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McCallinhart PE, Chade AR, Bender SB, Trask AJ. Expanding landscape of coronary microvascular disease in co-morbid conditions: Metabolic disease and beyond. J Mol Cell Cardiol 2024; 192:26-35. [PMID: 38734061 DOI: 10.1016/j.yjmcc.2024.05.004] [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: 03/01/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Coronary microvascular disease (CMD) and impaired coronary blood flow control are defects that occur early in the pathogenesis of heart failure in cardiometabolic conditions, prior to the onset of atherosclerosis. In fact, recent studies have shown that CMD is an independent predictor of cardiac morbidity and mortality in patients with obesity and metabolic disease. CMD is comprised of functional, structural, and mechanical impairments that synergize and ultimately reduce coronary blood flow in metabolic disease and in other co-morbid conditions, including transplant, autoimmune disorders, chemotherapy-induced cardiotoxicity, and remote injury-induced CMD. This review summarizes the contemporary state-of-the-field related to CMD in metabolic and these other co-morbid conditions based on mechanistic data derived mostly from preclinical small- and large-animal models in light of available clinical evidence and given the limitations of studying these mechanisms in humans. In addition, we also discuss gaps in current understanding, emerging areas of interest, and opportunities for future investigations in this field.
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Affiliation(s)
- Patricia E McCallinhart
- Center for Cardiovascular Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Alejandro R Chade
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO, United States of America; Department of Medicine, University of Missouri School of Medicine, Columbia, MO, United States of America
| | - Shawn B Bender
- Department of Biomedical Sciences, University of Missouri, Columbia, MO, United States of America; Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, United States of America; Research Service, Harry S Truman Memorial Veterans Hospital, Columbia, MO, United States of America.
| | - Aaron J Trask
- Center for Cardiovascular Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States of America; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America.
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Lakkas L, Naka KK, Bechlioulis A, Duni A, Moustakli M, Balafa O, Theodorou I, Katsouras CS, Dounousi E, Michalis LK. Coronary microcirculation and left ventricular diastolic function but not myocardial deformation indices are impaired early in patients with chronic kidney disease. Echocardiography 2023. [PMID: 37229577 DOI: 10.1111/echo.15598] [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: 12/28/2022] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
AIM To investigate abnormalities in myocardial strain and classic echocardiographic indices and coronary flow reserve (CFR), in younger versus older CKD patients. METHODS Sixty consecutive CKD patients (<60 years old n = 30, ≥60 years old n = 30) and 30 healthy controls (age- and gender-matched with younger CKD patients) were recruited. An echocardiographic assessment including myocardial strain indices (i.e. global longitudinal strain -GLS -, TWIST, UNTWIST rate) was performed at baseline and following dipyridamole administration in all participants. RESULTS Younger CKD patients had higher E/e', left ventricular mass index and relative wall thickness and lower E' (p < .005 for all) compared to healthy controls. Older CKD patients had lower E/A and E' (p < .05 for both) compared to younger CKD patients; these differences did not remain significant after adjustment for age. CFR was higher in healthy controls compared to younger and older CKD patients (p < .05 for both) without a significant difference between CKD groups. There were no significant differences in GLS, TWIST or UNTWIST values among the three groups of patients. Dipyridamole-induced changes did not differ significantly among the three groups. CONCLUSIONS Compared to healthy controls, impaired coronary microcirculation and left ventricular diastolic function, but not myocardial strain abnormalities, are found in young CKD patients and deteriorate with aging.
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Affiliation(s)
- Lampros Lakkas
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Katerina K Naka
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Aris Bechlioulis
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Anila Duni
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Maria Moustakli
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Ioanna Theodorou
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Evangelia Dounousi
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Lampros K Michalis
- 2nd Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
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Baaten CCFMJ, Vondenhoff S, Noels H. Endothelial Cell Dysfunction and Increased Cardiovascular Risk in Patients With Chronic Kidney Disease. Circ Res 2023; 132:970-992. [PMID: 37053275 PMCID: PMC10097498 DOI: 10.1161/circresaha.123.321752] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The endothelium is considered to be the gatekeeper of the vessel wall, maintaining and regulating vascular integrity. In patients with chronic kidney disease, protective endothelial cell functions are impaired due to the proinflammatory, prothrombotic and uremic environment caused by the decline in kidney function, adding to the increase in cardiovascular complications in this vulnerable patient population. In this review, we discuss endothelial cell functioning in healthy conditions and the contribution of endothelial cell dysfunction to cardiovascular disease. Further, we summarize the phenotypic changes of the endothelium in chronic kidney disease patients and the relation of endothelial cell dysfunction to cardiovascular risk in chronic kidney disease. We also review the mechanisms that underlie endothelial changes in chronic kidney disease and consider potential pharmacological interventions that can ameliorate endothelial health.
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Affiliation(s)
- Constance C F M J Baaten
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands (C.C.F.M.J.B., H.N.)
| | - Sonja Vondenhoff
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany (C.C.F.M.J.B., S.V., H.N.)
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands (C.C.F.M.J.B., H.N.)
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Kitada R, Otsuka K, Fukuda D. Role of plaque imaging for identification of vulnerable patients beyond the stage of myocardial ischemia. Front Cardiovasc Med 2023; 10:1095806. [PMID: 37008333 PMCID: PMC10063905 DOI: 10.3389/fcvm.2023.1095806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/21/2023] [Indexed: 03/19/2023] Open
Abstract
Chronic coronary syndrome (CCS) is a progressive disease, which often first manifests as acute coronary syndrome (ACS). Imaging modalities are clinically useful in making decisions about the management of patients with CCS. Accumulating evidence has demonstrated that myocardial ischemia is a surrogate marker for CCS management; however, its ability to predict cardiovascular death or nonfatal myocardial infarction is limited. Herein, we present a review that highlights the latest knowledge available on coronary syndromes and discuss the role and limitations of imaging modalities in the diagnosis and management of patients with coronary artery disease. This review covers the essential aspects of the role of imaging in assessing myocardial ischemia and coronary plaque burden and composition. Furthermore, recent clinical trials on lipid-lowering and anti-inflammatory therapies have been discussed. Additionally, it provides a comprehensive overview of intracoronary and noninvasive cardiovascular imaging modalities and an understanding of ACS and CCS, with a focus on histopathology and pathophysiology.
