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Lopez-Candales A, Sawalha K, Asif T. Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance. Postgrad Med 2024:1-11. [PMID: 38818874 DOI: 10.1080/00325481.2024.2360888] [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: 08/09/2023] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.
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Affiliation(s)
- Angel Lopez-Candales
- Cardiovascular Medicine Division University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Khalid Sawalha
- Cardiometabolic Fellowship, University Health Truman Medical Center and the University of Missouri-Kansas City, Kansas City, USA
| | - Talal Asif
- Division of Cardiovascular Diseases, University Health Truman Medical Center and the University of Missouri-Kansas City Kansas City, Kansas City, MO, USA
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2
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Marino AG, Gentile G, Lenci L, De Benedetto F, Tremamunno S, Cambise N, Belmusto A, Di Renzo A, Tinti L, De Vita A, Lanza GA. Comparison of Baseline and Post-Nitrate Exercise Testing in Patients with Angina but Non-Obstructed Coronary Arteries with Different Acetylcholine Test Results. J Clin Med 2024; 13:2181. [PMID: 38673454 PMCID: PMC11050539 DOI: 10.3390/jcm13082181] [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: 01/30/2024] [Revised: 03/07/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Intracoronary acetylcholine testing may induce epicardial coronary artery spasm (CAS) or coronary microvascular spasm (CMVS) in patients with angina syndromes but non-obstructive coronary artery disease, but their causal role in individual patients is not always clear. In this prospective, observational single-center study, we aimed to assess whether (1) the induction of myocardial ischemia/angina by electrocardiogram (ECG) exercise stress test (EST) differs between patients showing different results in response to acetylcholine testing (i.e., CAS, CMVS, or no spasm); (2) the preventive administration of short-acting nitrates has any different effects on the EST of those patients who showed a positive basal EST. We expected that if exercise-induced angina and/or ischemic ECG changes are related to CAS, they should improve after nitrates administration, whereas they should not significantly improve if they are caused by CMVS. Methods: We enrolled 81 patients with angina syndromes and non-obstructive coronary artery disease, who were divided into three groups according to acetylcholine testing: 40 patients with CAS (CAS-group), 14 with CMVS (CMVS-groups), and 27 with a negative test (NEG-group). All patients underwent a basal EST (B-EST). Patients with a positive B-EST repeated the test 24-48 h later, 5 min after the administration of short-acting nitrates (N-EST). Results: There were no significant differences among the groups in terms of the B-EST results. B-EST was positive in eight (20%) patients in the CAS-group, seven (50%) in the CMVS-group, and six (22%) in the NEG-group (p = 0.076). N-EST, performed in eight, six, and five of these patients, also showed similar results in the three groups. Furthermore, the N-EST results also did not significantly differ compared to B-EST in any group, remaining positive in seven (87.5%), four (66.7%), and four (80%) patients in the CAS-group, CMVS-group, and NEG-group, respectively (p = 0.78). Conclusions: Our data show that patients with angina and non-obstructive coronary artery disease show largely comparable results of the ECG exercise stress test and similar poor effects of short-acting nitrates on abnormal ECG exercise stress test results. On the whole, our findings suggest caution in attributing to the results of Ach testing a definite causal role for the clinical syndrome in individual patients.
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Affiliation(s)
- Angelo Giuseppe Marino
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Gentile
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ludovica Lenci
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabio De Benedetto
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Saverio Tremamunno
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nello Cambise
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonietta Belmusto
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio Di Renzo
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Lorenzo Tinti
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio De Vita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Gaetano Antonio Lanza
- Dipartimento di Scienze Cardiovascolari e del Torace, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
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3
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La S, Beltrame J, Tavella R. Sex-specific and ethnicity-specific differences in MINOCA. Nat Rev Cardiol 2024; 21:192-202. [PMID: 37775559 DOI: 10.1038/s41569-023-00927-6] [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] [Accepted: 08/28/2023] [Indexed: 10/01/2023]
Abstract
Suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) has received increasing attention over the past decade. Given the heterogeneity in the mechanisms underlying acute myocardial infarction in the absence of obstructive coronary arteries, the syndrome of MINOCA is considered a working diagnosis that requires further investigation after diagnostic angiography studies have been performed, including coronary magnetic resonance angiography and functional angiography. Although once considered an infrequent and low-risk form of myocardial infarction, recent data have shown that the prognosis of MINOCA is not as benign as previously assumed. However, despite increasing awareness of the condition, many questions remain regarding the diagnosis, risk stratification and treatment of MINOCA. Women seem to be more susceptible to MINOCA, but studies on the sex-specific differences of the disease are scarce. Similarly, ethnicity-specific factors might explain discrepancies in the observed prevalence or underlying pathophysiological mechanisms of MINOCA but data are also scarce. Therefore, in this Review, we provide an update on the latest evidence available on the sex-specific and ethnicity-specific differences in the clinical features, pathophysiological mechanisms, treatment and prognosis of MINOCA.
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Affiliation(s)
- Sarena La
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
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4
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Januszek R, Kołtowski Ł, Tomaniak M, Wańha W, Wojakowski W, Grygier M, Siłka W, Jan Horszczaruk G, Czarniak B, Kręcki R, Guzik B, Legutko J, Pawłowski T, Wnęk P, Roik M, Sławek-Szmyt S, Jaguszewski M, Roleder T, Dziarmaga M, Bartuś S. Implementation of Microcirculation Examination in Clinical Practice-Insights from the Nationwide POL-MKW Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:277. [PMID: 38399564 PMCID: PMC10890290 DOI: 10.3390/medicina60020277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/10/2023] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: The assessment of coronary microcirculation may facilitate risk stratification and treatment adjustment. The aim of this study was to evaluate patients' clinical presentation and treatment following coronary microcirculation assessment, as well as factors associated with an abnormal coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) values. Materials and Results: This retrospective analysis included 223 patients gathered from the national registry of invasive coronary microvascular testing collected between 2018 and 2023. Results: The frequency of coronary microcirculatory assessments in Poland has steadily increased since 2018. Patients with impaired IMR (≥25) were less burdened with comorbidities. Patients with normal IMR underwent revascularisation attempts more frequently (11.9% vs. 29.8%, p = 0.003). After microcirculation testing, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors were added more often for patients with IMR and CFR abnormalities, respectively, as compared to control groups. Moreover, patients with coronary microvascular dysfunction (CMD, defined as CFR and/or IMR abnormality), regardless of treatment choice following microcirculation assessment, were provided with trimetazidine (23.2%) and dihydropyridine CCBs (26.4%) more frequently than those without CMD who were treated conservatively (6.8%) and by revascularisation (4.2% with p = 0.002 and 0% with p < 0.001, respectively). Multivariable analysis revealed no association between angina symptoms and IMR or CFR impairment. Conclusions: The frequency of coronary microcirculatory assessments in Poland has steadily increased. Angina symptoms were not associated with either IMR or CFR impairment. After microcirculation assessment, patients with impaired microcirculation, expressed as either low CFR, high IMR or both, received additional pharmacotherapy treatment more often.
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Affiliation(s)
- Rafał Januszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, 30-705 Kraków, Poland
| | - Łukasz Kołtowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Mariusz Tomaniak
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Wojciech Siłka
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
| | - Grzegorz Jan Horszczaruk
- Faculty of Medical Science, Collegium Medicum. Cardinal Stefan Wyszyński University in Warsaw, 01-938 Warsaw, Poland;
- Department of Cardiology, Voivodeship Hospital in Łomża, 18-404 Łomża, Poland
| | - Bartosz Czarniak
- Provincial Specialist Hospital in Wloclawek, 87-800 Włocławek, Poland;
| | | | - Bartłomiej Guzik
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Tomasz Pawłowski
- Department of Cardiology, National Institute of Medicine of the Ministry of Internal Affairs and Administration, 02-507 Warsaw, Poland;
- Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Paweł Wnęk
- Provincial Specialist Hospital in Wroclaw, 51-124 Wrocław, Poland;
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Miłosz Jaguszewski
- 1st Department of Cardiology, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Tomasz Roleder
- Department of Cardiology, Wroclaw Medical University, 50-556 Wrocław, Poland;
| | - Miłosz Dziarmaga
- Department of Cardiology-Intensive Therapy and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
| | - Stanisław Bartuś
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
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De Luca M, Crisci G, Armentaro G, Cicco S, Talerico G, Bobbio E, Lanzafame L, Green CG, McLellan AG, Debiec R, Caferra P, Scicali R, Cannatà A, Israr MZ, Heaney LM, Salzano A. Endothelial Dysfunction and Heart Failure with Preserved Ejection Fraction-An Updated Review of the Literature. Life (Basel) 2023; 14:30. [PMID: 38255646 PMCID: PMC10817572 DOI: 10.3390/life14010030] [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: 11/11/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Heart failure (HF) is a clinical syndrome consisting of typical symptoms and signs due to structural and/or functional abnormalities of the heart, resulting in elevated intracardiac pressures and/or inadequate cardiac output. The vascular system plays a crucial role in the development and progression of HF regardless of ejection fraction, with endothelial dysfunction (ED) as one of the principal features of HF. The main ED manifestations (i.e., impaired endothelium-dependent vasodilation, increased oxidative stress, chronic inflammation, leukocyte adhesion, and endothelial cell senescence) affect the systemic and pulmonary haemodynamic and the renal and coronary circulation. The present review is aimed to discuss the contribution of ED to HF pathophysiology-in particular, HF with preserved ejection fraction-ED role in HF patients, and the possible effects of pharmacological and non-pharmacological approaches. For this purpose, relevant data from a literature search (PubMed, Scopus, EMBASE, and Medline) were reviewed. As a result, ED, assessed via venous occlusion plethysmography or flow-mediated dilation, was shown to be independently associated with poor outcomes in HF patients (e.g., mortality, cardiovascular events, and hospitalization due to worsening HF). In addition, SGLT2 inhibitors, endothelin antagonists, endothelial nitric oxide synthase cofactors, antioxidants, and exercise training were shown to positively modulate ED in HF. Despite the need for future research to better clarify the role of the vascular endothelium in HF, ED represents an interesting and promising potential therapeutic target.
