1
|
Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
Collapse
Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| |
Collapse
|
2
|
Soleymani M, Masoudkabir F, Shabani M, Vasheghani-Farahani A, Behnoush AH, Khalaji A. Updates on Pharmacologic Management of Microvascular Angina. Cardiovasc Ther 2022; 2022:6080258. [PMID: 36382021 PMCID: PMC9626221 DOI: 10.1155/2022/6080258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 10/17/2022] [Indexed: 01/14/2024] Open
Abstract
Microvascular angina (MVA), historically called cardiac syndrome X, refers to angina with nonobstructive coronary artery disease. This female-predominant cardiovascular disorder adds considerable health-related costs due to repeated diagnostic angiography and frequent hospital admissions. Despite the high prevalence of this diagnosis in patients undergoing coronary angiography, it is still a therapeutic challenge for cardiologists. Unlike obstructive coronary artery disease, with multiple evidence-based therapies and management guidelines, little is known regarding the management of MVA. During the last decade, many therapeutic interventions have been suggested for the treatment of MVA. However, there is a lack of summarization tab and update of current knowledge about pharmacologic management of MVA, mostly due to unclear pathophysiology. In this article, we have reviewed the underlying mechanisms of MVA and the outcomes of various medications in patients with this disease. Contrary to vasospastic angina in which normal angiogram is observed as well, nitrates are not effective in the treatment of MVA. Beta-blockers and calcium channel blockers have the strongest evidence of improving the symptoms. Moreover, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, estrogen, and novel antianginal drugs has had promising outcomes. Investigations are still ongoing for vitamin D, omega-3, incretins, and n-acetyl cysteine, which have resulted in beneficial initial outcomes. We believe that the employment of the available results and results of the future large-scale trials into cardiac care guidelines would help reduce the global cost of cardiac care tremendously.
Collapse
Affiliation(s)
- Mosayeb Soleymani
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsima Shabani
- Division of Cardiology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ali Vasheghani-Farahani
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
3
|
Aldiwani H, Mahdai S, Alhatemi G, Bairey Merz CN. Microvascular Angina: Diagnosis and Management. Eur Cardiol 2021; 16:e46. [PMID: 34950242 PMCID: PMC8674627 DOI: 10.15420/ecr.2021.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 01/18/2023] Open
Abstract
Recognition of suspected ischaemia with no obstructive coronary artery disease – termed INOCA – has increased over the past decades, with a key contributor being microvascular angina. Patients with microvascular angina are at higher risk for major adverse cardiac events including MI, stroke, heart failure with preserved ejection fraction and death but to date there are no clear evidence-based guidelines for diagnosis and treatment. Recently, the Coronary Vasomotion Disorders International Study Group proposed standardised criteria for diagnosis of microvascular angina using invasive and non-invasive approaches. The management strategy for remains empirical, largely due to the lack of high-levelevidence- based guidelines and clinical trials. In this review, the authors will illustrate the updated approach to diagnosis of microvascular angina and address evidence-based pharmacological and non-pharmacological treatments for patients with the condition.
Collapse
Affiliation(s)
- Haider Aldiwani
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center Los Angeles, California, US.,Scripps Health Institution Chula Vista Hospital, Department of Internal Medicine San Diego, US
| | - Suzan Mahdai
- Scripps Health Institution Chula Vista Hospital, Department of Internal Medicine San Diego, US
| | - Ghaith Alhatemi
- St Mary Mercy Hospital, Department of Internal Medicine Livonia, Michigan, US
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center Los Angeles, California, US
| |
Collapse
|
4
|
Wang J, Shang R, He L, Zhou R, Chen Z, Ma Y, Li X. Prediction of Deep Brain Stimulation Outcome in Parkinson's Disease With Connectome Based on Hemispheric Asymmetry. Front Neurosci 2021; 15:620750. [PMID: 34764846 PMCID: PMC8576048 DOI: 10.3389/fnins.2021.620750] [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: 10/27/2020] [Accepted: 09/28/2021] [Indexed: 11/25/2022] Open
Abstract
Parkinson’s disease (PD) is a neurodegenerative disease that is associated with motor and non-motor symptoms and caused by lack of dopamine in the substantia nigra of the brain. Subthalamic nucleus deep brain stimulation (STN-DBS) is a widely accepted therapy of PD that mainly inserts electrodes into both sides of the brain. The effect of STN-DBS was mainly for motor function, so this study focused on the recovery of motor function for PD after DBS. Hemispherical asymmetry in the brain network is considered to be a potential indicator for diagnosing PD patients. This study investigated the value of hemispheric brain connection asymmetry in predicting the DBS surgery outcome in PD patients. Four types of brain connections, including left intra-hemispheric (LH) connection, right intra-hemispheric (RH) connection, inter-hemispheric homotopic (Ho) connection, and inter-hemispheric heterotopic (He) connection, were constructed based on the resting state functional magnetic resonance imaging (rs-fMRI) performed before the DBS surgery. We used random forest for selecting features and the Ridge model for predicting surgical outcome (i.e., improvement rate of motor function). The functional connectivity analysis showed that the brain has a right laterality: the RH networks has the best correlation (r = 0.37, p = 5.68E-03) between the predicted value and the true value among the above four connections. Moreover, the region-of-interest (ROI) analysis indicated that the medioventral occipital cortex (MVOcC)–superior temporal gyrus (STG) and thalamus (Tha)–precentral gyrus (PrG) contributed most to the outcome prediction model for DBS without medication. This result provides more support for PD patients to evaluate DBS before surgery.