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Meariman JK, Zulli H, Perez A, Bajracharya S, Mohandas R. Small vessel disease: Connections between the kidney and the heart. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100257. [PMID: 38510186 PMCID: PMC10946057 DOI: 10.1016/j.ahjo.2023.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 03/22/2024]
Abstract
Small vessel disease is characterized by global dysfunction of the microvascular system leading to reduced perfusion of various organ systems. The kidney is significantly vulnerable for microvascular dysfunction given its intricate capillary network and extensive endocrine influence. Studies have demonstrated a relationship between impaired renal function and small vessel disease in other organ systems, particularly the heart. Here we discuss the relationship between the kidney and the heart in the setting of microvascular dysfunction and identify areas of future study to better understand this relationship and potentially identify novel therapeutic strategies.
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Affiliation(s)
- Jacob K. Meariman
- Section of Nephrology & Hypertension, Department of Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA 70112, United States of America
| | - Hannah Zulli
- Section of Nephrology & Hypertension, Department of Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA 70112, United States of America
| | - Annalisa Perez
- Section of Nephrology & Hypertension, Department of Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA 70112, United States of America
| | - S.D. Bajracharya
- Section of Nephrology & Hypertension, Department of Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA 70112, United States of America
| | - Rajesh Mohandas
- Section of Nephrology & Hypertension, Department of Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA 70112, United States of America
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Jain V, Gupta K, Bhatia K, Rajapreyar I, Singh A, Zhou W, Klein A, Nanda NC, Prabhu SD, Bajaj NS. Coronary flow abnormalities in chronic kidney disease: A systematic review and meta-analysis. Echocardiography 2022; 39:1382-1390. [PMID: 36198077 DOI: 10.1111/echo.15445] [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: 04/09/2022] [Revised: 07/10/2022] [Accepted: 08/15/2022] [Indexed: 10/10/2022] Open
Abstract
BACKGROUND Coronary vasomotion abnormalities have been described in small studies but not studied systematically. We aimed to review the present literature and analyze it to improve our understanding of chronic kidney disease (CKD) related-coronary microvascular dysfunction. OBJECTIVE Coronary flow reserve (CFR) is a well-known measure of coronary vasomotion. We aimed to assess the difference in CFR among participants with and without CKD. METHODS PubMed, Embase, and Cochrane CENTRAL were systematically reviewed to identify studies that compared CFR in participants with and without CKD. We estimated standardized mean differences in mean CFR reported in these studies. We performed subgroup analyses according to imaging modality, and the presence of significant epicardial coronary artery disease. RESULTS In 14 observational studies with 5966 and 1410 patients with and without CKD, the mean estimated glomerular filtration rate (eGFR) was 29 ± 04 and 87 ± 25 ml/min/1.73 m2 , respectively. Mean CFR was consistently lower in patients with CKD in all studies and the cumulative mean difference was statistically significant (2.1 ± .3 vs. 2.7 ± .5, standardized mean difference -.8, 95% CI -1.1, -.6, p < .05). The lower mean CFR was driven by both significantly higher mean resting flow velocity (.58 cm/s, 95% CI .17, .98) and lower mean stress flow velocity (-.94 cm/s, 95% CI -1.75, -.13) in studies with CKD. This difference remained significant across diagnostic modalities and even in absence of epicardial coronary artery disease. In meta-regression, there was a significant positive relationship between mean eGFR and mean CFR (p < .05). CONCLUSION Patients with CKD have a significantly lower CFR versus those without CKD, even in absence of epicardial coronary artery disease. There is a linear association between eGFR and CFR. Future studies are required to understand the mechanisms and therapeutic implications of these findings. KEY POINTS In this meta-analysis of observational studies, there was a significant reduction in coronary flow reserve in studies with chronic kidney disease versus those without. This difference was seen even in absence of epicardial coronary artery disease. In meta-regression, a lower estimate glomerular filtration rate was a significant predictor of lower coronary flow reserve. Coronary microvascular dysfunction, rather than atherosclerosis-related epicardial disease may underly increase cardiovascular risk in a patient with chronic kidney disease.
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Affiliation(s)
- Vardhmaan Jain
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kartik Gupta
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kirtipal Bhatia
- Department of Cardiology, Icahn School of Medicine at Mount Sinai (Morningside), New York, USA
| | - Indranee Rajapreyar
- Advanced Heart failure and Transplantation Center, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amitoj Singh
- Division of Cardiology, University of Arizona College of Medicine-Tucson, Arizona, USA
| | - Wunan Zhou
- National Institute of Health, Bethesda, Maryland, USA
| | - Allan Klein
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Navin C Nanda
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sumanth D Prabhu
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Asheville Cardiology Associates, Asheville, North Carolina, USA
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7
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Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, Rajkumar CA, Shun-Shin MJ, Ahmad Y, Sen S, Al-Lamee R, Petraco R. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J 2022; 43:1582-1593. [PMID: 34849697 PMCID: PMC9020988 DOI: 10.1093/eurheartj/ehab775] [Citation(s) in RCA: 102] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
AIMS This meta-analysis aims to quantify the association of reduced coronary flow with all-cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. METHODS AND RESULTS We systematically identified all studies between 1 January 2000 and 1 August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios (HRs) using a random-effects model. Seventy-nine studies with a total of 59 740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality [HR: 3.78, 95% confidence interval (CI): 2.39-5.97] and a higher incidence of MACE (HR 3.42, 95% CI: 2.92-3.99). Each 0.1 unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR: 1.16, 95% CI: 1.04-1.29) and MACE (per 0.1 CFR unit HR: 1.08, 95% CI: 1.04-1.11). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR: 5.44, 95% CI: 3.78-7.83) and MACE (HR: 3.56, 95% CI: 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR: 3.76, 95% CI: 2.35-6.00), heart failure (HR: 6.38, 95% CI: 1.95-20.90), heart transplant (HR: 3.32, 95% CI: 2.34-4.71), and diabetes mellitus (HR: 7.47, 95% CI: 3.37-16.55). CONCLUSION Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice, to target aggressive vascular risk modification for individuals at higher risk.