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Affiliation(s)
- Mariarosaria De Luca
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Giulia Crisci
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100 Catanzaro, Italy
| | - Sebastiano Cicco
- Internal Medicine Unit “Guido Baccelli” and Arterial Hypertension Unit “Anna Maria Pirrelli”, Department of Precision and Regenerative Medicine and Jonic Area (DiMePReJ), University of Bari Aldo Moro, Azienda Ospedaliero-Universitaria Policlinico, 70124 Bari, Italy
| | | | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Kuggen, 417 56 Gothenburg, Sweden
| | - Lorena Lanzafame
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Christopher G. Green
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Abbie G. McLellan
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Radek Debiec
- Department of Cardiovascular Sciences, University of Leicester, Leicester (UK), IHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK
| | - Paolo Caferra
- Department of Pharmacy, University of Pisa, 56126 Pisa, Italy
| | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy
| | - Antonio Cannatà
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College, London SE1 8WA, UK
| | - Muhammad Zubair Israr
- Department of Cardiovascular Sciences, University of Leicester, Leicester (UK), IHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK
| | - Liam M. Heaney
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
| | - Andrea Salzano
- Cardiac Unit, AORN A Cardarelli, 80131 Naples, Italy
- Cardiac Unit, University Hospital of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
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6
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Kest M, Ágoston A, Szabó GT, Kiss A, Üveges Á, Czuriga D, Komócsi A, Hizoh I, Kőszegi Z. Angiography-based coronary microvascular assessment with and without intracoronary pressure measurements: a systematic review. Clin Res Cardiol 2023:10.1007/s00392-023-02338-6. [PMID: 37987840 DOI: 10.1007/s00392-023-02338-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND In recent years, several indices have been proposed for quantifying coronary microvascular resistance. We intended to conduct a comprehensive review that systematically evaluates indices of microvascular resistance derived from angiography. OBJECTIVE The objective of this study was to identify and analyze angiography-derived indices of microvascular resistance that have been validated against an invasive reference method. We aimed to compare their limits of agreement with their reference methods and explore their advantages and inherent limitations. METHODS AND RESULTS We searched PubMed from inception until 2022 for studies on different techniques for quantifying microvascular resistance. Seven studies met the inclusion criteria. Five studies included techniques that applied calculations based solely on invasive angiography, and were validated against invasively measured thermodilution-derived index of microvascular resistance. The remaining two studies combined angiography with invasively measured intracoronary pressure data, and were validated against invasive Doppler measurements. We converted the ± 1.96 standard deviation limits of agreement with the reference method from the seven studies into percentages relative to the cut-off value of the reference method. The lower limits of agreement for angiography-based methods ranged from - 122 to - 60%, while the upper limits ranged from 74 to 135%. The range of the limits of agreement was considerably lower for the two combined angiography- and pressure-based methods, standing at - 52 to 60% and - 25 to 27%. CONCLUSION Our findings suggest that combined angiography- and pressure-based methods provide a more reliable assessment of microvascular resistance compared to methods relying solely on angiography. Central illustration. Comparative assessment of image-based methods quantifying microvascular resistance with and without intracoronary pressure measurements. Angiography-based methods rely on angiography alone to calculate the microvascular resistance by utilizing angiographic frame counting to extrapolate coronary flow (Q) and subsequently deriving distal coronary pressure using fluid dynamic equations. Combined angiography- and pressure-based methods utilize invasive intracoronary pressure gradients measured during rest and maximal vasodilation to determine coronary flow in their calculation of microvascular resistance. The combined methods showed more acceptable levels of agreement with their reference methods compared to angiography-based methods alone.
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Affiliation(s)
- Michael Kest
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - András Ágoston
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Gábor Tamás Szabó
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Áron Üveges
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Dániel Czuriga
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Hizoh
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Kőszegi
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary.
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary.
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7
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Liu H, Huang Y, Huang M, Wang M, Ming Y, Chen W, Chen Y, Tang Z, Jia B. From nitrate to NO: potential effects of nitrate-reducing bacteria on systemic health and disease. Eur J Med Res 2023; 28:425. [PMID: 37821966 PMCID: PMC10566198 DOI: 10.1186/s40001-023-01413-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023] Open
Abstract
Current research has described improving multisystem disease and organ function through dietary nitrate (DN) supplementation. They have provided some evidence that these floras with nitrate (NO3-) reductase are mediators of the underlying mechanism. Symbiotic bacteria with nitrate reductase activity (NRA) are found in the human digestive tract, including the mouth, esophagus and gastrointestinal tract (GT). Nitrate in food can be converted to nitrite under the tongue or in the stomach by these symbiotic bacteria. Then, nitrite is transformed to nitric oxide (NO) by non-enzymatic synthesis. NO is currently recognized as a potent bioactive agent with biological activities, such as vasodilation, regulation of cardiomyocyte function, neurotransmission, suppression of platelet agglutination, and prevention of vascular smooth muscle cell proliferation. NO also can be produced through the conventional L-arginine-NO synthase (L-NOS) pathway, whereas endogenous NO production by L-arginine is inhibited under hypoxia-ischemia or disease conditions. In contrast, exogenous NO3-/NO2-/NO activity is enhanced and becomes a practical supplemental pathway for NO in the body, playing an essential role in various physiological activities. Moreover, many diseases (such as metabolic or geriatric diseases) are primarily associated with disorders of endogenous NO synthesis, and NO generation from the exogenous NO3-/NO2-/NO route can partially alleviate the disease progression. The imbalance of NO in the body may be one of the potential mechanisms of disease development. Therefore, the impact of these floras with nitrate reductase on host systemic health through exogenous NO3-/NO2-/NO pathway production of NO or direct regulation of floras ecological balance is essential (e.g., regulation of body homeostasis, amelioration of diseases, etc.). This review summarizes the bacteria with nitrate reductase in humans, emphasizing the relationship between the metabolic processes of this microflora and host systemic health and disease. The potential effects of nitrate reduction bacteria on human health and disease were also highlighted in disease models from different human systems, including digestive, cardiovascular, endocrine, nervous, respiratory, and urinary systems, providing innovative ideas for future disease diagnosis and treatment based on nitrate reduction bacteria.
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Affiliation(s)
- Hongyu Liu
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yisheng Huang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Mingshu Huang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Min Wang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yue Ming
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Weixing Chen
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yuanxin Chen
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Zhengming Tang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Bo Jia
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China.
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8
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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9
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Taylor DJ, Aubiniere-Robb L, Gosling R, Newman T, Hose DR, Halliday I, Lawford PV, Narracott AJ, Gunn JP, Morris PD. Sex differences in coronary microvascular resistance measured by a computational fluid dynamics model. Front Cardiovasc Med 2023; 10:1159160. [PMID: 37485258 PMCID: PMC10357508 DOI: 10.3389/fcvm.2023.1159160] [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: 02/05/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Background Increased coronary microvascular resistance (CMVR) is associated with coronary microvascular dysfunction (CMD). Although CMD is more common in women, sex-specific differences in CMVR have not been demonstrated previously. Aim To compare CMVR between men and women being investigated for chest pain. Methods and results We used a computational fluid dynamics (CFD) model of human coronary physiology to calculate absolute CMVR based on invasive coronary angiographic images and pressures in 203 coronary arteries from 144 individual patients. CMVR was significantly higher in women than men (860 [650-1,205] vs. 680 [520-865] WU, Z = -2.24, p = 0.025). None of the other major subgroup comparisons yielded any differences in CMVR. Conclusion CMVR was significantly higher in women compared with men. These sex-specific differences may help to explain the increased prevalence of CMD in women.
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Affiliation(s)
- Daniel J. Taylor
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Louise Aubiniere-Robb
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Rebecca Gosling
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Tom Newman
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - D. Rodney Hose
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Ian Halliday
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Patricia V. Lawford
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Andrew J. Narracott
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Julian P. Gunn
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Paul D. Morris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Insigneo Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
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10
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Berkowicz P, Totoń-Żurańska J, Kwiatkowski G, Jasztal A, Csípő T, Kus K, Tyrankiewicz U, Orzyłowska A, Wołkow P, Tóth A, Chlopicki S. Accelerated ageing and coronary microvascular dysfunction in chronic heart failure in Tgαq*44 mice. GeroScience 2023; 45:1619-1648. [PMID: 36692592 PMCID: PMC10400753 DOI: 10.1007/s11357-022-00716-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/12/2022] [Indexed: 01/25/2023] Open
Abstract
Age represents a major risk factor in heart failure (HF). However, the mechanisms linking ageing and HF are not clear. We aimed to identify the functional, morphological and transcriptomic changes that could be attributed to cardiac ageing in a model of slowly progressing HF in Tgαq*44 mice in reference to the cardiac ageing process in FVB mice. In FVB mice, ageing resulted in the impairment of diastolic cardiac function and in basal coronary flow (CF), perivascular and interstitial fibrosis without changes in the cardiac activity of angiotensin-converting enzyme (ACE) or aldosterone plasma concentration. In Tgαq*44 mice, HF progression was featured by the impairment of systolic and diastolic cardiac function and in basal CF that was associated with a distinct rearrangement of the capillary architecture, pronounced perivascular and interstitial fibrosis, progressive activation of cardiac ACE and systemic angiotensin-aldosterone-dependent pathways. Interestingly, cardiac ageing genes and processes were represented in Tgαq*44 mice not only in late but also in early phases of HF, as evidenced by cardiac transcriptome analysis. Thirty-four genes and 8 biological processes, identified as being ageing related, occurred early and persisted along HF progression in Tgαq*44 mice and were mostly associated with extracellular matrix remodelling and fibrosis compatible with perivascular fibrosis resulting in coronary microvascular dysfunction (CMD) in Tgαq*44 mice. In conclusion, accelerated and persistent cardiac ageing contributes to the pathophysiology of chronic HF in Tgαq*44 mice. In particular, prominent perivascular fibrosis of microcirculation resulting in CMD represents an accelerated cardiac ageing phenotype that requires targeted treatment in chronic HF.
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Affiliation(s)
- Piotr Berkowicz
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Justyna Totoń-Żurańska
- Centre for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Kwiatkowski
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Agnieszka Jasztal
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Tamás Csípő
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Kamil Kus
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Urszula Tyrankiewicz
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Anna Orzyłowska
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Paweł Wołkow
- Centre for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Attila Tóth
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stefan Chlopicki
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland.
