Myocardial Ischemic Syndromes, Heart Failure Syndromes, Electrocardiographic Abnormalities, Arrhythmic Syndromes and Angiographic Diagnosis of Coronary Artery Spasm: Literature Review

Case Report: Delayed diagnosis: a case of left main coronary artery spasm

Left main coronary artery (LMCA) spasm is an exceedingly rare but potentially fatal condition. We present a case of severe stenosis of LMCA found by coronary angiography (CAG) due to recurrent chest pain, and subsequently received coronary artery bypass grafting (CABG). Nine years later, the patient was readmitted to the hospital because of precordial discomfort. During hospitalization, CAG was performed once again and showed no significant stenosis in the LMCA, leading to the diagnosis of LMCA spasm. This case emphasizes to interventional cardiologists the critical need to consider the possibility of LMCA spasm when diagnosing LMCA lesions. It highlights the importance of thorough and proactive pretreatment and comprehensive clinical judgment to minimize the risk of misdiagnosis.

Effects of statins in patients with coronary artery spasm: A nationwide population-based study

Controversies regarding the benefits of statin treatment on clinical outcomes in coronary artery spasm (CAS) without obstructive coronary artery disease (CAD) persist due to limited data. In this retrospective nationwide population-based cohort study from the Taiwan National Health Insurance Research Database during the period 2000-2012, the matched cohorts consisted of 12,000 patients with CAS. After propensity score matching with 1:1 ratio, 2216 patients were eligible for outcome analysis in either statin or nonstatin group, with the mean follow-up duration of 4.8 and 4.6 years, respectively. Statin users versus nonusers had a significantly reduced risk of major adverse cardiovascular events (MACEs) (6.7% vs. 9.5%, hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.55-0.84) and all-cause mortality (6.0% vs. 7.6%; HR 0.77; 95% CI 0.61-0.96). While the results of MACEs were mainly contributed by cardiovascular death (1.9% vs. 3.2%; HR 0.56; 95% CI 0.38-0.83) and ischemic stroke (3.8% vs. 5.4%; subdistribution HR 0.69; 95% CI 0.52-0.91), they were primarily driven by reductions in ischemic but not hemorrhagic stroke. The benefit of statins was significantly pronounced in patients with hypertension and diabetes. Nevertheless, the effect on MACEs was consistent irrespective of age, sex, dyslipidemia, and mental disorder. Statins significantly reduced the risk of MACEs and all-cause mortality in CAS patients. The benefit of statin therapy in reducing MACEs appeared to be linear, with greater risk reduction with higher doses and longer duration without upper threshold, reflecting the dose-dependent relationship of statins with MACEs in CAS patients.

Research progress of circular RNAs in myocardial ischemia

Circular RNAs (circRNAs) are a type of single-stranded RNA that forms a covalently closed continuous loop. Its structure, stability, properties, and cell- and tissue-specificity have gained considerable recognition in the research and clinical sectors, as its role has been observed in different diseases, such as cardiovascular diseases, cancers, and central nervous system diseases, etc. Cardiovascular disease is still named as the number one cause of death globally, with myocardial ischemia (MI) accounting for 15 % of mortality annually. A number of circRNAs have been identified and are being studied for their ability to reduce MI by inhibiting the molecular mechanisms associated with myocardial ischemia reperfusion injury, such as inflammation, oxidative stress, autophagy, apoptosis, and so on. CircRNAs play a significant role as crucial regulatory elements at transcriptional levels, regulating different proteins, and at posttranscriptional levels, having interactions with RNA-binding proteins, ribosomal proteins, micro-RNAS, and long non-coding RNAS, making it possible to exert their effects through the circRNA-miRNA-mRNA axis. CircRNAs are a potential novel biomarker and therapeutic target for myocardial ischemia and cardiovascular diseases in general. The purpose of this review is to summarize the relationship, function, and mechanism observed between circRNAs and MI injury, as well as to provide directions for future research and clinical trials.

Effects of a PRECEDE-PROCEED Model-Based Intervention on Fatigue in Patients With Coronary Heart Disease: A Randomized Controlled Trial

OBJECTIVE

This research aimed to determine how a 12-week PRECEDE-PROCEED model-based intervention affected fatigue in patients with coronary heart disease.

METHODS

This cluster randomized controlled trial recruited participants diagnosed with coronary heart disease at 2 community health centers in China. Participants in the control group (n = 36) received routine health education, whereas those in the intervention group (n = 38) were given a 12-week PRECEDE-PROCEED model-based intervention and routine health education. The intervention consisted of 6 training sessions on coronary heart disease, fatigue, fatigue management, self-management skills and social support. A primary outcome (fatigue) and 4 secondary outcomes (knowledge of fatigue, self-management, quality of life and body mass index) were assessed using the Fatigue Scale-14, Fatigue Cognitive Questionnaire for Patients with Coronary Heart Disease, Coronary Artery Disease Self-Management Scale, Chinese Cardiovascular Questionnaire of Quality of Life, and electronic weighing scale, respectively. Data were collected 3 times over 12 weeks.