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Affiliation(s)
- Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Haseeb Rahman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, Connecticut 06510, USA
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
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Suh SH, Oh TR, Choi HS, Kim CS, Bae EH, Oh KH, Lee J, Jung JY, Lee KB, Ma SK, Kim SW. Association Between Left Ventricular Geometry and Renal Outcomes in Patients With Chronic Kidney Disease: Findings From Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease Study. Front Cardiovasc Med 2022; 9:848692. [PMID: 35509274 PMCID: PMC9058055 DOI: 10.3389/fcvm.2022.848692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/30/2022] [Indexed: 01/19/2023] Open
Abstract
Background The impact of left ventricular (LV) geometry on the renal outcomes in patients with chronic kidney disease (CKD) has not been established yet. We aimed to investigate the association of LV geometry with renal outcomes and all-cause mortality in patients with pre-dialysis CKD. Methods A total of 2,144 subjects from the Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD) were categorized by LV geometry, which was defined by LV mass index and relative wall thickness [normal geometry, concentric remodeling, eccentric hypertrophy (eLVH), and concentric hypertrophy (cLVH)]. Study outcomes were composite renal events [decline of kidney function (the first occurrence of > 50% decline of eGFR or doubling of serum creatinine from the baseline) and onset of ESRD (initiation of dialysis or kidney transplantation) during follow-up periods)] and all-cause mortality. Results Cox regression analysis revealed that eLVH [adjusted hazard ratio (HR) 1.498, 95% confidence interval (CI) 1.197–1.873] and cLVH (adjusted HR 1.289, 95% CI 1.011–1.643) were associated with increased risk of composite renal events, whereas concentric remodeling (adjusted HR 1.881, 95% CI 1.135–3.118) and cLVH (adjusted HR 2.216, 95% CI 1.341–3.664) were associated with increased risk of all-cause mortality. Sensitivity analyses confirmed that concentric remodeling (adjusted HR 1.993, 95% CI 1.197–3.368) and eLVH (adjusted HR 1.588, 95% CI 1.261–2.001) are independently associated with all-cause mortality and composite renal events, respectively. Conclusion In conclusion, we report that LV geometry is significantly associated with adverse renal outcomes and all-cause mortality in patients with pre-dialysis CKD. Echocardiographic determination of LV geometry may help the early identification for the patients with high risk of CKD progression.
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Affiliation(s)
- Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Tae Ryom Oh
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Joongyub Lee
- Department of Prevention and Management, School of Medicine, Inha University, Incheon, South Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University of Gil Medical Center, Incheon, South Korea
| | - Kyu-Beck Lee
- Department of Internal Medicine, School of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University Seoul, Seoul, South Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
- *Correspondence: Soo Wan Kim,
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Bainey KR, Fleg JL, Hochman JS, Kunichoff DF, Anthopolos R, Chernyavskiy AM, Demkow M, Lopez-Quijano JM, Escobedo J, Poh KK, Ramos RB, Lima EG, Schuchlenz H, Ali ZA, Stone GW, Maron DJ, O'Brien SM, Spertus JA, Bangalore S. Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia. Am Heart J 2022; 243:187-200. [PMID: 34582775 PMCID: PMC10627379 DOI: 10.1016/j.ahj.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Jerome L Fleg
- National Heart Lung and Blood Institute, Bethesda, MD
| | | | | | | | - Alexander M Chernyavskiy
- E.Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Novosibirsk, Russia
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Kian Keong Poh
- National University Heart Center Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Herwig Schuchlenz
- oLKH Graz II, Department fuer Kardiologie und Intensivmedizin, Graz, Austria
| | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY; Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY; St Francis Hospital, Roslyn, NY
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, Durham, NC
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, MO
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Xiao F, Zhang W, He YN, Yang J, Liu X, Wang L, Zhang J, Dai H. Impaired perfusion in the myocardial microcirculation in asymptomatic patients with Stages 1-4 chronic kidney disease with intrarenal arterial lesions. Nephrol Dial Transplant 2021; 36:2066-2075. [PMID: 33877359 DOI: 10.1093/ndt/gfaa245] [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: 01/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Even mild renal disease is a powerful cardiovascular risk factor. However, the association between these pathophysiologic processes (especially in the early asymptomatic stage) is not known. METHODS We recruited 243 asymptomatic patients with Stages 1-4 chronic kidney disease (CKD) without obstructive coronary artery disease (CAD). We distinguished different degrees of severity of intrarenal arterial lesions (IALs) according to the Oxford classification. Myocardial microcirculation perfusion was measured using single-photon emission computed tomography (SPECT). Summed scores of 17 stress and rest image segments produced the summed stress score (SSS) and summed rest score (SRS), respectively. The summed difference score (SDS) was calculated as the difference between the SSS and SRS. Coronary microvascular disease (CMD) was defined as abnormal SPECT (SSS ≥4 or SDS ≥2) in the absence of obstructive CAD. RESULTS Participants showed a stepwise increase in CMD severity with IAL aggravation. SSS of no/mild/moderate/severe IALs was 1.64 ± 1.08, 2.56 ± 1.35, 4.42 ± 2.17 and 6.48 ± 3.52, respectively (P < 0.05 for all). SDS of no/mild/moderate/severe IALs was 1.29 ± 0.49, 1.75 ± 0.56, 3.06 ± 1.12 and 4.16 ± 1.85, respectively (P < 0.05 for all). The percentage of subclinical CMD in CKD patients with IALs was significantly higher than in those without IALs (69.57% versus 14.71%; P = 0.01). Multiple regression analysis showed that renal arteriolar hyalinization (odds ratio = 1.578, P = 0.009) was associated independently with subclinical CMD. CONCLUSIONS We demonstrated, for the first time, that impaired perfusion in the myocardial microcirculation in asymptomatic patients with Stages 1-4 CKD with IALs. Renal arteriolar hyalinization may be a useful marker of CMD in CKD.
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Affiliation(s)
- Fei Xiao
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Weiwei Zhang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ya-Ni He
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jie Yang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xinghong Liu
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ling Wang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianguo Zhang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Huanzi Dai
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
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11
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Zagatina A, Zhuravskaya N, Caprnda M, Shiwani HA, Gazdikova K, Rodrigo L, Kruzliak P, Shmatov D. Should we routinely assess coronary artery Doppler in daily echocardiography practice? Acta Cardiol 2021; 77:573-579. [PMID: 34538214 DOI: 10.1080/00015385.2021.1973771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A lot of people with coronary artery disease do not have specific symptoms, and myocardial infarction or death are the first manifestation of the disease. New accurate, non-invasive and safe screening methods are required that can assess the prognosis of patients during routine examinations performed on millions of people. The aim of this review was to discuss the current literature regarding the utility of non-invasive ultrasound imaging of the coronary artery in assessing a patient's prognosis in daily practice. Assessment of coronary artery flow during common stress echocardiography or echocardiography can provide additive incremental prognostic information without the burden of radiation. Exercise or pharmacologic stress echocardiography tests combined with coronary flow velocity reserve assessment has advantages over stress tests based only on regional wall motion abnormalities. Scanning of main coronary arteries as an addition to routine echocardiography can reveal patients at high risk of adverse cardiac events in the near future.