- Faculty of Medicine, Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland.
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Singh A, Bonnell G, De Prey J, Buchwald N, Eskander K, Kincaid KJ, Wilson CA. Small-vessel disease in the brain. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100277. [PMID: 38511094 PMCID: PMC10945899 DOI: 10.1016/j.ahjo.2023.100277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/22/2024]
Abstract
Cerebral small-vessels are generally located in the brain at branch points from major cerebral blood vessels and perfuse subcortical structures such as the white matter tracts, basal ganglia, thalamus, and pons. Cerebral small-vessel disease (CSVD) can lead to several different clinical manifestations including ischemic lacunar stroke, intracerebral hemorrhage, and vascular dementia. Risk factors for CSVD overlap with conventional vascular risk factors including hypertension, diabetes mellitus, and hypercholesterolemia, as well as genetic causes. As in cardiovascular disease, treatment of CSVD involves both primary and secondary prevention. Aspirin has not been established as a primary prevention strategy for CSVD among the general population; however, long-term antiplatelet therapy with aspirin alone continues to be the mainstay of secondary stroke prevention for non-cardioembolic ischemic stroke and high-risk TIA.
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Affiliation(s)
- Amita Singh
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Gabriel Bonnell
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Justin De Prey
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Natalie Buchwald
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Kyrillos Eskander
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Keith J. Kincaid
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
| | - Christina A. Wilson
- Department of Neurology, University of Florida, Gainesville, FL, United States of America
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12
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Sucato V, Novo G, Madaudo C, Di Fazio L, Vadalà G, Caronna N, D’Agostino A, Evola S, Tuttolomondo A, Galassi AR. Longitudinal Strain Analysis and Correlation with TIMI Frame Count in Patients with Ischemia with No Obstructive Coronary Artery (INOCA) and Microvascular Angina (MVA). J Clin Med 2023; 12:jcm12030819. [PMID: 36769468 PMCID: PMC9918252 DOI: 10.3390/jcm12030819] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
Background: The aim of the study is to evaluate the subclinical alterations of cardiac mechanics detected using speckle-tracking echocardiography and compare these data with the coronary angiography indices used during coronary angiography in a population of patients diagnosed with ischemia with no obstructive coronary artery (INOCA) and microvascular angina (MVA). Methods: The study included 85 patients admitted to our center between November 2019 and January 2022 who were diagnosed with INOCA compared with a control group of 70 healthy patients. A collection of anamnestic data and a complete cardiovascular physical examination, and echocardiogram at rest with longitudinal strain were performed for all patients. Furthermore, the TIMI frame count (TFC) for the three coronary vessels was calculated according to Gibson's indications. All parameters were compared with a control population with similar characteristics. Results: Patients with INOCA compared to the control population showed statistically significant changes in the parameters assessed on the longitudinal strain analysis. In particular, patients with INOCA showed statistically significant changes in GLS (-16.71) compared to the control population (-19.64) (p = 0.003). In patients with INOCA, the total TIMI frame count (tTFC) correlated with the GLS value with a correlation coefficient of 0.418 (p = 0.021). Conclusions: In patients with angina, documented myocardial ischemia, the absence of angiographically significant stenosis (INOCA) and LVEF > 50%, the prevalence of microvascular dysfunction documented by TFC was extremely represented. A statistically significant reduction in GLS was observed in these patients. TFC and longitudinal strain, therefore, appear to be two reliable, sensitive and easily accessible methods for the study of alterations in coronary microcirculation and the characterization of patients with INOCA and microvascular angina.
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Gao J, Meng T, Li M, Du R, Ding J, Li A, Yu S, Li Y, He Q. Global trends and frontiers in research on coronary microvascular dysfunction: a bibliometric analysis from 2002 to 2022. Eur J Med Res 2022; 27:233. [PMID: 36335406 PMCID: PMC9636644 DOI: 10.1186/s40001-022-00869-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is a leading cause of ischemic heart disease. Over the past few decades, considerable progress has been made with respect to research on CMD. The present study summarized the current research hotspots and trends on CMD by applying a bibliometric approach. METHODS Relevant publications between 2002 and 2022 were extracted from the Web of Science Core Collection. Visualization network maps of countries, institutions, authors, and co-cited authors were built using VOSviewer. CiteSpace was used for keyword analysis and the construction of a dual-map overlay of journals and a timeline view of co-cited references. RESULTS 1539 CMD-related publications were extracted for bibliometric analysis. The annual publications generally showed an upward trend. The United States of America was the most prolific country, with 515 publications (33.5%). Camici P. G. was the most influential author, whereas the European Heart Journal, Circulation, and Journal of the American College of Cardiology were the most authoritative journals. Research hotspot analysis revealed that endothelial dysfunction as well as reduced nitric oxide production or bioavailability played critical roles in CMD development. Positron emission tomography was the most widely used imaging method for diagnosis. In addition, microvascular angina, hypertrophic cardiomyopathy, and heart failure have attracted much attention as the main clinical implications. Furthermore, international standards for CMD diagnosis and management may be the future research directions. CONCLUSIONS This study offers a comprehensive view about the hotspots and development trends of CMD, which can assist subsequent researchers and guide future directions.
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Affiliation(s)
- Jing Gao
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Tiantian Meng
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Li
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruolin Du
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jingyi Ding
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anqi Li
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shanshan Yu
- Graduate School, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yixiang Li
- Graduate School, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Qingyong He
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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14
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Jovanovic I, Tesic M, Djordjevic-Dikic A, Giga V, Beleslin B, Aleksandric S, Boskovic N, Petrovic O, Marjanovic M, Vratonjic J, Paunovic I, Ivanovic B, Trifunovic-Zamaklar D. Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1134-1142. [PMID: 36218210 DOI: 10.1002/jcu.23313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 06/16/2023]
Abstract
This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.
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Affiliation(s)
- Ivana Jovanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Milorad Tesic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Olga Petrovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Marjanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Ivana Paunovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Branislava Ivanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Trifunovic-Zamaklar
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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15
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Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment. J Clin Med 2022; 11:jcm11195497. [PMID: 36233366 PMCID: PMC9571924 DOI: 10.3390/jcm11195497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.
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16
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Classification, Diagnosis, and Treatment of Coronary Microvascular Dysfunction. J Clin Med 2022; 11:jcm11154610. [PMID: 35956225 PMCID: PMC9369905 DOI: 10.3390/jcm11154610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
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17
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Roy TK, Secomb TW. Functional implications of microvascular heterogeneity for oxygen uptake and utilization. Physiol Rep 2022; 10:e15303. [PMID: 35581743 PMCID: PMC9114652 DOI: 10.14814/phy2.15303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023] Open
Abstract
In the vascular system, an extensive network structure provides convective and diffusive transport of oxygen to tissue. In the microcirculation, parameters describing network structure, blood flow, and oxygen transport are highly heterogeneous. This heterogeneity can strongly affect oxygen supply and organ function, including reduced oxygen uptake in the lung and decreased oxygen delivery to tissue. The causes of heterogeneity can be classified as extrinsic or intrinsic. Extrinsic heterogeneity refers to variations in oxygen demand in the systemic circulation or oxygen supply in the lungs. Intrinsic heterogeneity refers to structural heterogeneity due to stochastic growth of blood vessels and variability in flow pathways due to geometric constraints, and resulting variations in blood flow and hematocrit. Mechanisms have evolved to compensate for heterogeneity and thereby improve oxygen uptake in the lung and delivery to tissue. These mechanisms, which involve long-term structural adaptation and short-term flow regulation, depend on upstream responses conducted along vessel walls, and work to redistribute flow and maintain blood and tissue oxygenation. Mathematically, the variance of a functional quantity such as oxygen delivery that depends on two or more heterogeneous variables can be reduced if one of the underlying variables is controlled by an appropriate compensatory mechanism. Ineffective regulatory mechanisms can result in poor oxygen delivery even in the presence of adequate overall tissue perfusion. Restoration of endothelial function, and specifically conducted responses, should be considered when addressing tissue hypoxemia and organ failure in clinical settings.
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Affiliation(s)
- Tuhin K. Roy
- Department of AnesthesiologyMayo ClinicRochesterMinnesotaUSA
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Thakker RA, Rodriguez Lozano J, Rodriguez Lozano P, Motiwala A, Rangasetty U, Khalife W, Chatila K. Coronary Microvascular Disease. Cardiol Ther 2022; 11:23-31. [PMID: 34993903 PMCID: PMC8933600 DOI: 10.1007/s40119-021-00250-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Indexed: 01/15/2023] Open
Abstract
Coronary microvascular disease or dysfunction (CMVD) has been associated with adverse cardiovascular outcomes. Despite a growing prevalence, guidelines on definitive treatment are lacking. Proposed mechanisms of endothelial dysfunction and resultant inflammation have been demonstrated as the underlying cause. Imaging modalities such as echocardiography, cardiac MRI, PET, and in some instances CT, have been shown to be useful in diagnosing CMVD mainly through assessment of coronary blood flow. Invasive measurements through thermodilution and pressure sensor-guided Doppler microcatheters have also been utilized. Treatment options are directed at targeting inflammatory pathways and angina. In our review, we highlight the current literature on the background of CMVD, diagnostic modalities, and management of this disease.
