epicardial coronary artery and microvascular beds. Peripheral vascular techniques and endothelial biomarkers can be used to indirectly assess coronary ED. In this review of coronary artery ED, we discuss the current state of the field, the techniques used to measure ED and its clinical implications.
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Affiliation(s)
- Lee Bockus
- Deparment of Medicine, University of Washington, Seattle, Washington, USA
| | - Francis Kim
- Deparment of Medicine, University of Washington, Seattle, Washington, USA
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18
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Travieso A, Jeronimo-Baza A, Faria D, Shabbir A, Mejia-Rentería H, Escaned J. Invasive evaluation of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:2474-2486. [PMID: 35618991 PMCID: PMC9553758 DOI: 10.1007/s12350-022-02997-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022]
Abstract
Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Adrian Jeronimo-Baza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Daniel Faria
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Asad Shabbir
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Hernan Mejia-Rentería
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain.
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19
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Feenstra RG, Boerhout CK, Vink CE, Woudstra J, Wittekoek ME, de Waard GA, Appelman Y, Eringa EC, Marques KM, de Winter RJ, van de Hoef TP, Beijk MA, Piek JJ. Haemodynamic characterisation of different endotypes in coronary artery vasospasm in reaction to acetylcholine. IJC HEART & VASCULATURE 2022; 42:101105. [PMID: 36017267 PMCID: PMC9396389 DOI: 10.1016/j.ijcha.2022.101105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 10/25/2022]
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Management des chronischen Koronarsyndroms. Herz 2022; 47:472-482. [DOI: 10.1007/s00059-022-05137-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/27/2022]
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Feenstra RGT, Boerhout CKM, Woudstra J, Vink CEM, Wittekoek ME, de Waard GA, Appelman Y, Eringa EC, Marques KMJ, de Winter RJ, Beijk MAM, van de Hoef TP, Piek JJ. Presence of Coronary Endothelial Dysfunction, Coronary Vasospasm, and Adenosine-Mediated Vasodilatory Disorders in Patients With Ischemia and Nonobstructive Coronary Arteries. Circ Cardiovasc Interv 2022; 15:e012017. [PMID: 35904014 DOI: 10.1161/circinterventions.122.012017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary function testing in patients with ischemia and nonobstructive coronary arteries (INOCA) commonly includes assessment of adenosine-mediated vasodilation and acetylcholine spasm provocation. The purpose of this study was to evaluate the diagnostic value of additional endothelial function testing for the diagnosis of vasomotor dysfunction in patients with INOCA. METHODS In this retrospective cohort study, we included patients with INOCA who underwent clinically indicated comprehensive coronary function testing. Endothelial dysfunction was defined as a <50% increase in coronary blood flow, determined by Doppler flow, and/or epicardial vasoconstriction compared to baseline, in response to low-dose acetylcholine. Coronary artery spasm (CAS) was defined as vasospastic angina or microvascular angina in response to coronary high-dose acetylcholine. An impaired adenosine-mediated vasodilation was defined as a coronary flow reserve <2.5 and/or hyperemic microvascular resistance ≥2.5. RESULTS Among all 110 patients, 79% had endothelial dysfunction, 62% had CAS, and 29% had an impaired adenosine-mediated vasodilation. Endothelial dysfunction was present in 80% of patients who tested positively for CAS and/or an impaired adenosine-mediated vasodilation. Endothelial function testing increases the diagnostic yield of coronary function testing that only incorporates adenosine testing and spasm provocation by 17% to 92%. Of patients with normal adenosine-mediated vasodilation and no inducible CAS, 68% had endothelial dysfunction. CONCLUSIONS Concomitant endothelial dysfunction was prevalent in the vast majority of patients with INOCA with inducible CAS and/or an impaired adenosine-mediated vasodilation. In patients with INOCA without inducible CAS and normal adenosine-mediated vasodilation, two-thirds had endothelial dysfunction. These results indicate the relevance to perform endothelial function testing in patients with INOCA in view of its therapeutic implication.
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Affiliation(s)
- Rutger G T Feenstra
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Janneke Woudstra
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | | | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Etto C Eringa
- Department of Physiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam UMC, the Netherlands (E.C.E.).,Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (E.C.E.)
| | - Koen M J Marques
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.).,Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands (T.P.v.d.H.)
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
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22
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Kunadian V, Raharjo DE. Breaking down the barriers in the management of INOCA: how can we do better in the diagnosis of coronary vasomotor disorders? EUROINTERVENTION 2022; 17:1201-1203. [PMID: 35177382 PMCID: PMC9725083 DOI: 10.4244/eij-e-21-00008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Vijay Kunadian
- 4th Floor, William Leech Building, Newcastle University Medical School, NE2 4HH Newcastle upon Tyne, United Kingdom
| | - Daniell Edward Raharjo
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom,Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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