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Affiliation(s)
- Angela Zagatina
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Nadezhda Zhuravskaya
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Martin Caprnda
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Haaris A. Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Trust, Lancaster, United Kingdom
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia
- Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Luis Rodrigo
- Faculty of Medicine, University of Oviedo, Central University Hospital of Asturias (HUCA), Oviedo, Spain
| | - Peter Kruzliak
- 2nd Department of Surgery, Faculty of Medicine, Masaryk University and St. Annés University Hospital, Brno, Czech Republic
| | - Dmitry Shmatov
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
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12
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Abstract
Cardiovascular risk increases as glomerular filtration rate (GFR) declines in progressive renal disease and is maximal in patients with end-stage renal disease requiring maintenance dialysis. Atherosclerotic vascular disease, for which hyperlipidemia is the main risk factor and lipid-lowering therapy is the key intervention, is common. However, the pattern of dyslipidemia changes with low GFR and the association with vascular events becomes less clear. While the pathophysiology and management of patients with early chronic kidney disease (CKD) is similar to the general population, advanced and end-stage CKD is characterized by a disproportionate increase in fatal events, ineffectiveness of statin therapy, and greatly increased risk associated with coronary interventions. The most effective strategies to reduce atherosclerotic cardiovascular disease in CKD are to slow the decline in renal function or to restore renal function by transplantation.
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Affiliation(s)
- Matthew J Tunbridge
- Nephrology Department, Royal Brisbane and Women's Hospital, Level 9 Ned Hanlon Building, Butterfield Street, Herston, QLD 4029, Australia; University of Queensland, Mayne Medical Building, 288 Herston Road, Herston, QLD 4029, Australia
| | - Alan G Jardine
- University of Queensland, Mayne Medical Building, 288 Herston Road, Herston, QLD 4029, Australia; Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF GCRC 126 University Place, Glasgow G12 8TA, UK.
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13
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Selenium and Coenzyme Q10 Supplementation Improves Renal Function in Elderly Deficient in Selenium: Observational Results and Results from a Subgroup Analysis of a Prospective Randomised Double-Blind Placebo-Controlled Trial. Nutrients 2020; 12:nu12123780. [PMID: 33317156 PMCID: PMC7764721 DOI: 10.3390/nu12123780] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 12/20/2022] Open
Abstract
A low selenium intake is found in European countries, and is associated with increased cardiovascular mortality. There is an association between selenium level and the severity of kidney disease. An association between inflammation and selenium intake is also reported. The coenzyme Q10 level is decreased in kidney disease. The aim of this study was to examine a possible association between selenium and renal function in an elderly population low in selenium and coenzyme Q10, and the impact of intervention with selenium and coenzyme Q10 on the renal function. The association between selenium status and creatinine was studied in 589 elderly persons. In 215 of these (mean age 71 years) a randomised double-blind placebo-controlled prospective trial with selenium yeast (200 µg/day) and coenzyme Q10 (200 mg/day) (n = 117) or placebo (n = 98) was conducted. Renal function was determined using measures of glomerular function at the start and after 48 months. The follow-up time was 5.1 years. All individuals were low on selenium (mean 67 μg/L (SD 16.8)). The changes in renal function were evaluated by measurement of creatinine, cystatin-C, and the use of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) algorithm, and by the use of T-tests, repeated measures of variance and ANCOVA analyses. An association between low selenium status and impaired renal function was observed. Intervention causes a significantly lower serum creatinine, and cystatin-C concentration in the active treatment group compared with those on placebo (p = 0.0002 and p = 0.001 resp.). The evaluation with CKD-EPI based on both creatinine and cystatin-C showed a corresponding significant difference (p < 0.0001). All validations showed corresponding significant differences. In individuals with a deficiency of selenium and coenzyme Q10, low selenium status is related to impaired renal function, and thus supplementation with selenium and coenzyme Q10 results in significantly improved renal function as seen from creatinine and cystatin-C and through the CKD-EPI algorithm. The explanation could be related to positive effects on inflammation and oxidative stress as a result of the supplementation.
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14
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Microvascular disease in chronic kidney disease: the base of the iceberg in cardiovascular comorbidity. Clin Sci (Lond) 2020; 134:1333-1356. [PMID: 32542397 PMCID: PMC7298155 DOI: 10.1042/cs20200279] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) is a relentlessly progressive disease with a very high mortality mainly due to cardiovascular complications. Endothelial dysfunction is well documented in CKD and permanent loss of endothelial homeostasis leads to progressive organ damage. Most of the vast endothelial surface area is part of the microcirculation, but most research in CKD-related cardiovascular disease (CVD) has been devoted to macrovascular complications. We have reviewed all publications evaluating structure and function of the microcirculation in humans with CKD and animals with experimental CKD. Microvascular rarefaction, defined as a loss of perfused microvessels resulting in a significant decrease in microvascular density, is a quintessential finding in these studies. The median microvascular density was reduced by 29% in skeletal muscle and 24% in the heart in animal models of CKD and by 32% in human biopsy, autopsy and imaging studies. CKD induces rarefaction due to the loss of coherent vessel systems distal to the level of smaller arterioles, generating a typical heterogeneous pattern with avascular patches, resulting in a dysfunctional endothelium with diminished perfusion, shunting and tissue hypoxia. Endothelial cell apoptosis, hypertension, multiple metabolic, endocrine and immune disturbances of the uremic milieu and specifically, a dysregulated angiogenesis, all contribute to the multifactorial pathogenesis. By setting the stage for the development of tissue fibrosis and end organ failure, microvascular rarefaction is a principal pathogenic factor in the development of severe organ dysfunction in CKD patients, especially CVD, cerebrovascular dysfunction, muscular atrophy, cachexia, and progression of kidney disease. Treatment strategies for microvascular disease are urgently needed.
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15
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Coronary microcirculation and left ventricular diastolic function: comparison between patients on hemodialysis and peritoneal dialysis. J Echocardiogr 2020; 19:103-112. [PMID: 32979192 DOI: 10.1007/s12574-020-00493-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND End-stage renal disease is considered to influence coronary microcirculation and left ventricular (LV) diastolic function. We investigated whether differences exist in LV diastolic function indices and coronary flow reserve (CFR) between patients on hemodialysis (HD) and peritoneal dialysis (PD). METHODS A complete transthoracic echocardiographic study was performed on 21 HD and 22 PD patients and LV diastolic function was evaluated. CFR was estimated using transthoracic Doppler echocardiography on the left anterior descending artery, during high-dose dypiridamole infusion. RESULTS HD and PD groups did not differ regarding Doppler-derived diastolic indices, but they significantly differed in the frequency of severe LV hypertrophy (38.1% in HD vs 4.5% in PD group, p = 0.009) and grade II diastolic dysfunction (42.9% in HD vs 4.5% in PD group, p = 0.004). No patient had restrictive filling pattern. There was no difference in the prevalence of arterial hypertension and diabetes mellitus in patients with grade II vs less than grade II dysfunction. Mean CFR was similar in the HD and PD groups (2.25 ± 0.65 vs 2.36 ± 0.76, p = 0.635) and lower in patients with grade II diastolic dysfunction (1.87 ± 0.43 vs 2.44 ± 0.72, p = 0.023) and diabetes (1.70 ± 0.59 vs 2.39 ± 0.68, p = 0.04). LV mass index was negatively associated with CFR (r = - 0.308, p = 0.045). CONCLUSION Patients on HD had more advanced diastolic dysfunction compared to PD, independently of the presence of hypertension and diabetes. CFR did not differ between HD and PD patients, but it was significantly lower in diabetics and in patients with more advanced diastolic dysfunction.