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Affiliation(s)
- Ravi A. Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77550 USA
| | | | | | - Afaq Motiwala
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX USA
| | | | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX USA
| | - Khaled Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX USA
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Myocardial Microvascular Physiology in Acute and Chronic Coronary Syndromes, Aortic Stenosis, and Heart Failure. J Interv Cardiol 2022; 2022:9846391. [PMID: 35935124 PMCID: PMC9297731 DOI: 10.1155/2022/9846391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 01/10/2023] Open
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20
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Yu L, Lu X, Xu C, Li T, Wang Y, Liu A, Wang Y, Chen L, Xu H. Overview of Microvascular Angina Pectoris and Discussion of Traditional Chinese Medicine Intervention. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:1497722. [PMID: 35035497 PMCID: PMC8754603 DOI: 10.1155/2022/1497722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022]
Abstract
Previous research and treatment of coronary heart disease mostly focused on the large epicardial vessels, with limited research on the small endocardial coronary arteries or arterioles that could not be detected by coronary angiography, especially microvascular angina caused by microvascular stenosis or microcirculation dysfunction. Conventional Western medicine therapies have no specific efficacy, but traditional Chinese medicine has significant advantages in this regard. In particular, traditional Chinese medicine of supplementing Qi and activating blood circulation protects the vascular endothelium, relaxes coronary microvessels, reduces myocardial no-reflow after ischemia-reperfusion, increases myocardial hypoxia tolerance, constrains the aggregation of platelet, and increases the rate of blood flow. Moreover, these treatments can significantly improve patients' symptoms through multitarget comprehensive intervention. Here, we analyzed the pathogenesis of microvascular angina pectoris, the treatment status of modern medicine, and the research on the multitarget intervention of traditional Chinese medicine to provide new research ideas for correctly identifying the role of coronary microcirculation in coronary artery disease to solve clinical problems and prevent cardiovascular events.
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Affiliation(s)
- Linghua Yu
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Xiaoyan Lu
- China-Japan Friendship Hospital, Beijing, China
| | - Chenxi Xu
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Tong Li
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Yanling Wang
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Anxiang Liu
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Yubi Wang
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Li Chen
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Huangyu Xu
- Beijing University of Traditional Chinese Medicine, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
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21
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Bilak JM, Alam U, Miller CA, McCann GP, Arnold JR, Kanagala P. Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction: Pathophysiology, Assessment, Prevalence and Prognosis. Card Fail Rev 2022; 8:e24. [PMID: 35846985 PMCID: PMC9274364 DOI: 10.15420/cfr.2022.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) currently accounts for approximately half of all new heart failure cases in the community. HFpEF is closely associated with chronic lifestyle-related diseases, such as obesity and type 2 diabetes, and clinical outcomes are worse in those with than without comorbidities. HFpEF is pathophysiologically distinct from heart failure with reduced ejection fraction, which may explain, in part, the disparity of treatment options available between the two heart failure phenotypes. The mechanisms underlying HFpEF are complex, with coronary microvascular dysfunction (MVD) being proposed as a potential key driver in its pathophysiology. In this review, the authors highlight the evidence implicating MVD in HFpEF pathophysiology, the diagnostic approaches for identifying MVD (both invasive and non-invasive) and the prevalence and prognostic significance of MVD.
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Affiliation(s)
- Joanna M Bilak
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Uazman Alam
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of ManchesterManchester, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of LiverpoolLiverpool, UK
| | - Christopher A Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science CentreManchester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield HospitalLeicester, UK
| | - Prathap Kanagala
- Liverpool University Hospitals NHS Foundation TrustLiverpool, UK
- Liverpool Centre for Cardiovascular Sciences, Faculty of Health and Life SciencesLiverpool, UK
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22
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Abstract
Up to half of patients undergoing elective coronary angiography for the investigation of chest pain do not present with evidence of obstructive coronary artery disease. These patients are often discharged with a diagnosis of non-cardiac chest pain, yet many could have an ischaemic basis for their symptoms. This type of ischaemic chest pain in the absence of obstructive coronary artery disease is referred to as INOCA (ischaemia with non-obstructive coronary arteries). This comprehensive review of INOCA management looks at why these patients require treatment, who requires treatment based on diagnostic evaluation, what clinical treatment targets should be considered, how to treat patients using a personalised medicine approach, when to initiate treatment, and where future research is progressing.
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Affiliation(s)
- John F Beltrame
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Dione Jones
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Chris Zeitz
- Adelaide Medical School, University of Adelaide, Queen Elizabeth Hospital Campus, Woodville South, Adelaide, SA, Australia
- Department of Cardiology, Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
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23
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Shimokawa H, Suda A, Takahashi J, Berry C, Camici PG, Crea F, Escaned J, Ford T, Yii E, Kaski JC, Kiyooka T, Mehta PK, Ong P, Ozaki Y, Pepine C, Rimoldi O, Safdar B, Sechtem U, Tsujita K, Yasuda S, Beltrame JF, Merz CNB. Clinical characteristics and prognosis of patients with microvascular angina: an international and prospective cohort study by the Coronary Vasomotor Disorders International Study (COVADIS) Group. Eur Heart J 2021; 42:4592-4600. [PMID: 34038937 PMCID: PMC8633728 DOI: 10.1093/eurheartj/ehab282] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/01/2021] [Accepted: 04/23/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis of patients with microvascular angina (MVA). METHODS AND RESULTS The Coronary Vasomotor Disorders International Study Group proposed the diagnostic criteria for MVA. We prospectively evaluated the clinical characteristics of patients according to these criteria and their prognosis. The primary endpoint was the composite of major cardiovascular events (MACE), verified by institutional investigators, which included cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina. During the period from 1 July 2015 to 31 December 2018, 686 patients with MVA were registered from 14 institutes in 7 countries from 4 continents. Among them, 64% were female and the main ethnic groups were Caucasians (61%) and Asians (29%). During follow-up of a median of 398 days (IQR 365-744), 78 MACE occurred (6.4% in men vs. 8.6% in women, P = 0.19). Multivariable Cox proportional hazard analysis disclosed that hypertension and previous history of coronary artery disease (CAD), including acute coronary syndrome and stable angina pectoris, were independent predictors of MACE. There was no sex or ethnic difference in prognosis, although women had lower Seattle Angina Questionnaire scores than men (P < 0.05). CONCLUSIONS This first international study provides novel evidence that MVA is an important health problem regardless of sex or ethnicity that a diagnosis of MVA portends a substantial risk for MACE associated with hypertension and previous history of CAD, and that women have a lower quality of life than men despite the comparable prognosis.
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Affiliation(s)
- Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Sendai, Japan
- International University of Health and Welfare, Narita, Japan
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Sendai, Japan
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Filippo Crea
- Department of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Tom Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Eric Yii
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Juan Carlos Kaski
- Department of Cardiovascular Science, Cardiovascular and Cell Sciences Res Institute, St George’s, University of London, UK
| | - Takahiko Kiyooka
- Department of Cardiology, Tokai University Oiso Hospital, Oiso, Japan
| | - Puja K Mehta
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University School of Medicine, Toyonaka, Aichi, Japan
| | - Carl Pepine
- Division of Cardiovascular Medicine, University of Florida, College of Medicine, Gainesville, FL, USA
| | - Ornella Rimoldi
- Institute of Molecular Bioimaging and Physiology, Consiglio Nazionale delle Ricerche, Segrate, Italy
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Sendai, Japan
| | - John F Beltrame
- The Discipline of Medicine, University of Adelaide, Basil Hetzel Institute, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - C Noel Bairey Merz
- Department of Cardiology, Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, Los Angeles, CA, USA
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24
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Sinha A, Rahman H, Webb A, Shah AM, Perera D. Untangling the pathophysiologic link between coronary microvascular dysfunction and heart failure with preserved ejection fraction. Eur Heart J 2021; 42:4431-4441. [PMID: 34529791 PMCID: PMC8599060 DOI: 10.1093/eurheartj/ehab653] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023] Open
Abstract
Coronary microvascular disease (CMD), characterized by impaired coronary flow reserve (CFR), is a common finding in patients with stable angina. Impaired CFR, in the absence of obstructive coronary artery disease, is also present in up to 75% of patients with heart failure with preserved ejection fraction (HFpEF). Heart failure with preserved ejection fraction is a heterogeneous syndrome comprising distinct endotypes and it has been hypothesized that CMD lies at the centre of the pathogenesis of one such entity: the CMD–HFpEF endotype. This article provides a contemporary review of the pathophysiology underlying CMD, with a focus on the mechanistic link between CMD and HFpEF. We discuss the central role played by subendocardial ischaemia and impaired lusitropy in the development of CMD–HFpEF, as well as the clinical and research implications of the CMD–HFpEF mechanistic link. Future prospective follow-up studies detailing outcomes in patients with CMD and HFpEF are much needed to enhance our understanding of the pathological processes driving these conditions, which may lead to the development of physiology-stratified therapy to improve the quality of life and prognosis in these patients.
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Affiliation(s)
- Aish Sinha
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Andrew Webb
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Ajay M Shah
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, St. Thomas' Hospital, Westminster bridge road, London SE1 7EH, UK
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25
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Lanza GA, Morrone D, Pizzi C, Tritto I, Bergamaschi L, De Vita A, Villano A, Crea F. Diagnostic approach for coronary microvascular dysfunction in patients with chest pain and no obstructive coronary artery disease. Trends Cardiovasc Med 2021; 32:448-453. [PMID: 34384879 DOI: 10.1016/j.tcm.2021.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/15/2022]
Abstract
A large number of studies has demonstrated that abnormalities of coronary microcirculation may be responsible for both acute and chronic cardiac ischemic syndromes. In clinical practice the microvascular origin of myocardial ischemia and angina is usually considered in patients who are found to have normal or near-normal coronary arteries at angiography. In this article, we review the diagnostic approach to patients with suspected coronary microvascular dysfunction as a cause of ischemic syndromes and also suggest a classification of chronic and acute microvascular coronary ischemic syndrome, including myocardial infarction with normal coronary arteries.