RESULTS

Compared with the control group, the intervention group showed a statistically significant improvement in the level of fatigue (8.72 vs 7.06, P < .001), knowledge of fatigue (P < .001), self-management skills (P < .001), and quality of life (P < .001). However, there was no significant difference in body mass index between the 2 groups (P = .504).

CONCLUSIONS

The findings suggest that a well-designed intervention based on the PRECEDE-PROCEED model could alleviate fatigue symptoms and increase knowledge of fatigue, self-management skills and quality of life in patients with coronary heart disease.

TFAP2C inhibits cell autophagy to alleviate myocardial ischemia/reperfusion injury by regulating miR-23a-5p/SFRP5/Wnt5a axis

Myocardial ischemia/reperfusion (MI/R) injury contributes to severe injury for cardiomyocytes. In this study, we aimed to explore the underlying mechanism of TFAP2C on cell autophagy in MI/R injury. MTT assay measured cell viability. The cells injury was evaluated by commercial kits. IF detected the level of LC3B. Dual luciferase reporter gene assay, ChIP or RIP assay were performed to verify the interactions between crucial molecules. We found that TFAP2C and SFRP5 expression were decreased while miR-23a-5p and Wnt5a increased in AC16 cells in response to H/R condition. H/R induction led to cell injury and induced autophagy, which were reversed by TFAP2C overexpression or 3-MA treatment (an autophagy inhibitor). Mechanistically, TFAP2C suppressed miR-23a expression through binding to miR-23a promoter, and SFRP5 was a target gene of miR-23a-5p. Moreover, miR-23a-5p overexpression or rapamycin reversed the protective impacts of TFAP2C overexpression on cells injury and autophagy upon H/R condition. In conclusion, TFAP2C inhibited autophagy to improve H/R-induced cells injury by mediating miR-23a-5p/SFRP5/Wnt5a axis.

Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review

Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.

Case report: A rare manifestation of vasospasm induced myocardial infarction with ST-segment elevation in a young male patient

Background

Minority of acute myocardial infarctions (MI) are caused by a non-atherosclerotic occlusion of the coronary artery. We present a case report, where MI with ST-segment elevation was provoked by a vasospasm, which is a rare aetiological finding.

Case presentation

27-year-old male patient presented to the emergency department because of a sudden onset chest pain radiating to the left arm. The patient underwent percutaneous coronary intervention (PCI) to the right coronary artery (RCA) 3 months ago due to inferior wall MI, however, chest pain episodes kept on recurring at night throughout the whole period after the intervention. During current admission, initial electrocardiogram (ECG) demonstrated ST-segment elevation in leads II, III and aVF. Coronary angiogram revealed diffuse severe narrowing of the right coronary artery, which was relieved with intracoronary administration of nitrates and verapamil. After coronary angiogram patient was given oral long-acting nitrates and verapamil, however, during the following days nocturnal chest pain episodes reoccurred. It was decided to swap verapamil to diltiazem, which led to complete cessation of angina episodes. The patient was discharged in stable condition and symptom free. It was suspected that the first MI was of vasospastic origin, which likely led to unnecessary stenting.

Conclusions

This clinical case has demonstrated the challenges clinician could face in order to correctly diagnose vasospasm-induced MI because of its rare occurrence and highly variable presentation. We strongly suggest using intracoronary nitroglycerine during coronary angiography as a standard practice to avoid a potential diagnostic error and unnecessary stenting. Although, in some cases the reason behind coronary artery spasm (CAS) remains unclear, medical treatment can be very effective for CAS prevention.

Cellular Mechanisms of Coronary Artery Spasm

Coronary artery spasm (CAS) is a reversible phenomenon caused by spontaneous excessive vascular smooth muscle contractility and vascular wall hypertonicity, which results in partial or complete closure of the lumen of normal or atherosclerotic coronary arteries. The clinical picture of CAS includes chest discomfort which is similar in quality to that of stable effort angina. Mechanisms underlying the development of CAS are still unclear. CAS certainly is a multifactorial disease. In this review, we paid attention to the role of the main pathophysiologic mechanisms in CAS: endothelial dysfunction, chronic inflammation, oxidative stress, smooth muscle hypercontractility, atherosclerosis and thrombosis, and mutations leading to deficient aldehyde dehydrogenase 2 (ALDH2) activity. These findings might shed novel insight on the underlying mechanisms and identify potential diagnostic and therapeutic targets for cardiovascular diseases in the future.