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16
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Radhakrishnan A, Price AM, Pickup LC, Law JP, McGee KC, Fabritz L, Senior R, Steeds RP, Ferro CJ, Townend JN. Coronary flow velocity reserve and inflammatory markers in living kidney donors. Int J Cardiol 2020; 320:141-147. [PMID: 32805328 PMCID: PMC7584109 DOI: 10.1016/j.ijcard.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/03/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction is prevalent in chronic kidney disease (CKD), and may contribute to the development of myocardial dysfunction in CKD. Coronary flow velocity reserve (CFVR) is a marker of coronary microvascular function and falls with increasing CKD stage. Living kidney donors have renal function consistent with early stage CKD and concern has been raised about their cardiovascular risk. No studies to date have investigated the presence of coronary microvascular dysfunction in living kidney donors. METHODS 25 healthy controls and 23 living kidney donors were recruited and underwent assessment with transthoracic echocardiography, Doppler CFVR, myocardial contrast echocardiography and serum multiplex immunoassay panels. RESULTS Doppler CFVR was significantly reduced in living kidney donors compared to controls (mean CFVR 3.4 ± 0.7 vs 3.8 ± 0.6, mean difference 0.4 95% confidence interval 0.03-0.8, p =.036). Quantitative myocardial contrast echocardiography showed a trend towards reduced coronary flow reserve in living kidney donors. Compared to controls, living kidney donors had higher serum high sensitivity C reactive peptide (hsCRP) and lower levels of uromodulin. CONCLUSIONS This is the first study of CFVR in living kidney donors. We have shown that the modest drop in estimated glomerular filtration rate in living kidney donors is associated with lower values of Doppler CFVR compared to controls, suggesting that isolated reductions in renal function may lead to altered microvascular function. The increase in hsCRP and reduction in uromodulin suggests that chronic subclinical inflammation may contribute to altered microvascular function in this population.
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Affiliation(s)
- Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom.
| | - Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Kirsty C McGee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Larissa Fabritz
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Roxy Senior
- Cardiac Research Unit, Northwick Park Hospital, London, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Affiliation(s)
- Leah Rethy
- Division of Cardiology Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Matthew J Feinstein
- Division of Cardiology Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Arjun Sinha
- Division of Cardiology Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Chad Achenbach
- Division of Infectious Diseases Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Sanjiv J Shah
- Division of Cardiology Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
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18
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Coronary microvascular function in athletes with abnormal exercise test results. Neth Heart J 2019; 27:621-628. [PMID: 31654324 PMCID: PMC6890891 DOI: 10.1007/s12471-019-01336-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AIMS In asymptomatic athletes, abnormal exercise test (ET) results have a poor positive predictive value. It is unknown whether abnormal ET results in the absence of obstructive coronary artery disease (CAD) are related to coronary microvascular dysfunction. It is also unknown whether they should be considered false-positive ET results or a consequence of physiological adaptation to sport. In our study, we evaluated whether athletes with abnormal ET results and documented myocardial ischaemia in the absence of obstructive CAD have an attenuated microvascular function and whether coronary microvascular dysfunction is related to endothelial dysfunction. METHODS AND RESULTS Nine athletes with concordant abnormal ET and myocardial perfusion scintigraphy (MPS) results without obstructive CAD were compared with age- and gender-matched individuals with a low-to-intermediate a priori risk of CAD. Coronary flow reserve was assessed by Rubidium-82 positron emission tomography (PET) imaging. Endothelin‑1 concentrations were measured to evaluate endothelial function. Coronary flow reserve was significantly lower in athletes (3.3 ± 0.8 versus 4.2 ± 0.6, p = 0.014 respectively). Endothelin‑1 levels were significantly higher in athletes (1.3 ± 0.2 pg/ml versus 1.0 ± 0.2 pg/ml, p = 0.012 respectively). There was no correlation between endothelin‑1 concentrations and mean global coronary flow reserve (r = 0.12). CONCLUSION Athletes with abnormal ET and MPS outcomes indicative for myocardial ischaemia and no obstructive CAD have a lower coronary flow reserve compared with non-athletes with low-to-intermediate a priori risk of CAD, suggesting an attenuated coronary microvascular function. Higher endothelin‑1 concentrations in athletes suggest that endothelial-dependent dysfunction is an important determinant of the attenuated microvascular function.
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19
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Usui E, Murai T, Kanaji Y, Hoshino M, Yamaguchi M, Hada M, Hamaya R, Kanno Y, Lee T, Yonetsu T, Kakuta T. Clinical significance of concordance or discordance between fractional flow reserve and coronary flow reserve for coronary physiological indices, microvascular resistance, and prognosis after elective percutaneous coronary intervention. EUROINTERVENTION 2019; 14:798-805. [PMID: 29336308 DOI: 10.4244/eij-d-17-00449] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We aimed to investigate the impact of concordance or discordance of fractional flow reserve (FFR) and coronary flow reserve (CFR) on coronary flow profiles and microvascular resistance after percutaneous coronary intervention (PCI), and the prognostic impact of the periprocedural physiological indices. METHODS AND RESULTS A total of 249 de novo physiologically significant coronary lesions from 231 patients who underwent FFR, CFR, and index of microcirculatory resistance (IMR) examinations before and after PCI were included. Baseline characteristics and physiological indices were compared between the concordant (FFR ≤0.80 and CFR <2.0, n=114) and discordant (FFR ≤0.80 and CFR ≥2.0, n=135) groups. Follow-up data were collected to determine predictors of cardiac events. Shortening of the mean transit time, CFR improvement, and decrease in the hyperaemic IMR were all significantly greater in the concordant territories. Cox proportional hazards analysis showed that a lower pre-PCI CFR was an independent predictor of adverse events at a median follow-up of 26.5 months, whereas neither the pre- nor post-PCI FFR was predictive of events. Event-free survival was significantly worse in patients with a lower pre-PCI CFR. CONCLUSIONS FFR/CFR concordantly abnormal territories provide a favourable benefit as assessed by coronary physiological indices after elective PCI. The pre-PCI CFR may predict adverse cardiac events.