Collapse
Affiliation(s)
- Jingqi Wang
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China
| | - Ruihong Shang
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China
| | - Le He
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, School of Medicine, Tsinghua University, Beijing, China
| | - Rongsong Zhou
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, China
| | - Zhensen Chen
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Yu Ma
- Department of Neurosurgery, Tsinghua University Yuquan Hospital, Beijing, China
| | - Xuesong Li
- School of Computer Science and Technology, Beijing Institute of Technology, Beijing, China
| |
Collapse
|
5
|
Patient factors and outcomes associated with discordance between quantitative and qualitative cardiac PET ischemia information. PLoS One 2021; 16:e0246149. [PMID: 33657111 PMCID: PMC7928488 DOI: 10.1371/journal.pone.0246149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 01/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiac PET can provide quantitative myocardial blood flow (MBF) estimates. The frequency and clinical significance of discordant ischemia information between quantitative and qualitative parameters is unclear. METHODS This retrospective, cohort study analyzed 256 Rb-82 stress-rest PET/CT studies. Global MBF and myocardial flow reserve (MFR) were estimated in absolute units for quantitative results and sum-stress and difference scores were used for qualitative results. Four groups of patients were evaluated based on a specific definition of concordant and discordant quantitative and qualitative results. RESULTS 31% of cases demonstrated discordance. Factors associated with microvascular disease were more common in the groups with abnormal quantitative results, regardless of the qualitative findings. Patients with concordant abnormal results had a significantly increased risk of myocardial infarction, heart failure, percutaneous intervention, and all-cause-mortality at 1 year compared to patients with concordant normal results. In patients with discordant results of abnormal quantitative and normal qualitative findings, there was a higher prevalence of heart failure than in controls (12.5% vs 0%, p = 0.01). CONCLUSIONS Discordance in qualitative and quantitative ischemia measures from PET is common, and further study is needed to clarify its prognostic implications. Moreover, quantitative estimation of MBF and MFR appears to add value to qualitative visual interpretation by supporting qualitative findings when results are concordant. Abnormal quantitative findings, regardless of concordance or discordance with qualitative findings, occurred in patients with risk factors associated with diffuse disease and with increased risk of heart failure admission.
Collapse
|
6
|
Aguiar Rosa S, Rocha Lopes L, Fiarresga A, Ferreira RC, Mota Carmo M. Coronary microvascular dysfunction in hypertrophic cardiomyopathy: Pathophysiology, assessment, and clinical impact. Microcirculation 2020; 28:e12656. [PMID: 32896949 DOI: 10.1111/micc.12656] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022]
Abstract
Myocardial ischemia constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy. Chronic and recurrent myocardial ischemia leads to fibrosis, which may culminate in myocardial dysfunction. Since the direct visualization of coronary microcirculation in vivo is not possible, its function must be studied indirectly. Invasive and noninvasive techniques allow microcirculatory dysfunction to be evaluated, including echocardiography, magnetic resonance, positron emission tomography, and cardiac catheterization. Blunted myocardial blood flow and coronary flow reserve have been suggested to associate with unfavorable prognosis. Microcirculatory dysfunction may be one additional important parameter to take into account for risk stratification beyond the conventional risk factors.