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Affiliation(s)
- Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy.
| | - Doralisa Morrone
- Università di Pisa, Dipartimento di patologia chirurgica, medica, molecolare e dell'area critica, Pisa, Italy
| | - Carmine Pizzi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Isabella Tritto
- Università di Perugia, Dipartimento di Medicina, Sezione di Cardiologia e Fisiopatologia Cardiovascolare, Perugia, Italy
| | - Luca Bergamaschi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Antonio De Vita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
| | - Angelo Villano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Dipartimento di Medicina Cardiovascolare, Roma, Italy
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26
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Junqueira CLC, Ferreira E, Junqueira ASM, de Almeida Cyrino FZG, Maranhão PA, Kraemer-Aguiar LG, Bottino DA, Coelho de Souza MDG, Bouskela E. Peripheral microvascular dysfunction is also present in patients with ischemia and no obstructive coronary artery disease (INOCA). Clin Hemorheol Microcirc 2021; 79:381-393. [PMID: 34151847 DOI: 10.3233/ch-201065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In patients with ischemia and no obstructive coronary artery disease (INOCA), coronary microvascular dysfunction is associated with higher rate of major adverse cardiovascular events. OBJECTIVE To demonstrate if microvascular dysfunction present in coronary microcirculation of patients with INOCA may be detected noninvasively in their peripheral circulation. METHODS 25 patients with INOCA and 25 apparently healthy individuals (controls) were subjected to nailfold videocapillaroscopy (NVC) and venous occlusion plethysmography (VOP) to evaluate peripheral microvascular function and blood collection for biomarkers analysis, including soluble vascular cell adhesion molecule-1 (sVCAM-1), endothelin-1 (ET-1) and C-reactive protein (CRP). RESULTS Red blood cell velocity (RBCV) before and after ischemia (RBCVmax) were significantly lower in patients with INOCA (p = 0.0001). Time to reach maximal red blood cell velocity (TRBCVmax) was significantly longer in INOCA group (p = 0.0004). Concerning VOP, maximal blood flow (p = 0.004) and its relative increment were significantly lower in patients with INOCA (p = 0.0004). RBCVmax showed significant correlations with sVCAM-1 (r = -0.38, p < 0.05), ET-1 (r = -0.73, p < 0.05) and CRP (r = -0.33, p < 0.05). Relative increment of maximal post-ischemic blood flow was significantly correlated with sVCAM-1 (r = -0.42, p < 0.05) and ET-1 (r = -0.48, p < 0.05). CONCLUSIONS The impairment of microvascular function present in coronary microcirculation of patients with INOCA can be also detected in peripheral microcirculation.
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Affiliation(s)
- Camillo L C Junqueira
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Esmeralci Ferreira
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Departamento de Cardiologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Brazil
| | | | | | - Priscila Alves Maranhão
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Luiz Guilherme Kraemer-Aguiar
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Brazil
| | - Daniel Alexandre Bottino
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Maria das Graças Coelho de Souza
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Eliete Bouskela
- Laboratório de Pesquisas Clínicas e Experimentais em Biologia Vascular, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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27
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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.
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28
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Celaya-Alcala JT, Lee GV, Smith AF, Li B, Sakadžić S, Boas DA, Secomb TW. Simulation of oxygen transport and estimation of tissue perfusion in extensive microvascular networks: Application to cerebral cortex. J Cereb Blood Flow Metab 2021; 41:656-669. [PMID: 32501155 PMCID: PMC7922761 DOI: 10.1177/0271678x20927100] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/23/2020] [Accepted: 02/15/2020] [Indexed: 12/13/2022]
Abstract
Advanced imaging techniques have made available extensive three-dimensional microvascular network structures. Simulation of oxygen transport by such networks requires information on blood flow rates and oxygen levels in vessels crossing boundaries of the imaged region, which is difficult to obtain experimentally. Here, a computational method is presented for estimating blood flow rates, oxygen levels, tissue perfusion and oxygen extraction, based on incomplete boundary conditions. Flow rates in all segments are estimated using a previously published method. Vessels crossing the region boundary are classified as arterioles, capillaries or venules. Oxygen levels in inflowing capillaries are assigned based on values in outflowing capillaries, and similarly for venules. Convective and diffusive oxygen transport is simulated. Contributions of each vessel to perfusion are computed in proportion to the decline in oxygen concentration along that vessel. For a vascular network in the mouse cerebral cortex, predicted tissue oxygen levels show a broad distribution, with 99% of tissue in the range of 20 to 80 mmHg under reference conditions, and steep gradients near arterioles. Perfusion and extraction estimates are consistent with experimental values. A 30% reduction in perfusion or a 30% increase in oxygen demand, relative to reference levels, is predicted to result in tissue hypoxia.
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Affiliation(s)
| | - Grace V Lee
- Program in Applied Mathematics,
University of Arizona, Tucson, AZ, USA
| | - Amy F Smith
- Department of Physiology, University
of Arizona, Tucson, AZ, USA
| | - Bohan Li
- Department of Mathematics,
University of Arizona, Tucson, AZ, USA
| | - Sava Sakadžić
- Athinoula A. Martinos Center for
Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
| | - David A Boas
- Athinoula A. Martinos Center for
Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
- Department of Biomedical
Engineering, Boston University, Boston, MA, USA
| | - Timothy W Secomb
- Department of Mathematics,
University of Arizona, Tucson, AZ, USA
- Program in Applied Mathematics,
University of Arizona, Tucson, AZ, USA
- Department of Physiology, University
of Arizona, Tucson, AZ, USA
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29
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Sinha A, Rahman H, Perera D. Coronary microvascular disease: current concepts of pathophysiology, diagnosis and management. Cardiovasc Endocrinol Metab 2021; 10:22-30. [PMID: 33634252 PMCID: PMC7901821 DOI: 10.1097/xce.0000000000000223] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/23/2020] [Indexed: 12/28/2022]
Abstract
Coronary microvascular disease (CMD) is present in 30% of patients with angina and is associated with increased morbidity and mortality. We now have an improved understanding of the pathophysiology of CMD and the invasive and noninvasive tests that can be used to make the diagnosis. Recent studies have shown that management of CMD guided by physiological testing yields better results than empirical treatment. Despite major advances in diagnosing and stratifying this condition, therapeutic strategies remain limited and poorly defined. This review article discusses recent advances in understanding the pathophysiology of CMD, the modalities that are available to diagnose it clinically, current management options and a look at what is in store for the future.
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Affiliation(s)
- Aish Sinha
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Haseeb Rahman
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - Divaka Perera
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
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30
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Zhang Y, Wang X, Liu R, Li Q, Tian W, Lei H, Shi C. The effectiveness and safety of nicorandil in the treatment of patients with microvascular angina: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23888. [PMID: 33466132 PMCID: PMC7808505 DOI: 10.1097/md.0000000000023888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microvascular angina has become a clinical and frequent cardiovascular disease in recent years, which is complicated and there is no clear treatment. Today, Western medicine still deals with microvascular angina with standardized treatment based on the stable angina. Firstly, it is to control the risk factors of atherosclerosis, and the second is to reduce the oxygen consumption of the patient's heart muscle. In the previous randomized controlled clinical trials, it has shown that nicorandil can improve the symptoms of angina for the treatment of microvascular angina, but there is a lack of high-quality randomized controlled trials on the clinical effectiveness and safety of nicorandil in the treatment of microvascular angina, and the lack of evaluation of its effectiveness and safety. Therefore, this paper aims to understand whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug through the method of systematic evaluation. METHODS Retrieval of relevant network electronic databases by computer: SinoMed, CNKI, WanFang Data, VIP, PubMed, EMbase and The Cochrane Library, the retrieval time is from the establishment of each database to December 2017, to collect randomized controlled studies of nicorandil in the treatment of microvascular angina. At the same time, it is supplemented by manual search of the included literature references, as far as possible to increase the included literature imformation. Two researchers independently browse the topics and abstracts, and select, find, read the full text of the relevant literature, and screen the literature according to the criteria for inclusion and exclusion established in advance, then extract the data, and cross-check, and resolve the differences through multi-person discussion. Data analysis of collected information is performed by using RevMan 5.3 software. RESULTS The data of the included literature are statistically analyzed by meta-analysis, and the key outcome indicators are used to determine whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug. CONCLUSION Through the method of evidence-based medicine, this study finds the existing problems and defects in the current research, which will provide high-quality evidence-based medical evidence for nicorandil's treatment of microvascular angina, and it help the clinical treatment and further research. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/DSQG9.
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Affiliation(s)
- Ye Zhang
- Nursing Teaching and Research Section of Medical Department, Hetao College, Yunzhong Street, Shuanghe Town, Linhe District, Bayannur
| | - Xiaojuan Wang
- Parasitology Teaching and Research Section of School of Basic Medical Sciences, Inner Mongolia Medical University, Jinshan Development Zone
| | - Ruijuan Liu
- Nursing Teaching and Research Section of Medical Department, Hetao College, Yunzhong Street, Shuanghe Town, Linhe District, Bayannur
| | - Qingsheng Li
- Department of Pharmacy, the Affiliated Hospital of Inner Mongolia Medical University, NO.1 Tongdao North Road, Huimin District, Hohhot 010050
| | - Wei Tian
- Department of Pharmacy, Bayannur Hospital, NO.98 Wulanbuhe Road, Linhe District, Bayannur
| | - Hong Lei
- Department of Pharmacy, Inner Mongolia People's Hospital, NO.20 Zhaowuda Road, Saihan District, Hohhot
| | - Conghong Shi
- Department of Cardiovascular Medicine, the Fourth Hospital of Baotou, NO.29 Aogeng Road, Qingshan District, Baotou, Inner Mongolia Autonomous Region, PR of China
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31
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Roy TK, Secomb TW. Effects of impaired microvascular flow regulation on metabolism-perfusion matching and organ function. Microcirculation 2020; 28:e12673. [PMID: 33236393 DOI: 10.1111/micc.12673] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Impaired tissue oxygen delivery is a major cause of organ damage and failure in critically ill patients, which can occur even when systemic parameters, including cardiac output and arterial hemoglobin saturation, are close to normal. This review addresses oxygen transport mechanisms at the microcirculatory scale, and how hypoxia may occur in spite of adequate convective oxygen supply. The structure of the microcirculation is intrinsically heterogeneous, with wide variations in vessel diameters and flow pathway lengths, and consequently also in blood flow rates and oxygen levels. The dynamic processes of structural adaptation and flow regulation continually adjust microvessel diameters to compensate for heterogeneity, redistributing flow according to metabolic needs to ensure adequate tissue oxygenation. A key role in flow regulation is played by conducted responses, which are generated and propagated by endothelial cells and signal upstream arterioles to dilate in response to local hypoxia. Several pathophysiological conditions can impair local flow regulation, causing hypoxia and tissue damage leading to organ failure. Therapeutic measures targeted to systemic parameters may not address or may even worsen tissue oxygenation at the microvascular level. Restoration of tissue oxygenation in critically ill patients may depend on restoration of endothelial cell function, including conducted responses.