Apolipoprotein (a)/Lipoprotein(a)-Induced Oxidative-Inflammatory α7-nAChR/p38 MAPK/IL-6/RhoA-GTP Signaling Axis and M1 Macrophage Polarization Modulate Inflammation-Associated Development of Coronary Artery Spasm

Objective. Apolipoprotein (a)/lipoprotein(a) (Lp(a)), a major carrier of oxidized phospholipids, and α7-nicotinic acetylcholine receptor (α7-nAChR) may play an important role in the development of coronary artery spasm (CAS). In CAS, the association between Lp(a) and the α7-nAChR-modulated inflammatory macrophage polarization and activation and smooth muscle cell dysfunction remains unknown. Methods. We investigated the relevance of Lp(a)/α7-nAChR signaling in patient monocyte-derived macrophages and human coronary artery smooth muscle cells (HCASMCs) using expression profile correlation analyses, fluorescence-assisted cell sorting flow cytometry, immunoblotting, quantitative real-time polymerase chain reaction, and clinicopathological analyses. Results. There are increased serum Lp(a) levels (3.98-fold, $p=0.011$ ) and macrophage population (3.30-fold, $p=0.013$ ) in patients with CAS compared with patients without CAS. Serum Lp(a) level was positively correlated with high-sensitivity C-reactive protein ( $r^2=0.48$ , $p<0.01$ ), IL-6 ( $r^2=0.38$ , $p=0.03$ ), and α7-nAChR ( $r^2=0.45$ , $p<0.01$ ) in patients with CAS, but not in patients without CAS. Compared with untreated or low-density lipoprotein- (LDL-) treated macrophages, Lp(a)-treated macrophages exhibited markedly enhanced α7-nAChR mRNA expression ( $p<0.01$ ) and activity ( $p<0.01$ ), in vitro and ex vivo. Lp(a) but not LDL preferentially induced CD80+ macrophage (M1) polarization and reduced the inducible nitric oxide synthase expression and the subsequent NO production. While shRNA-mediated loss of α7-nAChR function reduced the Lp(a)-induced CD80+ macrophage pool, both shRNA and anti-IL-6 receptor tocilizumab suppressed Lp(a)-upregulated α7-nAChR, p-p38 MAPK, IL-6, and RhoA-GTP protein expression levels in cultures of patient monocyte-derived macrophages and HCASMCs. Conclusions. Elevated Lp(a) levels upregulate α7-nAChR/IL-6/p38 MAPK signaling in macrophages of CAS patients and HCASMC, suggesting that Lp(a)-triggered inflammation mediates CAS through α7-nAChR/p38 MAPK/IL-6/RhoA-GTP signaling induction, macrophage M1 polarization, and HCASMC activation.

Segmentation and Classification of Heart Angiographic Images Using Machine Learning Techniques

Heart angiography is a test in which the concerned medical specialist identifies the abnormality in heart vessels. This type of diagnosis takes a lot of time by the concerned physician. In our proposed method, we segmented the interested regions of heart vessels and then classified. Segmentation and classification of heart angiography provides significant information for the physician as well as patient. Contradictorily, in the mention domain of heart angiography, the charge is prone to error, phase overwhelming, and thought-provoking task for the physician (heart specialist). An automatic segmentation and classification of heart blood vessels descriptions can improve the truthfulness and speed up the finding of heart illnesses. In this work, we recommend a computer-assisted conclusion arrangement for the localization of human heart blood vessels within heart angiographic imageries by using multiclass ensemble classification mechanism. In the proposed work, the heart blood vessels will be first segmented, and the various features according to accuracy have been extracted. Low-level features such as texture, statistical, and geometrical features were extracted in human heart blood vessels. At last, in the proposed framework, heart blood vessels have been categorized in their four respective classes including normal, block, narrow, and blood flow-reduced vessels. The proposed approach has achieved best result which provides very useful, easy, accurate, and time-saving environment to cardiologists for the diagnosis of heart-related diseases.

Association between Coronary Artery Spasm and the risk of incident Diabetes: A Nationwide population-based Cohort Study

Background: Non-diabetic coronary artery spasm (CAS) without obstructive coronary artery disease increases insulin resistance. We investigated the risk of incident type 2 diabetes (diabetes) associated with CAS. Methods: Patient records were retrospectively collected from the Taiwan National Health Insurance Research Database during the period 2000-2012. The matched cohorts consisted of 12,413 patients with CAS and 94,721 patients in the control group. Results: During the entire follow-up, the incidence of newly-diagnosed diabetes was 22.2 events per 1000 person-years in the CAS group and 13.9 events per 1000 person-years in the control group. The increased risk of CAS-related incident diabetes was observed regardless of sex and length of follow-up. The median time to incident diabetes was 2.9 and 3.5 years in the CAS and the control group (P <0.001), respectively, regardless of sex. Although age did not affect the risk of CAS-related incident diabetes, the risk was less apparent in the subgroups of male, dyslipidemia, chronic obstructive pulmonary disease, stroke, gout and medicated hypertension. However, CAS patients aged <50 years compared with patients ≥50 years had a greater risk of incident diabetes in females but not in males. Older CAS patients developed diabetes in a shorter length of time than younger patients. Conclusion: CAS is a risk factor for incident diabetes regardless of sex. However, females aged <50 years have a more apparent risk for CAS-related diabetes than old females, which is not observed in males. The median time of 2.9 years to incident diabetes warrants close follow-up.