Collapse
Affiliation(s)
- Sílvia Aguiar Rosa
- Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Luís Rocha Lopes
- Inherited Cardiac Disease Unit, Bart's Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, UK.,Centro Cardiovascular, Universidade de Lisboa, Lisbon, Portugal
| | | | | | | |
Collapse
|
7
|
Moroni F, Ammirati E, Hainsworth AH, Camici PG. Association of White Matter Hyperintensities and Cardiovascular Disease. Circ Cardiovasc Imaging 2020; 13:e010460. [DOI: 10.1161/circimaging.120.010460] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cardiac and cerebrovascular diseases are currently the leading causes of mortality and disability worldwide. Both the heart and brain display similar vascular anatomy, with large conduit arteries running on the surface of the organ providing tissue perfusion through an intricate network of penetrating small vessels. Both organs rely on fine tuning of local blood flow to match metabolic demand. Blood flow regulation requires adequate functioning of the microcirculation in both organs, with loss of microvascular function, termed small vessel disease (SVD) underlying different potential clinical manifestations. SVD in the heart, known as coronary microvascular dysfunction, can cause chronic or acute myocardial ischemia and may lead to development of heart failure. In the brain, cerebral SVD can cause an acute stroke syndrome known as lacunar stroke or more subtle pathological alterations of the brain parenchyma, which may eventually lead to neurological deficits or cognitive decline in the long term. Coronary microcirculation cannot be visualized in vivo in humans, and functional information can be deduced by measuring the coronary flow reserve. The diagnosis of cerebral SVD is largely based on brain magnetic resonance imaging, with white matter hyperintensities, microbleeds, and brain atrophy reflecting key structural changes. There is evidence that such structural changes reflect underlying cerebral SVD. Here, we review interactions between SVD and cardiovascular risk factors, and we discuss the evidence linking cerebral SVD with large vessel atheroma, atrial fibrillation, heart failure, and heart valve disease.
Collapse
Affiliation(s)
- Francesco Moroni
- Cardiothoracic and Vascular Department, Vita-Salute University and San Raffaele Hospital, Milan, Italy (F.M., P.G.C.)
| | - Enrico Ammirati
- De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (E.A.)
| | - Atticus H. Hainsworth
- Molecular and Clinical Sciences Research Institute, St George’s, University of London, United Kingdom (A.H.H.)
- Department of Neurology, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (A.H.H.)
| | - Paolo G. Camici
- Cardiothoracic and Vascular Department, Vita-Salute University and San Raffaele Hospital, Milan, Italy (F.M., P.G.C.)
| |
Collapse
|
8
|
Bairey Merz CN, Pepine CJ, Shimokawa H, Berry C. Treatment of coronary microvascular dysfunction. Cardiovasc Res 2020; 116:856-870. [PMID: 32087007 PMCID: PMC7061279 DOI: 10.1093/cvr/cvaa006] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/18/2019] [Indexed: 12/30/2022] Open
Abstract
Contemporary data indicate that patients with signs and symptoms of ischaemia and non-obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD) with elevated risk for adverse outcomes. Coronary endothelial (constriction with acetylcholine) and/or microvascular (limited coronary flow reserve with adenosine) dysfunction are well-documented, and extensive non-obstructive atherosclerosis is often present. Despite these data, patients with INOCA currently remain under-treated, in part, because existing management guidelines do not address this large, mostly female population due to the absence of evidence-based data. Relatively small sample-sized, short-term pilot studies of symptomatic mostly women, with INOCA, using intense medical therapies targeting endothelial, microvascular, and/or atherosclerosis mechanisms suggest symptom, ischaemia, and coronary vascular functional improvement, however, randomized, controlled outcome trials testing treatment strategies have not been completed. We review evidence regarding CMD pharmacotherapy. Potent statins in combination with angiotensin-converting enzyme inhibitor (ACE-I) or receptor blockers if intolerant, at maximally tolerated doses appear to improve angina, stress testing, myocardial perfusion, coronary endothelial function, and microvascular function. The Coronary Microvascular Angina trial supports invasive diagnostic testing with stratified therapy as an approach to improve symptoms and quality of life. The WARRIOR trial is testing intense medical therapy of high-intensity statin, maximally tolerated ACE-I plus aspirin on longer-term outcomes to provide evidence for guidelines. Novel treatments and those under development appear promising as the basis for future trial planning.
Collapse
Affiliation(s)
- C Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA 90048, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, 1329 SW 16th Street, PO Box 100288, Gainesville, FL 32610-0288, USA
| | - Hiroki Shimokawa
- Division of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| |
Collapse
|
9
|
Suhrs HE, Michelsen MM, Prescott E. Treatment strategies in coronary microvascular dysfunction: A systematic review of interventional studies. Microcirculation 2019; 26:e12430. [PMID: 29130567 DOI: 10.1111/micc.12430] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/06/2017] [Indexed: 12/12/2022]
Abstract
CMD has been associated with a wide spectrum of diseases and conditions, and it has proven to be a strong prognostic marker of morbidity and mortality. Despite increased attention, guideline-based treatment recommendations are lacking. We performed a systematic review of pharmacological and nonpharmacological interventions to improve coronary perfusion, assessed by IC Doppler, TTDE, PET, CMRI, transthoracic contrast perfusion echocardiography, and dilution techniques. No restrictions were made regarding the study design (randomized, placebo-controlled/randomized with active comparators/nonrandomized with or without a control group), the cardiac condition studied, or the coronary microvascular function at baseline. An electronic database search yielded 4485 records of which 80 studies met our inclusion criteria. Included studies were sorted according to intervention and study design. Studies were small and heterogeneous in methodology, and only few were placebo-controlled. Although some treatments looked promising, we found that no specific treatment was sufficiently well documented to be recommended in any patient groups. There is a need for larger well-designed clinical trials, and we suggest that future studies stratify study populations according to pathogenic mechanisms, thereby investigating whether an individualized treatment approach would be more successful.