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Affiliation(s)
- Tuhin K Roy
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy W Secomb
- Department of Physiology, University of Arizona, Tucson, AZ, 85724, USA
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32
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Ai H, Feng Y, Gong Y, Zheng B, Jin Q, Zhang HP, Sun F, Li J, Chen Y, Huo Y, Huo Y. Coronary Angiography-Derived Index of Microvascular Resistance. Front Physiol 2020; 11:605356. [PMID: 33391020 PMCID: PMC7772433 DOI: 10.3389/fphys.2020.605356] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 11/16/2020] [Indexed: 01/10/2023] Open
Abstract
A coronary angiography-derived index of microvascular resistance (caIMR) is proposed for physiological assessment of microvasular diseases in coronary circulation. The aim of the study is to assess diagnostic performance of caIMR, using wire-derived index of microvascular resistance (IMR) as the reference standard. IMR was demonstrated in 56 patients (57 vessels) with stable/unstable angina pectoris and no obstructive coronary arteries in three centers using the Certus pressure wire. Based on the aortic pressure wave and coronary angiograms from two projections, the caIMR was computed and assessed in blinded fashion against the IMR at an independent core laboratory. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the caIMR with a cutoff value of 25 were 84.2% (95% CI: 72.1% to 92.5%), 86.1% (95% CI: 70.5% to 95.3%), 81.0% (95% CI: 58.1% to 94.6%), 88.6% (95% CI: 76.1% to 95.0%), and 77.3% (95% CI: 59.5% to 88.7%) against the IMR with a cutoff value of 25. The receiver-operating curve had area under the curve of 0.919 and the correlation coefficient equaled to 0.746 between caIMR and wire-derived IMR. Hence, caIMR could eliminate the need of a pressure wire, reduce technical error, and potentially increase adoption of physiological assessment of microvascular diseases in patients with ischemic heart disease.
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Affiliation(s)
- Hu Ai
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Yundi Feng
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qinhua Jin
- Department of Cardiovascular, PLA General Hospital, Beijing, China
| | - Hui-Ping Zhang
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Fucheng Sun
- Department of Cardiology, Beijing Hospital, Beijing, China.,National Center of Gerontology, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiovascular, PLA General Hospital, Beijing, China
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China.,Department of Cardiology, Peking University First Hospital, Beijing, China.,Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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33
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Suda A, Takahashi J, Beltrame JF, Berry C, Camici PG, Crea F, Escaned J, Ford T, Carlos Kaski J, Kiyooka T, Metha PK, Ong P, Ozaki Y, Pepine C, Rimoldi O, Safdar B, Sechtem U, Tsujita K, Yii E, Noel Bairey Merz C, Shimokawa H. International prospective cohort study of microvascular angina - Rationale and design. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2020; 31:100630. [PMID: 32984497 PMCID: PMC7494778 DOI: 10.1016/j.ijcha.2020.100630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with signs and symptoms of myocardial ischemia and non-obstructive coronary artery disease (CAD) frequently have coronary functional abnormalities, including coronary microvascular dysfunction. Those with the latter are grouped under the term "microvascular angina" (MVA). Although diagnostic criteria exist for MVA, as recently proposed by our COVADIS (COronary VAsomotor Disorders International Study) group and the condition has been increasingly recognized in clinical practice, the clinical characteristics and long-term prognosis of MVA patients in the current era remain to be fully elucidated. AIMS In the present study, we aimed to prospectively assess the clinical characteristics and long-term prognosis of MVA subjects in the current era in an international, multicenter, observational, and prospective registry study. METHODS A total of 15 medical centers across 7 countries (USA, UK, Germany, Spain, Italy, Australia, and Japan) enrolled subjects fulfilling the COVADIS diagnostic criteria for MVA as follows; (1) signs and/or symptoms of myocardial ischemia, (2) absence of obstructive CAD, and (3) objective evidence of myocardial ischemia and/or coronary microvascular dysfunction. The primary endpoint was the composite of major cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, hospitalization due to heart failure or unstable angina. Between July 2015 and December 2018, a total of 706 subjects with MVA (M/F 256/450, 61.1 ± 11.8 [SD] yrs.) were registered. Subjects will be followed for at least 1 year. SUMMARY The present study will provide important information regarding the clinical characteristics, management, and long-term prognosis of MVA patients in the current era.
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Affiliation(s)
- Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - John F Beltrame
- The Discipline of Medicine, University of Adelaide, Basil Hetzel Institute, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Tom Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St George's, University of London, UK
| | - Takahiko Kiyooka
- Department of Cardiology, Tokai University Oiso Hospital, Oiso, Japan
| | - Puja K Metha
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University, Toyonaka, Aichi, Japan
| | - Carl Pepine
- Division of Cardiovascular Medicine, University of Florida, College of Medicine, Gainesville, FL, USA
| | - Ornella Rimoldi
- Institute of Molecular Bioimaging and Physiology, Consiglio Nazionale delle Ricerche, Segrate, Italy
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Eric Yii
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- International University of Health and Welfare, Narita, Japan
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Serum prolidase activity in patients with cardiac syndrome X. North Clin Istanb 2020; 7:471-477. [PMID: 33163883 PMCID: PMC7603856 DOI: 10.14744/nci.2020.09086] [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: 12/09/2019] [Accepted: 04/10/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE: Although the underlying mechanism is not yet fully understood, Cardiac Syndrome X (CSX) is defined as microvascular dysfunction. Prolidase plays a role in collagen synthesis. Increased serum prolidase activity (SPA) has been shown to correlate with collagen turnover. Augmented collagen turn-over may be associated with vascular fibrosis and microvascular dysfunction. In this study, we assessed whether there was a correlation between CXS and prolidase activity. METHODS: This case-control study included 45 consecutive CSX patients (mean age 50.7±6.5 years, 27 women) and 40 healthy controls (mean age 51.2±6.5 years, 25 women). Prolidase activity was determined with the Human Xaa-Pro Dipeptidase/Prolidase enzyme-linked immunosorbent assay kit (Cusabio Biotech Co. Ltd, China). RESULTS: Mean prolidase activity was 898.8±639.1 mU/mL in the CSX group and 434.1±289.8 mU/mL in the control group (p<0.001). In ROC analysis, it was found that the SPA value above 350 mU/mL sympathizes with the diagnosis of CSX. CONCLUSION: Increased SPA in CXS patients may play an essential role in the pathophysiology of CSX, leading to augmented oxidative stress and vascular fibrosis, endothelial dysfunction, and increased microvascular resistance.
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35
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Gallone G, Baldetti L, Tzanis G, Gramegna M, Latib A, Colombo A, Henry TD, Giannini F. Refractory Angina: From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovasc Interv 2020; 13:1-19. [PMID: 31918927 DOI: 10.1016/j.jcin.2019.08.055] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
Abstract
Despite optimal combination of guideline-directed anti-ischemic therapies and myocardial revascularization, a substantial proportion of patients with stable coronary artery disease continues to experience disabling symptoms and is often referred as "no-option." The appraisal of the pathways linking ischemia to symptom perception indicates a complex model of heart-brain interactions in the generation of the subjective anginal experience and inspired novel approaches that may be clinically effective in alleviating the angina burden of this population. Conversely, the prevailing ischemia-centered view of angina, with the focus on traditional myocardial revascularization as the sole option to address ischemia on top of medical therapy, hinders the experimental characterization and broad-scale clinical implementation of strongly needed therapeutic options. The interventionist, often the first physician to establish the diagnosis of refractory angina pectoris (RAP) following coronary angiography, should be aware of the numerous emerging technologies with the potential to improve quality of life in the growing population of RAP patients. This review describes the current landscape and the future perspectives on nonpharmacological treatment technologies for patients with RAP, with a view on the underlying physiopathological rationale and current clinical evidence.
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Affiliation(s)
- Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, Città della Scienza e della Salute Hospital, University of Turin, Turin, Italy
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Georgios Tzanis
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Bronx, New York. https://twitter.com/azeemlatib
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio; University of Florida, Gainesville, Florida
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy.
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36
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Schindler TH, Bateman TM, Berman DS, Chareonthaitawee P, De Blanche LE, Dilsizian V, Dorbala S, Gropler RJ, Shaw L, Soman P, Winchester DE, Verberne H, Ahuja S, Beanlands RS, Di Carli MF, Murthy VL, Ruddy TD, Schwartz RG. Appropriate Use Criteria for PET Myocardial Perfusion Imaging. J Nucl Med 2020; 61:1221-1265. [PMID: 32747510 DOI: 10.2967/jnumed.120.246280] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | - Daniel S Berman
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Panithaya Chareonthaitawee
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia
| | | | - Vasken Dilsizian
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia
| | - Sharmila Dorbala
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Robert J Gropler
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Leslee Shaw
- American College of Cardiology, Washington, D.C.,Society of Cardiovascular Computed Tomography, Arlington, Virginia
| | - Prem Soman
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American College of Cardiology, Washington, D.C
| | | | - Hein Verberne
- European Association of Nuclear Medicine, Vienna, Austria
| | - Sukhjeet Ahuja
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | - Rob S Beanlands
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Society of Nuclear Cardiology, Fairfax, Virginia.,American College of Cardiology, Washington, D.C.,Canadian Society of Cardiovascular Nuclear and CT Imaging, Ottawa, Ontario, Canada.,Canadian Cardiovascular Society, Ottawa, Ontario, Canada; and
| | - Marcelo F Di Carli
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,American Heart Association, Dallas, Texas
| | | | - Terrence D Ruddy
- Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia.,Canadian Society of Cardiovascular Nuclear and CT Imaging, Ottawa, Ontario, Canada.,Canadian Cardiovascular Society, Ottawa, Ontario, Canada; and
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Lanza GA, Crea F, Kaski JC. Clinical outcomes in patients with primary stable microvascular angina: is the jury still out? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 5:283-291. [PMID: 31168622 DOI: 10.1093/ehjqcco/qcz029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 01/14/2023]
Abstract
Several studies have demonstrated that angina chest pain in presence of normal or near normal coronary arteries (NCAs) is mainly related to coronary microvascular dysfunction (CMD). However, controversial findings exist about clinical outcome of these patients. In this article, we critically review characteristics and results of the main clinical studies reporting clinical outcome of stable patients with angina chest pain and non-obstructive coronary artery disease (NO-CAD). Published data indicate that clinical outcomes of these patients are heterogeneous, but those with strict criteria for primary stable microvascular angina (MVA, i.e. typical angina with NCAs mainly related to efforts) do not appear to have an increased mortality or risk of major coronary events. A major determinant of outcome in patients with MVA and NO-CAD seems instead related to non-critical atherosclerotic disease, the presence of which should suggest a more aggressive management of cardiovascular risk factors and preventive management. Future studies should assess whether CMD may have a relevant prognostic role in the latter clinical context and/or in other clinical settings of NO-CAD different from primary stable MVA.