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Affiliation(s)
- Eisuke Usui
- Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
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20
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Radhakrishnan A, Pickup LC, Price AM, Law JP, Edwards NC, Steeds RP, Ferro CJ, Townend JN. Coronary microvascular dysfunction: a key step in the development of uraemic cardiomyopathy? Heart 2019; 105:1302-1309. [PMID: 31239278 PMCID: PMC6711343 DOI: 10.1136/heartjnl-2019-315138] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/05/2019] [Accepted: 06/02/2019] [Indexed: 01/13/2023] Open
Abstract
The syndrome of uraemic cardiomyopathy, characterised by left ventricular hypertrophy, diffuse fibrosis and systolic and diastolic dysfunction, is common in chronic kidney disease and is associated with an increased risk of cardiovascular morbidity and mortality. The pathophysiological mechanisms leading to uraemic cardiomyopathy are not fully understood. We suggest that coronary microvascular dysfunction may be a key mediator in the development of uraemic cardiomyopathy, a phenomenon that is prevalent in other myocardial diseases that share phenotypical similarities with uraemic cardiomyopathy such as hypertrophic cardiomyopathy and heart failure with preserved ejection fraction. Here, we review the current understanding of uraemic cardiomyopathy, highlight different methods of assessing coronary microvascular function and evaluate the current evidence for coronary microvascular dysfunction in chronic kidney disease.
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Affiliation(s)
- Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nicola C Edwards
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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21
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Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and meta-analysis. Int J Cardiol 2018; 254:1-9. [DOI: 10.1016/j.ijcard.2017.10.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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22
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Hayashi T, Joki N, Tanaka Y, Iwasaki M, Kubo S, Matsukane A, Takahashi Y, Imamura Y, Hirahata K, Hase H. Thallium-201 washout rate of stress myocardial perfusion imaging as a predictor of mortality in diabetic kidney disease patients initiating hemodialysis: an observational, follow-up study. Clin Exp Nephrol 2018; 22:142-150. [DOI: 10.1007/s10157-017-1414-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/16/2017] [Indexed: 10/19/2022]
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23
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Tsuda N, Shiraishi S, Sakamoto F, Yuki H, Ogasawara K, Yoshida M, Tomiguchi S, Tsujita K, Yamashita Y. Quantification of myocardial perfusion reserve using dynamic SPECT images of patients with chronic kidney disease. J Cardiol 2018; 71:174-180. [PMID: 28865679 DOI: 10.1016/j.jjcc.2017.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/24/2017] [Accepted: 07/10/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Noriko Tsuda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
| | - Shinya Shiraishi
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Fumi Sakamoto
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideaki Yuki
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Koji Ogasawara
- Diagnostic Radiology, Kumamoto Chuo Hospital, Kumamoto, Japan
| | | | - Seiji Tomiguchi
- Department of Diagnostic Medical Imaging, School of Health Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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24
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Charytan DM, Skali H, Shah NR, Veeranna V, Cheezum MK, Taqueti VR, Kato T, Bibbo CR, Hainer J, Dorbala S, Blankstein R, Di Carli MF. Coronary flow reserve is predictive of the risk of cardiovascular death regardless of chronic kidney disease stage. Kidney Int 2017; 93:501-509. [PMID: 29032954 DOI: 10.1016/j.kint.2017.07.025] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 07/14/2017] [Accepted: 07/27/2017] [Indexed: 01/09/2023]
Abstract
Microvascular rarefaction is found in experimental uremia, but data from patients with chronic kidney disease (CKD) are limited. We therefore quantified absolute myocardial blood flow and coronary flow reserve (the ratio of peak to resting flow) from myocardial perfusion positron emission tomography scans at a single institution. Individuals were classified into standard CKD categories based on the estimated glomerular filtration rate. Associations of coronary flow reserve with CKD stage and cardiovascular mortality were analyzed in models adjusted for cardiovascular risk factors. The coronary flow reserve was significantly associated with CKD stage, declining in early CKD, but it did not differ significantly among individuals with stage 4, 5, and dialysis-dependent CKD. Flow reserve with preserved kidney function was 2.01, 2.06 in stage 1 CKD, 1.91 in stage 2, 1.68 in stage 3, 1.54 in stage 4, 1.66 in stage 5, and 1.55 in dialysis-dependent CKD. Coronary flow reserve was significantly associated with cardiovascular mortality in adjusted models (hazard ratio 0.76, 95% confidence interval: 0.63-0.92 per tertile of coronary flow reserve) without evidence of effect modification by CKD. Thus, coronary flow reserve is strongly associated with cardiovascular risk regardless of CKD severity and is low in early stage CKD without further decrement in stage 5 or dialysis-dependent CKD. This suggests that CKD physiology rather than the effects of dialysis is the primary driver of microvascular disease. Our findings highlight the potential contribution of microvascular dysfunction to cardiovascular risk in CKD and the need to define mechanisms linking low coronary flow reserve to mortality.
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Affiliation(s)
- David M Charytan
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Renal Division, Brigham & Women's Hospital, Boston, Massachusetts, USA.
| | - Hicham Skali
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Nishant R Shah
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Vikas Veeranna
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Michael K Cheezum
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Viviany R Taqueti
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Takashi Kato
- Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Gifu Prefectural General Medical Center, Gifu City, Japan
| | - Courtney R Bibbo
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Jon Hainer
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Ron Blankstein
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
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25
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Michelsen MM, Pena A, Mygind ND, Frestad D, Gustafsson I, Hansen HS, Kastrup J, Bech J, Høst N, Prescott E. Coronary Flow Velocity Reserve Assessed by Transthoracic Doppler: The iPOWER Study: Factors Influencing Feasibility and Quality. J Am Soc Echocardiogr 2016; 29:709-16. [DOI: 10.1016/j.echo.2016.02.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Indexed: 01/07/2023]
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Simova I. Coronary Flow Velocity Reserve Assessment with Transthoracic Doppler Echocardiography. Eur Cardiol 2015; 10:12-18. [PMID: 30310417 PMCID: PMC6159450 DOI: 10.15420/ecr.2015.10.01.12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/23/2015] [Indexed: 11/04/2022] Open
Abstract
Coronary flow velocity reserve (CFVR) reflects global coronary atherosclerotic burden, endothelial function and state of the microvasculature. It could be measured using transthoracic Doppler echocardiography in a non-invasive, feasible, reliable and reproducible fashion, following a standardised protocol with different vasodilatory stimuli. CFVR measurement is a recommended complement to vasodilator stress echocardiography. It could serve as a diagnostic tool for coronary microvascular dysfunction and in the setting of epicardial coronary artery stenoses could help in identification and assessment of functional significance of coronary lesions and follow-up of patients after coronary interventions. CFVR has also a prognostic significance in different clinical situations.