Collapse
Affiliation(s)
- Hannah E Suhrs
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen NV, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen NV, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen NV, Denmark
| |
Collapse
|
10
|
Michelsen MM, Rask AB, Suhrs E, Raft KF, Høst N, Prescott E. Effect of ACE-inhibition on coronary microvascular function and symptoms in normotensive women with microvascular angina: A randomized placebo-controlled trial. PLoS One 2018; 13:e0196962. [PMID: 29883497 PMCID: PMC5993253 DOI: 10.1371/journal.pone.0196962] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/23/2018] [Indexed: 12/13/2022] Open
Abstract
Objective Studies have suggested a beneficial effect of angiotensin-converting enzyme (ACE) inhibition. To explore whether the ACE inhibitor ramipril has a direct effect on the microvasculature beyond the blood pressure (BP) lowering effect, we investigated whether ramipril improved coronary microvascular function in normotensive women with coronary microvascular dysfunction (CMD). Methods We included 63 normotensive women with angina, no epicardial stenosis>50% and CMD defined as a coronary flow velocity reserve (CFVR)<2.2 assessed by adenosine stress-echocardiography in a randomized double-blinded, superiority trial with 1:1 allocation to placebo or ramipril (maximum dose 10 mg depending on blood pressure) for 24±6 weeks. Primary outcome was CFVR. Secondary outcomes were left ventricular systolic and diastolic function and symptoms evaluated by Seattle Angina Questionnaire (clinicaltrials.gov, NCT02525081). Results Follow-up was available on 55 patients. BP remained unchanged during treatment in both groups. CFVR improved in both the ramipril (p = 0.004) and placebo group (p = 0.026) with no difference between groups (p = 0.63). Symptoms improved in both groups with no significant between-group differences. No changes were detected in parameters of systolic and diastolic function. No serious adverse reactions were reported. Conclusions In normotensive women with angina and CMD, treatment with ramipril had no significant effect on CFVR or symptoms compared with placebo. The effect of ACE inhibition previously reported may be mediated by blood pressure reduction.
Collapse
Affiliation(s)
- Marie Mide Michelsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna Bay Rask
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Elena Suhrs
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Nis Høst
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
11
|
Naya M, Tamaki N, Tsutsui H. Coronary flow reserve estimated by positron emission tomography to diagnose significant coronary artery disease and predict cardiac events. Circ J 2014; 79:15-23. [PMID: 25744627 DOI: 10.1253/circj.cj-14-1060] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Coronary artery disease (CAD) is a major cause of death in Japan. Coronary angiography is useful to assess the atherosclerotic burden in CAD patients, but its ability to predict whether patients will respond favorably to optimal medical therapy and revascularization is limited. The measurement of the fractional flow reserve with angiography is a well-validated method for identifying ischemic vessels. However, neither an anatomical assessment nor a functional assessment can delineate microvasculature or estimate its function. The quantitative coronary flow reserve (CFR) estimated from sequential myocardial perfusion images obtained by positron emission tomography (PET) during stress provides an accurate index of hyperemic reactivity to vasodilatory agents in the myocardium. In fact, there is growing evidence that the CFR reflects disease activity in the entire coronary circulation, including epicardial coronary artery stenosis, diffuse atherosclerosis, and microvascular dilatory function. Importantly, reduced CFR is observed even in patients without flow-limiting coronary stenosis, and its evaluation can improve the risk stratification of patients at any stage of CAD. This review focuses on the application of CFR estimated by cardiac PET for the diagnosis and risk stratification of patients with CAD.