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Affiliation(s)
- Gaetano Antonio Lanza
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Istituto di Cardiologia, Largo A. Gemelli, 8, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Istituto di Cardiologia, Largo A. Gemelli, 8, Rome, Italy
| | - Juan Carlos Kaski
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London, London, UK
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38
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Ziegelstein RC. I think it's all in my head, doc. J Psychosom Res 2020; 134:110109. [PMID: 32307102 DOI: 10.1016/j.jpsychores.2020.110109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Roy C Ziegelstein
- Johns Hopkins University School of Medicine, Miller Research Building, 733 N. Broadway, Suite 115, Baltimore, MD 21205, United States of America.
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39
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Levy BI, Heusch G, Camici PG. The many faces of myocardial ischaemia and angina. Cardiovasc Res 2020; 115:1460-1470. [PMID: 31228187 DOI: 10.1093/cvr/cvz160] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/25/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
Obstructive disease of the epicardial coronary arteries is the main cause of angina. However, a number of patients with anginal symptoms have normal coronaries or non-obstructive coronary artery disease (CAD) despite electrocardiographic evidence of ischaemia during stress testing. In addition to limited microvascular vasodilator capacity, the coronary microcirculation of these patients is particularly sensitive to vasoconstrictor stimuli, in a condition known as microvascular angina. This review briefly summarizes the determinants and control of coronary blood flow (CBF) and myocardial perfusion. It subsequently analyses the mechanisms responsible for transient myocardial ischaemia: obstructive CAD, coronary spasm and coronary microvascular dysfunction in the absence of epicardial coronary lesions, and variable combinations of structural anomalies, impaired endothelium-dependent and/or -independent vasodilation, and enhanced perception of pain. Lastly, we exemplify mechanism of angina during tachycardia. Distal to a coronary stenosis, coronary dilator reserve is already recruited and can be nearly exhausted at rest distal to a severe stenosis. Increased heart rate reduces the duration of diastole and thus CBF when metabolic vasodilation is no longer able to increase CBF. The increase in myocardial oxygen consumption and resulting metabolic vasodilation in adjacent myocardium without stenotic coronary arteries further acts to divert blood flow away from the post-stenotic coronary vascular bed through collaterals.
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Affiliation(s)
- Bernard I Levy
- Inserm U970 and Vessels and Blood Institute, 8 Rue Guy Patin, Paris, France
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, Universitätsklinikum Essen, Essen, Germany
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
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40
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Sandhu VK, Wei J, Thomson LEJ, Berman DS, Schapira J, Wallace D, Weisman MH, Bairey Merz CN, Ishimori ML. Five-Year Follow-Up of Coronary Microvascular Dysfunction and Coronary Artery Disease in Systemic Lupus Erythematosus: Results From a Community-Based Lupus Cohort. Arthritis Care Res (Hoboken) 2020; 72:882-887. [PMID: 31058466 DOI: 10.1002/acr.23920] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 04/30/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was undertaken to investigate prospective change in the prevalence of coronary microvascular dysfunction (CMD) and obstructive coronary artery disease (CAD) in a cohort of subjects with systemic lupus erythematosus (SLE) initially evaluated for anginal chest pain (CP). Prior work documented a relatively high prevalence of CMD in the absence of obstructive CAD in subjects with SLE. METHODS Twenty female SLE subjects with CP who underwent stress cardiac magnetic resonance imaging (CMRI) and coronary computed tomography angiography at baseline were reevaluated at 5 years. RESULTS Seventeen subjects (85%) were available and reenrolled, of which 11 (65%) had persistent CP at follow-up. Fourteen subjects had complete follow-up CMRI, of which 36% (n = 5) demonstrated CMD at follow-up. Further, 25% (1 of 4) of the originally abnormal myocardial perfusion reserve index (MPRI) findings at baseline were lower at follow-up, while 2 additional abnormal MPRI findings at follow-up were noted in previously normal MPRI results. The prevalence of CMD and nonobstructive/obstructive CAD both was unchanged between baseline and follow-up, respectively (both P values not significant). During follow-up, 33% of subjects (5 of 15) had adverse cardiac outcomes, including pericarditis, unstable angina, or intracranial aneurysm clipping procedure. CONCLUSION At the 5-year follow-up of SLE subjects with CP who were evaluated at baseline and follow-up, a majority had persistent CP, and nearly one-half had similar or worse myocardial perfusion consistent with CMD without obstructive CAD. These findings propose an alternative explanation for CP in SLE subjects compared to the more common SLE-related accelerated obstructive CAD accounting for CP and adverse outcomes. These findings support further studies of CMD as an etiology for cardiac morbidity and mortality in SLE.
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Affiliation(s)
| | - Janet Wei
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Jay Schapira
- Cedars-Sinai Medical Center, Los Angeles, California
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41
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Baggiano A, Guglielmo M, Muscogiuri G, Guaricci AI, Del Torto A, Pontone G. (Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance. Eur Heart J Suppl 2020; 22:E116-E120. [PMID: 32523454 PMCID: PMC7270897 DOI: 10.1093/eurheartj/suaa075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.
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Affiliation(s)
- Andrea Baggiano
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marco Guglielmo
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | | | - Andrea Igoren Guaricci
- Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital "Policlinico" of Bari, Bari, Italy
| | - Alberico Del Torto
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy.,Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital "Policlinico" of Bari, Bari, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, Via C. Parea 4, 20138 Milan, Italy
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42
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Sucato V, Novo G, Saladino A, Evola S, Galassi AR. Coronary microvascular dysfunction. Minerva Cardioangiol 2020; 68:153-163. [PMID: 32083426 DOI: 10.23736/s0026-4725.20.05070-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with coronary microvascular dysfunction (CMVD) represent a widespread population and despite the good prognosis, many of them have a poor quality of life with strong limitations in their daily activities because of the angina symptoms. This article summarizes the most frequent clinical presentation pictures like stable and unstable microvascular angina. Main risk factors are discussed, followed by the latest updates on the subject about different pathogenic hypotheses, diagnosis and treatment. Not very well understood microvascular alterations, like slow flow phenomenon and no reflow are discussed and both prognosis and the impact of the disease in the quality of life are analyzed.
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Affiliation(s)
- Vincenzo Sucato
- Division of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy -
| | - Giuseppina Novo
- Division of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy
| | - Antonino Saladino
- Division of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy
| | - Salvatore Evola
- Division of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy
| | - Alfredo R Galassi
- Division of Cardiology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy
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43
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Ischemia in patients with no obstructive coronary artery disease: classification, diagnosis and treatment of coronary microvascular dysfunction. Coron Artery Dis 2020; 31:472-476. [DOI: 10.1097/mca.0000000000000855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith LR, Salifu MO, McFarlane IM. Non-Obstructive Coronary Artery Disease in Women: Current Evidence and Future Directions. INTERNATIONAL JOURNAL OF CLINICAL RESEARCH & TRIALS 2020; 5:152. [PMID: 33447689 PMCID: PMC7806203 DOI: 10.15344/2456-8007/2020/152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Over half of women who present with angina are found to have negative coronary angiographic assessments. Of these patients, up to 50% are diagnosed with coronary microvascular dysfunction (CMD), which refers to pathologic changes within the small vessels of the coronary circulation. The hallmark of the pathophysiology of CMD is that endothelial damage, which occurs due to a multitude of conditions and risk factors, is the inciting event for the development and progression of CMD. CMD leads to a mismatch in myocardial demand and perfusion, leading to signs and symptoms of cardiac ischemia in the absence of obstructive lesions in the major vessels. CMD can be diagnosed through a variety of both invasive methods that allow a more specific evaluation of the microvasculature and non-invasive imaging techniques, such as cardiac positron emission tomography (PET) and magnetic resonance imaging (MRI). Risk factors for CMD overlap significantly with those of obstructive coronary artery disease (CAD) - hypertension, hypercholesterolemia, and diabetes remain salient predictors. However, these conditions only account for 20% of CMD cases in females. FINDINGS Women have sex-specific risk factors such as menopause, pregnancy, polycystic ovarian syndrome (PCOS), and a higher proclivity toward chronic inflammatory disorders. Estrogen has a cardioprotective effect by increasing production of nitric oxide, a potent vasodilator released by endothelial cells. As a result, the hormonal changes of menopause may accelerate endothelial damage, and in turn, CMD. Current treatments focus on addressing the risk factors of cardiovascular disease, such as anti-hypertensive drugs, weight loss, and glucose control. CONCLUSION Given the multifactorial nature of CMD in women, and the extensive atypical risk factors for cardiac disease, a more nuanced approach is needed that addresses the varied pathophysiology of CMD.