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Affiliation(s)
- Iana Simova
- National Cardiology Hospital, Sofia, Bulgaria
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Westergren HU, Grönros J, Heinonen SE, Miliotis T, Jennbacken K, Sabirsh A, Ericsson A, Jönsson-Rylander AC, Svedlund S, Gan LM. Impaired Coronary and Renal Vascular Function in Spontaneously Type 2 Diabetic Leptin-Deficient Mice. PLoS One 2015; 10:e0130648. [PMID: 26098416 PMCID: PMC4476758 DOI: 10.1371/journal.pone.0130648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 05/22/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Type 2 diabetes is associated with macro- and microvascular complications in man. Microvascular dysfunction affects both cardiac and renal function and is now recognized as a main driver of cardiovascular mortality and morbidity. However, progression of microvascular dysfunction in experimental models is often obscured by macrovascular pathology and consequently demanding to study. The obese type 2 diabetic leptin-deficient (ob/ob) mouse lacks macrovascular complications, i.e. occlusive atherosclerotic disease, and may therefore be a potential model for microvascular dysfunction. The present study aimed to test the hypothesis that these mice with an insulin resistant phenotype might display microvascular dysfunction in both coronary and renal vascular beds. METHODS AND RESULTS In this study we used non-invasive Doppler ultrasound imaging to characterize microvascular dysfunction during the progression of diabetes in ob/ob mice. Impaired coronary flow velocity reserve was observed in the ob/ob mice at 16 and 21 weeks of age compared to lean controls. In addition, renal resistivity index as well as pulsatility index was higher in the ob/ob mice at 21 weeks compared to lean controls. Moreover, plasma L-arginine was lower in ob/ob mice, while asymmetric dimethylarginine was unaltered. Furthermore, a decrease in renal vascular density was observed in the ob/ob mice. CONCLUSION In parallel to previously described metabolic disturbances, the leptin-deficient ob/ob mice also display cardiac and renal microvascular dysfunction. This model may therefore be suitable for translational, mechanistic and interventional studies to improve the understanding of microvascular complications in type 2 diabetes.
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Affiliation(s)
- Helena U. Westergren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Alan Sabirsh
- CVMD iMED, AstraZeneca R&D Mölndal, Mölndal, Sweden
| | | | | | - Sara Svedlund
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Li-Ming Gan
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- CVMD iMED, AstraZeneca R&D Mölndal, Mölndal, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- * E-mail:
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Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
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Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
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Mohandas R, Segal MS, Huo T, Handberg EM, Petersen JW, Johnson BD, Sopko G, Bairey Merz CN, Pepine CJ. Renal function and coronary microvascular dysfunction in women with symptoms/signs of ischemia. PLoS One 2015; 10:e0125374. [PMID: 25951606 PMCID: PMC4423851 DOI: 10.1371/journal.pone.0125374] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/23/2015] [Indexed: 12/16/2022] Open
Abstract
Objectives Chronic kidney disease (CKD) is more prevalent among women and is associated with adverse cardiovascular events. Among women with symptoms and signs of ischemia enrolled in the Women’s Ischemia Syndrome Evaluation (WISE), a relatively high mortality rate was observed in those with no obstructive coronary artery disease. Coronary microvascular dysfunction or reduced coronary flow reserve (CFR) was a strong and independent predictor of adverse outcomes. The objective of this analysis was to determine if renal function was associated with coronary microvascular dysfunction in women with signs and symptoms of ischemia. Methods The WISE was a multicenter, prospective, cohort study of women undergoing coronary angiography for suspected ischemia. Among 198 women with additional measurements of CFR, we determined the estimated glomerular filtration rate (eGFR) with the CKD-EPI equation. We tested the association between eGFR and CFR with regression analysis. Results The median eGFR was 89 ml/min. The eGFR correlated with CFR (r = 0.22; P = 0.002). This association persisted even after covariate adjustment. Each 10-unit decrease in eGFR was associated with a 0.04-unit decrease in CFR (P = 0.04).There was a strong interaction between eGFR and age (P = 0.006): in those ≥60 years old, GFR was strongly correlated with CFR (r = 0.55; P<0.0001). No significant correlation was noted in those <60 years old. Conclusions Reduced renal function was significantly associated with lower CFR in women with symptoms and signs of ischemia. Coronary microvascular dysfunction warrants additional study as a mechanism contributing to increased risk of cardiovascular events in CKD.
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Affiliation(s)
- Rajesh Mohandas
- Nephrology and Hypertension Section, North Florida/South Georgia Veterans Health System, Gainesville, Florida, United States of America
- Division of Nephrology, Hypertension & Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Mark S. Segal
- Nephrology and Hypertension Section, North Florida/South Georgia Veterans Health System, Gainesville, Florida, United States of America
- Division of Nephrology, Hypertension & Transplantation, University of Florida, Gainesville, Florida, United States of America
| | - Tianyao Huo
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Eileen M. Handberg
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, United States of America
| | - John W. Petersen
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, United States of America
| | - B. Delia Johnson
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - George Sopko
- National Institutes of Health, Bethesda, Maryland, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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Mohandas R, Segal M, Srinivas TR, Johnson BD, Wen X, Handberg EM, Petersen JW, Sopko G, Merz CNB, Pepine CJ. Mild renal dysfunction and long-term adverse outcomes in women with chest pain: results from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE). Am Heart J 2015; 169:412-8. [PMID: 25728732 DOI: 10.1016/j.ahj.2014.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with accelerated atherosclerosis and adverse cardiovascular outcomes, but mechanisms are unclear. We hypothesized that mild CKD independently predicts adverse outcomes in women with symptoms and signs of ischemia. METHODS We categorized 876 women from the Women's Ischemia Syndrome Evaluation cohort according to estimated glomerular filtration rate (eGFR) (eGFR ≥90 mL/min per 1.73 m(2) [normal], 60-89 mL/min per 1.73 m(2) [mild CKD], ≤59 mL/min per 1.73 m(2) [severe CKD]). Time to death from all-cause and cardiovascular causes and major adverse outcomes were assessed by multivariate regression adjusted for baseline covariates. RESULTS Obstructive coronary artery disease (CAD) was present only in few patients (39%). Even after adjusting for CAD severity, renal function remained a strong independent predictor of all-cause and cardiac mortality (P < .001). Every 10-unit decrease in eGFR was associated with a 14% increased risk of all-cause mortality (adjusted hazard ratio [AHR] 1.14 [1.08-1.20], P < .0001), 16% increased risk of cardiovascular mortality (AHR 1.16 [1.09-1.23], P < .0001), and 9% increased risk of adverse cardiovascular events (AHR 1.09 [1.03-1.15], P = .002). CONCLUSIONS Even mild CKD is a strong independent predictor of all-cause and cardiac mortality in women with symptoms/signs of ischemia, regardless of underlying obstructive CAD severity, underscoring the need to better understand the interactions between ischemic heart disease and CKD.