Collapse
Affiliation(s)
- Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | | | | |
Collapse
|
12
|
The blunting of coronary flow reserve in hypertension with left ventricular hypertrophy is transmural and correlates with systolic blood pressure. J Hypertens 2014; 32:2465-71; discussion 2471. [DOI: 10.1097/hjh.0000000000000338] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Alexánderson E, Jácome R, Jiménez-Santos M, Ochoa JM, Romero E, Cabral MAP, Ricalde A, Iñarra F, Meave A, Alexánderson G. Evaluation of the endothelial function in hypertensive patients with 13N-ammonia PET. J Nucl Cardiol 2012; 19:979-86. [PMID: 22689073 DOI: 10.1007/s12350-012-9584-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 05/15/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Essential hypertension is one of the main risk factors for the development of coronary artery disease (CAD). Hypertension causes endothelial dysfunction which is considered an early sign for the development of CAD. Positron emission tomography is a non-invasive imaging technique that measures myocardial blood flow (MBF), allowing us to identify patients with endothelial dysfunction. METHODS AND RESULTS 19 patients without comorbidities recently diagnosed hypertensive, as well as 21 healthy volunteers were studied. A three-phase (rest, cold pressor test, and adenosine-induced hyperemia) (13)N-ammonia PET was performed, and MBF was measured. Endothelial-Dependent Vasodilation Index, ΔMBF, and coronary flow reserve (CFR) were calculated for each patient. Hypertensive patients had a significantly higher systolic and diastolic blood pressures compared with the control group (134.6 ± 11.7/86.4 ± 10.6 mm Hg and 106.0 ± 11.8/71.4 ± 6.6 mm Hg, respectively, P < .001). The ENDEVI (1.28 ± 0.26 vs 1.79 ± 0.30, P < .001), the ΔMBF (0.81 ± 0.50 vs 0.25 ± 0.21, P < .001) and the CFR (2.18 ± 0.88 vs 3.17 ± 0.68, P = .001) were significantly lower in the hypertensive patients compared to the control group, 84% of the former group had endothelial dysfunction i.e., ENDEVI < 1.5 and 58% had vasomotor abnormalities, i.e., CFR < 2.5. CONCLUSIONS In this study, we showed that recently diagnosed hypertensive patients have coronary endothelial dysfunction and vasomotor disturbances which are early signs for the development of CAD.
Collapse
Affiliation(s)
- Erick Alexánderson
- Unidad PET/CT Ciclotrón, Facultad de Medicina, Universidad Nacional Autónoma de México, Edificio de Investigación, Planta Baja, Ciudad Universitaria, CP 04510, Mexico City, DF, Mexico.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Murthy VL, Di Carli MF. Non-invasive quantification of coronary vascular dysfunction for diagnosis and management of coronary artery disease. J Nucl Cardiol 2012; 19:1060-72; quiz 1075. [PMID: 22714648 PMCID: PMC6526508 DOI: 10.1007/s12350-012-9590-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Venkatesh L. Murthy
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Marcelo F. Di Carli
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA
| |
Collapse
|
15
|
Nemes A, Kalapos A, Sasi V, Ungi T, Nagy FT, Zimmermann Z, Forster T, Ungi I. Detection of perfusion abnormalities on coronary angiograms in hypertension by myocardium selective densitometric perfusion assessments. Int J Cardiol 2012; 157:428-9. [PMID: 22531317 DOI: 10.1016/j.ijcard.2012.03.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 03/21/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022]
|
16
|
Izzo P, Macchi A, De Gennaro L, Gaglione A, Di Biase M, Brunetti ND. Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2012; 1:158-69. [PMID: 24062904 PMCID: PMC3760523 DOI: 10.1177/2048872612449111] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/30/2012] [Indexed: 01/03/2023]
Abstract
Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine.
Collapse
Affiliation(s)
- Paolo Izzo
- Cardiology Department, Clinica ‘Villa Bianca’, Bari, Italy
| | - Andrea Macchi
- Cardiology Department, Busto Arsizio Hospital, (VA), Italy
| | | | | | | | | |
Collapse
|
17
|
Traub-Weidinger T, Graf S, Beheshti M, Ofluoglu S, Zettinig G, Khorsand A, Nekolla SG, Kletter K, Dudczak R, Pirich C. Coronary vasoreactivity in subjects with thyroid autoimmunity and subclinical hypothyroidism before and after supplementation with thyroxine. Thyroid 2012; 22:245-51. [PMID: 22233129 DOI: 10.1089/thy.2011.0183] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The association of subclinical hypothyroidism (SCH) with increased risk for cardiovascular disease is still controversial. This study aimed to examine coronary vascular reactivity by positron emission tomography (PET) in asymptomatic patients with SCH before and after levothyroxine (LT4) supplementation. METHODS Ten patients (7 women and 3 men; mean age 43±15 years) with untreated autoimmune SCH, defined by elevated levels of thyroid-stimulating hormone (mean TSH: 16.9±11.3 μU/mL), normal levels of free thyroxine (0.9±0.1 μg/mL), free triiodothyronine (3.2±0.4 pg/mL), and positive thyroid peroxidase antibodies were studied. Eight euthyroid subjects with similar low-risk cardiovascular risk profile served as controls. Myocardial blood flow (MBF) and coronary flow reserve (CFR) were quantitatively assessed with rest/stress N-13 ammonia PET at baseline and after 6 months of LT4 replacement therapy (given only to patients). RESULTS At baseline, stress MBF and CFR corrected (c) for rate pressure product (RPP) and myocardial vascular resistance (MVR) during stress were significantly reduced in SCH compared with controls (stress MBF: 2.87±0.93 vs. 4.79±1.16 mL/g/min, p=0.003; CFR: 2.6±0.73 vs. 4.66±1.38, p=0.004; MVR: 40.14±18.76 vs. 20.47±6.24 mmHg/mL/min, p=0.02). Supplementation therapy with LT4 normalized TSH in all subjects and was associated with an increase in CFR (2.6±0.73 vs. 3.81±1.19, p=0.003) and with a tendency toward a decrease in MVR. Differences in CFR between SCH and controls were also seen after correction of resting MBF for RPP. CONCLUSIONS In asymptomatic subjects with SCH due to thyroid autoimmunity, coronary microvascular function is impaired and improves after supplementation with LT4. This may partially explain the increased cardiovascular risk attributed to SCH.