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Affiliation(s)
| | | | - Isabel M. McFarlane
- Corresponding Author: Dr. Isabel M. McFarlane, Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA, Tel: 718-270-2390, Fax: 718-270-1324;
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Rahman H, Ryan M, Lumley M, Modi B, McConkey H, Ellis H, Scannell C, Clapp B, Marber M, Webb A, Chiribiri A, Perera D. Coronary Microvascular Dysfunction Is Associated With Myocardial Ischemia and Abnormal Coronary Perfusion During Exercise. Circulation 2019; 140:1805-1816. [PMID: 31707835 PMCID: PMC6882540 DOI: 10.1161/circulationaha.119.041595] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 10/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (MVD) is defined by impaired flow augmentation in response to a pharmacological vasodilator in the presence of nonobstructive coronary artery disease. It is unknown whether diminished coronary vasodilator response correlates with abnormal exercise physiology or inducible myocardial ischemia. METHODS Patients with angina and nonobstructive coronary artery disease had simultaneous coronary pressure and flow velocity measured using a dual sensor-tipped guidewire during rest, supine bicycle exercise, and adenosine-mediated hyperemia. Microvascular resistance (MR) was calculated as coronary pressure divided by flow velocity. Wave intensity analysis quantified the proportion of accelerating wave energy (perfusion efficiency). Global myocardial blood flow and subendocardial:subepicardial perfusion ratio were quantified using 3-Tesla cardiac magnetic resonance imaging during hyperemia and rest; inducible ischemia was defined as hyperemic subendocardial:subepicardial perfusion ratio <1.0. Patients were classified as having MVD if coronary flow reserve <2.5 and controls if coronary flow reserve ≥2.5, with researchers blinded to the classification. RESULTS Eighty-five patients were enrolled (78% female, 57±10 years), 45 (53%) were classified as having MVD. Of the MVD group, 82% had inducible ischemia compared with 22% of controls (P<0.001); global myocardial perfusion reserve was 2.01±0.41 and 2.68±0.49 (P<0.001). In controls, coronary perfusion efficiency improved from rest to exercise and was unchanged during hyperemia (59±11% vs 65±14% vs 57±18%; P=0.02 and P=0.14). In contrast, perfusion efficiency decreased during both forms of stress in MVD (61±12 vs 44±10 vs 42±11%; both P<0.001). Among patients with a coronary flow reserve <2.5, 62% had functional MVD, with normal minimal MR (hyperemic MR<2.5 mmHg/cm/s), and 38% had structural MVD with elevated hyperemic MR. Resting MR was lower in those with functional MVD (4.2±1.0 mmHg/cm/s) than in those with structural MVD (6.9±1.7 mmHg/cm/s) or controls (7.3±2.2 mmHg/cm/s; both P<0.001). During exercise, the structural group had a higher systolic blood pressure (188±25 mmHg) than did those with functional MVD (161±27 mmHg; P=0.004) and controls (156±30 mmHg; P<0.001). Functional and structural MVD had similar stress myocardial perfusion and exercise perfusion efficiency values. CONCLUSION In patients with angina and nonobstructive coronary artery disease, diminished coronary flow reserve characterizes a cohort with inducible ischemia and a maladaptive physiological response to exercise. We have identified 2 endotypes of MVD with distinctive systemic vascular responses to exercise; whether endotypes have a different prognosis or require different treatments merits further investigation.
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Affiliation(s)
- Haseeb Rahman
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Ryan
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Matthew Lumley
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Bhavik Modi
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Hannah McConkey
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Howard Ellis
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Cian Scannell
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Brian Clapp
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Michael Marber
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Andrew Webb
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
| | - Amedeo Chiribiri
- Biomedical Engineering & Imaging Sciences (A.C., C.S.), King’s College London, United Kingdom
| | - Divaka Perera
- From The British Heart Foundation Centre of Research Excellence, Schools of Cardiovascular Medicine & Sciences (H.R., M.R., M.L., B.M., H.M., H.E., B.C., M.M., A.W., D.P.), King’s College London, United Kingdom
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Abstract
In recent years, it has become apparent that coronary microvascular dysfunction plays a pivotal pathogenic role in angina pectoris. Functional and structural mechanisms can affect the physiological function of the coronary microvasculature and lead to myocardial ischemia in people without coronary atheromatous disease and also in individuals with obstructive coronary artery disease. Abnormal dilatory responses of the coronary microvessels, coronary microvascular spasm, and extravascular compressive forces have been identified as pathogenic mechanisms in both chronic and acute forms of ischemic heart disease. The condition characterized by anginal symptoms and evidence of myocardial ischemia triggered by coronary microvascular dysfunction, in the absence of obstructive coronary disease, is known as microvascular angina. The concept of microvascular angina, however, may extend further to include patients with obstructive coronary artery disease and individuals with angina after coronary revascularization or heart transplantation because coronary microvascular dysfunction contributes to myocardial ischemia in many such patients. Patients with microvascular angina constitute a sizeable proportion of all cases of stable angina undergoing diagnostic coronary angiography and of those with persisting angina after successful coronary revascularization. Coronary microvascular dysfunction is also often responsible for angina in individuals with cardiomyopathy and heart valve disease as well as acute coronary syndrome cases such as Takotsubo syndrome and myocardial infarction with no obstructive coronary artery disease. Patients with stable microvascular angina present typically with effort or rest chest pain and a reduced coronary flow reserve or microvascular spasm. This condition, which affects women and men, can markedly impair quality of life and prognosis and represents a substantial cost burden to healthcare systems and individuals alike. In recent years, progress in the diagnosis of myocardial ischemia and the use of tests to investigate functional and structural causes for a reduced coronary flow reserve and microvascular spasm have allowed the identification of an increased number of cases of microvascular angina in everyday clinical practice. Although some of the available anti-anginal drugs may be helpful, treatment of coronary microvascular dysfunction remains a major challenge. The present article discusses the fundamental role that coronary microvascular dysfunction plays in the pathogenesis of ischemic heart disease, the clinical characteristics of patients presenting with microvascular angina, and possible diagnostic and therapeutic strategies.
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Affiliation(s)
- Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom (J.-C.K)
| | - Filippo Crea
- Institute of Cardiology, Catholic University, Rome, Italy (F.C.)
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.)
| | - Paolo G Camici
- Vita-Salute University and Department of Cardiology San Raffaele Hospital, Milan, Italy (P.G.C.)
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Rahman H, Corcoran D, Aetesam-ur-Rahman M, Hoole SP, Berry C, Perera D. Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory. Heart 2019; 105:1536-1542. [PMID: 31366574 PMCID: PMC6774766 DOI: 10.1136/heartjnl-2019-315042] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/24/2019] [Accepted: 05/08/2019] [Indexed: 01/09/2023] Open
Abstract
Around 40% of all patients undergoing angiography are found to have normal coronary arteries or non-obstructive coronary artery disease (NOCAD). Despite the high prevalence, this is a group who rarely receive a definitive diagnosis, are frequently labelled and managed inappropriately and by and large, continue to remain symptomatic. Half of this group will have coronary microvascular dysfunction (CMD), associated with a higher rate of major adverse cardiovascular events; identifying CMD represents a therapeutic target of unmet need. As the pressure wire has revolutionised our ability to interrogate epicardial coronary disease during the time of angiography, measuring flow can similarly classify NOCAD during a single procedure. Assessment of flow is a function that is already integral to some pressure wires and furthermore, the familiarity and usage of the combined Doppler and pressure wire is rapidly increasing-these are techniques that readily lend themselves to the skillset of a practising interventional cardiologist. We present a structured algorithm designed for cardiologists who frequently encounter NOCAD in the catheter laboratory, identifying specific disease phenotypes within this heterogeneous population with linked therapy. This review paper clearly explains the rationale for this algorithm and outlines its applicability to routine clinical practice and also, the importance of phenotyping for future research. Ultimately, personalised therapy could improve outcomes for both patients and healthcare providers; while these approaches in turn will need robust evaluation to ensure that they improve both clinical outcomes and health economic benefits, this proposal will provide a framework for future trials and evaluations.
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Affiliation(s)
- Haseeb Rahman
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Stephen P Hoole
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Divaka Perera
- The BHF Centre of Excellence and the NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King’s College London, London, UK
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Lanza GA. Diagnostic Approach to Patients with Stable Angina and No Obstructive Coronary Arteries. Eur Cardiol 2019; 14:97-102. [PMID: 31360230 PMCID: PMC6659043 DOI: 10.15420/ecr.2019.22.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/04/2019] [Indexed: 01/24/2023] Open
Abstract
The diagnosis of microvascular angina (MVA) is usually considered in patients presenting with angina symptoms and evidence of MI on non-invasive stress tests but normal coronary arteries at angiography. A definitive diagnosis of MVA, however, would require the presence of coronary microvascular dysfunction. Several invasive (e.g. intracoronary Doppler wire recording and thermodilution) and non-invasive (e.g. PET, cardiac MRI, transthoracic Doppler echocardiography) methods can be applied to obtain a diagnosis. Both endothelium-dependent and -independent coronary microvascular dilator function, as well as increased microvascular constrictor activity, should be investigated. The main issues in the assessment of clinical and diagnostic findings in patients with suspected MVA are discussed and a diagnostic approach is suggested.
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Affiliation(s)
- Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute Rome, Italy
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49
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Cortese F, Giordano P, Scicchitano P, Faienza MF, De Pergola G, Calculli G, Meliota G, Ciccone MM. Uric acid: from a biological advantage to a potential danger. A focus on cardiovascular effects. Vascul Pharmacol 2019; 120:106565. [PMID: 31152976 DOI: 10.1016/j.vph.2019.106565] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023]
Abstract
Non-communicable diseases represent nowadays the most common cause of death worldwide, having largely overcome infectious diseases. Among them, cardiovascular diseases constitute the majority. Given these premise, great efforts have been made by scientific societies to emphasize the fundamental role of cardiovascular prevention and risk factors control. In addition to classical cardiovascular risk factors such as smoking, arterial hypertension, hypercholesterolemia and male gender, new risk factors are emerging from international literature. Among them, uric acid is the protagonist. Several evidences show a direct role of hyperuricemia in the determinism of metabolic and vascular disorders. From the other hand, some researchers have demonstrated that uric acid is only a marker of cardiovascular damage and not a risk factor for its development. Aim of this review is to evaluate the scientific evidences on the role of uric acid in cardiovascular diseases in order to shed light on this confusing topic.
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Affiliation(s)
- Francesca Cortese
- Cardiological Unit, Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Italy.
| | - Paola Giordano
- Department of Biomedicine and Human Oncology, Pediatric Section, University "A.Moro" of Bari, Bari, Italy
| | | | - Maria Felicia Faienza
- Department of Biomedicine and Human Oncology, Pediatric Section, University "A.Moro" of Bari, Bari, Italy
| | - Giovanni De Pergola
- Departmentof Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari Aldo Moro, Bari, Italy
| | | | - Giovanni Meliota
- Cardiological Unit, Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Italy
| | - Marco Matteo Ciccone
- Cardiological Unit, Cardiovascular Disease Section, Department of Organ Transplantation, University of Bari, Italy
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50
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Chest pain in the absence of obstructive coronary artery disease. Int J Cardiol 2019; 280:19-28. [DOI: 10.1016/j.ijcard.2018.09.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/06/2023]
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