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Parnham SFC, Gleadle JM, De Pasquale CG, Selvanayagam JB. Myocardial Ischemia Assessment in Chronic Kidney Disease: Challenges and Pitfalls. Front Cardiovasc Med 2014; 1:13. [PMID: 26664863 PMCID: PMC4668858 DOI: 10.3389/fcvm.2014.00013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 12/07/2014] [Indexed: 01/15/2023] Open
Abstract
Coronary artery disease is the leading cause of mortality and morbidity in the chronic kidney disease (CKD) population and often presents with atypical symptoms. Current diagnostic investigations of myocardial ischemia in CKD lack sensitivity and specificity or may have adverse effects. We present a case vignette and explore the challenges of diagnostic myocardial stress investigation in patients with CKD.
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Affiliation(s)
- Susie F C Parnham
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Jonathan M Gleadle
- School of Medicine, Flinders University , Bedford Park, SA , Australia ; Department of Renal Medicine, School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Joseph B Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
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Kono Y, Fukuda S, Hanatani A, Nakanishi K, Otsuka K, Taguchi H, Shimada K. Remote ischemic conditioning improves coronary microcirculation in healthy subjects and patients with heart failure. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:1175-81. [PMID: 25210440 PMCID: PMC4154883 DOI: 10.2147/dddt.s68715] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Remote ischemic conditioning (RIC) is a treatment modality that suppresses inflammation and improves endothelial function, which are factors involved in the pathogenesis of heart failure (HF) with reduced left ventricular ejection fraction. Coronary flow reserve (CFR) is a physiological index of coronary microcirculation and is noninvasively measured by transthoracic Doppler echocardiography (TTDE). This study aimed to investigate the effects of RIC on CFR in healthy subjects and patients with HF, through the assessment by TTDE. METHODS Ten patients with HF with left ventricular ejection fraction of less than 40%, and ten healthy volunteers were enrolled in this study. RIC treatment was performed twice a day for 1 week. Our custom-made RIC device was programmed to automatically conduct 4 cycles of 5 minutes inflation and 5 minutes deflation of a blood pressure cuff to create intermittent arm ischemia. CFR measurements and laboratory tests were examined before, and after 1 week of RIC treatment. RESULTS One week of RIC treatment was well tolerated in both groups. RIC treatment increased CFR from 4.0 ± 0.9 to 4.6 ± 1.3 (mean ± standard deviation) in healthy subjects (P=0.02), and from 1.9 ± 0.4 to 2.3 ± 0.7 in patients with HF (P = 0.03), respectively. Systolic blood pressure in healthy subjects, and heart rate in HF patients decreased after RIC treatment (both P<0.01). CONCLUSION This study demonstrated that a 1 week course of RIC treatment improved coronary microcirculation in healthy subjects and patients with HF associated with reduced left ventricular ejection fraction.
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Affiliation(s)
- Yasushi Kono
- Department of Medicine, Osaka Ekisaikai Hospital, Osaka, Japan
| | - Shota Fukuda
- Department of Medicine, Osaka Ekisaikai Hospital, Osaka, Japan
| | - Akihisa Hanatani
- Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Osaka, Japan
| | - Koki Nakanishi
- Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Osaka, Japan
| | - Kenichiro Otsuka
- Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Osaka, Japan
| | | | - Kenei Shimada
- Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Osaka, Japan
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Park K, Kim M, Cho YR, Park JS, Park TH, Kim MH, Kim YD. Association between Cardiac Troponin Level and Coronary Flow Reserve in Patients without Coronary Artery Disease: Insight from a Thermodilution Technique Using an Intracoronary Pressure Wire. Korean Circ J 2014; 44:141-7. [PMID: 24876854 PMCID: PMC4037635 DOI: 10.4070/kcj.2014.44.3.141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/25/2014] [Accepted: 04/04/2014] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cardiac troponins are associated with increased mortality, even among patients with no coronary artery disease. Elevated cardiac troponin levels are frequently observed in patients without significant coronary lesions, although the mechanism underlying this finding is unclear. The aim of our study was to evaluate the association between the levels of cardiac troponin and coronary flow reserve (CFR). SUBJECTS AND METHODS We evaluated serum cardiac troponin-I in 19 patients (9 female; age 61.9±10.9 year-old). All patients had an ejection fraction >40% and angiographically normal coronary arteries. Simultaneous measurements of fractional flow reserve (FFR), the index of microcirculatory resistance (IMR), and CFR measurements using an intracoronary temperature- and pressure-sensing guidewire under basal conditions and during maximal hyperemia were performed in three vessels: the left anterior descending artery (LAD), left circumflex artery (LCX) and right coronary artery (RCA). RESULTS All patients were followed for a median of 13 months. FFR, IMR, and CFR measurements were performed successfully in all subjects. Mean CFRs of LAD, LCX, and RCA were 1.98±1.20, 2.75±2.11, and 4.44±2.51, respectively. Mean IMRs of LAD, LCX and RCA were 33.28±18.78, 29.11±26.70, and 30.55±23.65, respectively. There was a poor correlation between CFR and troponin-I values in each vessel. In selecting the lowest value of CFR in each patient as the corresponding value, the lowest CFR was not associated with troponin-I levels (r=-0.219, p=0.367). CONCLUSION In patients without significant coronary lesions, the correlation between CFR and troponin-I level was not significant using a thermodilution technique. Further study of a larger population with longer-term follow-up may be needed to more fully understand microvascular dysfunction.
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Affiliation(s)
- Kyungil Park
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Minkwan Kim
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Young-Rak Cho
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jong-Sung Park
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Tea-Ho Park
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Moo Hyun Kim
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Young-Dae Kim
- Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Korea. ; Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Risk Stratification with Cardiac Rubidium-82 Positron Emission Tomography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yalta K, Yilmaz MB. Coronary microvascular dysfunction portends poor prognosis in the setting of chronic renal failure: Harnessing dual marker strategy for better risk-stratification? Int J Cardiol 2014; 171:275-6. [DOI: 10.1016/j.ijcard.2013.11.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 11/25/2013] [Indexed: 11/29/2022]
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