Collapse
|
18
|
Daniele S, Nappi C, Acampa W, Storto G, Pellegrino T, Ricci F, Xhoxhi E, Porcaro F, Petretta M, Cuocolo A. Incremental prognostic value of coronary flow reserve assessed with single-photon emission computed tomography. J Nucl Cardiol 2011; 18:612-9. [PMID: 21626091 DOI: 10.1007/s12350-011-9345-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 01/24/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND We assessed the prognostic value of coronary flow reserve (CFR) estimated by single-photon emission computed tomography (SPECT) in patients with suspected myocardial ischemia. METHODS AND RESULTS Myocardial perfusion and CFR were assessed in 106 patients using dipyridamole/rest Tc-99m sestamibi SPECT and follow-up was obtained in 103 (97%) patients. Four early revascularized patients were excluded and 99 were assigned to normal (summed stress score <3) vs abnormal myocardial perfusion and to normal (≥2.0) vs abnormal CFR. During the follow-up (5.8 ± 2.1 years), 28 patients experienced a cardiac event (cardiac death, nonfatal myocardial infarction, and late revascularization). Abnormal perfusion (P < .01) and abnormal CFR (P < .05) were independent predictors of cardiac events at Cox proportional hazard regression analysis. Also in patients with normal perfusion, abnormal CFR was associated with a higher annual event rate compared with normal CFR (5.2% vs 0.7%; P < .05). CFR data improved the prognostic power of the model including clinical and myocardial perfusion data increasing the global chi-square from 18.6 to 22.8 (P < .05). Finally, at parametric survival analysis, in patients with normal perfusion the time to achieve ≥2% risk of events was >60 months in those with normal and <12 months in those with abnormal CFR. CONCLUSIONS Myocardial perfusion findings and CFR at SPECT imaging are both independent predictors of cardiac events. Estimated CFR provides incremental prognostic information over those obtained from clinical and myocardial perfusion data, particularly in patients with normal perfusion findings.
Collapse
Affiliation(s)
- Stefania Daniele
- SDN Foundation, Institute of Diagnostic and Nuclear Development, Naples, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Storto G, Soricelli A, Pellegrino T, Petretta M, Cuocolo A. Assessment of the arterial input function for estimation of coronary flow reserve by single photon emission computed tomography: comparison of two different approaches. Eur J Nucl Med Mol Imaging 2011; 36:2034-41. [PMID: 19526233 DOI: 10.1007/s00259-009-1186-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 05/21/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Attempts to estimate coronary flow reserve (CFR) with single photon emission computed tomography (SPECT) tracers have been recently made. We compared two different methods for the estimation of CFR by SPECT imaging. METHODS Fourteen patients with coronary artery disease underwent dipyridamole 99mTc-sestamibi SPECT and intracoronary Doppler within 5 days. Myocardial blood flow (MBF) was estimated by measurement of first transit counts in the right pulmonary artery (PA) and left ventricular (LV) chamber, and myocardial counts from SPECT images. Estimated CFR was expressed as the ratio of stress MBF to rest MBF. RESULTS Rest and stress MBF obtained using first transit counts from PA were higher compared to that from LV chamber (rest: 1.05 ± 0.38 vs 0.87 ± 0.34 counts/pixel per s, respectively, p < 0.01 and stress: 1.34 ± 0.45 vs 0.91 ± 0.20 counts/pixel per s, respectively, p < 0.05). In the study vessels, CFR by Doppler was 1.39 ± 0.42, and SPECT CFR obtained using first transit counts from PA and LV chamber were 1.36 ± 0.43 and 1.16 ± 0.39, respectively (p across categories NS). A significant relationship between SPECT CFR obtained using first transit counts from PA and CFR by Doppler was found (r = 0.85, p < 0.001). No relationship between SPECT CFR obtained using first transit counts from LV chamber and CFR by intracoronary Doppler was OBSERVED (R = 0.43, P = NS). CONCLUSION SPECT-estimated CFR obtained using first transit counts from right PA is more accurate and correlates better with the results of intracoronary Doppler than estimated CFR obtained using arterial input function from LV chamber.
Collapse
|
20
|
Debbabi H, Bonnin P, Levy BI. Effects of blood pressure control with perindopril/indapamide on the microcirculation in hypertensive patients. Am J Hypertens 2010; 23:1136-43. [PMID: 20508624 DOI: 10.1038/ajh.2010.115] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Microvascular rarefaction and endothelium dysfunction are hallmarks of hypertension. We assessed whether antihypertensive treatments affect the microcirculation and whether the fixed-dose combination perindopril/indapamide (per/ind) modifies the microcirculation of hypertensive patients independently of blood pressure reduction. METHODS One hundred ninety-three consecutive patients were enrolled into one of four groups depending on their blood pressure and existing treatment: (i) controlled hypertensive patients treated with per/ind (controlled-per/ind), (ii) controlled hypertensive patients treated with agents other than angiotensin-converting enzyme (ACE) inhibitors or diuretics (controlled-other), (iii) uncontrolled hypertensive patients treated with agents other than ACE inhibitors or diuretics (uncontrolled-other), (iv) untreated normotensive subjects. Macro- and microcirculation parameters were evaluated once in every patient. We used intravital video microscopy to measure dermal capillary density in the dorsum of the fingers. Microvascular endothelial function was assessed by measuring the perfusion increases after pilocarpine iontophoresis and central hemodynamic parameters by tonometry. RESULTS Capillary density was significantly higher in controlled-per/ind patients (99 ± 12 capillaries/mm(2)) than in all other groups (P < 0.05). Controlled-per/ind patients had a significantly greater endothelial response to pilocarpine than patients from all other groups (P < 0.05). Central hemodynamic parameters were similarly improved in both controlled groups compared with the uncontrolled-other group (P < 0.05). CONCLUSIONS Thus, hypertensive patients with blood pressure controlled with the combination per/ind had normalized capillary density and endothelial function, whereas other antihypertensive treatments, excluding ACE inhibitors or diuretics, had less effect despite similar blood pressure control.
Collapse
|
21
|
Abstract
Detailed studies over the past 30 years have built up an impressive evidence base for the presence of myocardial ischemia in patients who have hypertension. This relationship ranges from the obvious association with obstructive coronary artery disease to mechanisms related to hemodynamic, microcirculatory, and neuroendocrine abnormalities. All of these factors serve to destabilize the critical balance between myocardial oxygen supply and demand. We have at our disposal a range of sophisticated investigations that allow us to demonstrate the presence and extent of the ischemia and therefore to target specific therapies to reduce the risk to these patients. Achieving target BP and managing all reversible components of the patient's cardiovascular risk status reduce to a minimum the clinical sequelae of myocardial ischemia in this vulnerable population..
Collapse
Affiliation(s)
- Brian P Murphy
- Cardiac Department, Stobhill Hospital, Glasgow, Scotland, UK
| | | | | |
Collapse
|
22
|
Petretta M, Soricelli A, Storto G, Cuocolo A. Assessment of coronary flow reserve using single photon emission computed tomography with technetium 99m-labeled tracers. J Nucl Cardiol 2008; 15:456-65. [PMID: 18513652 DOI: 10.1016/j.nuclcard.2008.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The quantitative assessment of coronary flow reserve (CFR) may be useful for the functional evaluation of coronary artery disease (CAD), allowing judgment of its severity, tracking of disease progression, and evaluation of the anti-ischemic efficacy of therapeutic strategies. Invasive techniques, such as intracoronary Doppler ultrasound and the pressure-derived method, which directly assess CFR velocity and fractional flow reserve, have been used for the evaluation of the physiologic significance of coronary lesions. Considerable progress has been made in the improvement of technologies directed toward the noninvasive quantification of myocardial blood flow and CFR. Positron emission tomography has emerged as an accurate technique to quantify CFR. The absolute measurements obtained with this noninvasive approach have been widely validated. Nevertheless, it has not been applied to routine studies because of its high cost and complexity. On the other hand, technetium 99m-labeled tracers have been largely used for the evaluation of myocardial perfusion with single photon emission computed tomography (SPECT) imaging in patients with suspected or known CAD. Recently, attempts to estimate CFR with SPECT tracers have been made to obtain, with noninvasive methods, data for quantitative functional assessment of CAD. This review analyzes the relative merit and limitations of CFR measurements by cardiac SPECT imaging with Tc-99m-labeled tracers and describes the potential clinical applications of this technique.
Collapse
Affiliation(s)
- Mario Petretta
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, University Federico II, Naples, Italy
| | | | | | | |
Collapse
|
23
|
Vesely MR, Dilsizian V. Nuclear Cardiac Stress Testing in the Era of Molecular Medicine. J Nucl Med 2008; 49:399-413. [DOI: 10.2967/jnumed.107.033530] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
24
|
Storto G, Cirillo P, Vicario MLE, Pellegrino T, Sorrentino AR, Petretta M, Galasso G, De Sanctis V, Piscione F, Cuocolo A. Estimation of coronary flow reserve by Tc-99m sestamibi imaging in patients with coronary artery disease: comparison with the results of intracoronary Doppler technique. J Nucl Cardiol 2004; 11:682-8. [PMID: 15592191 DOI: 10.1016/j.nuclcard.2004.08.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study compared coronary flow reserve (CFR) estimated by technetium 99m sestamibi imaging with the results obtained with intracoronary Doppler in patients with coronary artery disease. Intraobserver and interobserver reproducibility of the radionuclide-estimated CFR was also assessed. METHODS AND RESULTS Fourteen consecutive patients (mean age, 54 +/- 7 years) with documented coronary artery disease in whom percutaneous coronary intervention was planned underwent dipyridamole (0.74 mg/kg) sestamibi imaging and intracoronary Doppler within 5 days. Myocardial blood flow (MBF) was estimated by measurement of first transit counts in the pulmonary artery and myocardial counts from single photon emission computed tomography images. Estimated CFR was expressed as the ratio of stress MBF to rest MBF. In the study vessels, CFR was 1.36 +/- 0.43 as estimated by sestamibi and 1.39 +/- 0.42 by intracoronary Doppler ( P = .69). A significant relationship between CFR estimated by sestamibi and CFR obtained by intracoronary Doppler was observed ( r = 0.85, P < .001). On Bland-Altman analysis, the mean difference between CFR by sestamibi and by Doppler was 0.03 and the intraclass correlation coefficients for intraobserver and interobserver reproducibility were high (all P < .001) for both global and regional CFR. CONCLUSIONS This study demonstrates a good agreement between CFR estimated by sestamibi imaging and by intracoronary Doppler results and a lack of intraobserver and interobserver variability of this noninvasive approach.
Collapse
Affiliation(s)
- Giovanni Storto
- Department of Biomorphological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Nishiguchi S, Shiomi S, Kawamura E, Ishizu H, Habu D, Torii K, Kawabe J. Evaluation of ammonia metabolism in the skeletal muscles of patients with cirrhosis using N-13 ammonia PET. Ann Nucl Med 2003; 17:417-9. [PMID: 12971644 DOI: 10.1007/bf03006613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Skeletal muscle is said to compensate for the decreased ammonia metabolism in patients with cirrhosis. Branched-chain amino acids (BCAA) are being used as a treatment for hyperammonemia, and are believed to decrease blood ammonia by consumption of BCAA in skeletal muscles. We examined ammonia metabolism of the skeletal muscles in patients with liver cirrhosis after administration of BCAA using 13N-ammonia positron emission tomography (PET). METHODS The subjects were patients with compensated or decompensated liver cirrhosis. PET studies were performed before and 2 hours after injection of BCAA. Serial dynamic PET scans (2 min x 10 frames) were started simultaneously with 13N-ammonia injection. The standardized uptake value (SUV) of both thighs was calculated. RESULTS In the patient with compensated liver cirrhosis, there was little difference in the rate of increase in SUV before to after administration of BCAA. However, in the patient with decompensated liver cirrhosis, the rate of increase in SUV after administration was higher than that before administration of BCAA. CONCLUSION Ammonia metabolism in the muscle of patients with liver cirrhosis could be examined noninvasively under physiological conditions using 13N-ammonia PET. The muscles were found to metabolize ammonia partially, and the role of this contribution to metabolism of ammonia in patients with decompensated liver cirrhosis is particularly important.
Collapse
Affiliation(s)
- Shuhei Nishiguchi
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Japan
| | | | | | | | | | | | | |
Collapse
|
26
|
Gullberg GT, Di Bella EV, Sinusas AJ. Estimation of coronary flow reserve: can SPECT compete with other modalities? J Nucl Cardiol 2001; 8:620-5. [PMID: 11593228 DOI: 10.1067/mnc.2001.118121] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|