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Pasupathy S, Tavella R, Zeitz C, Edwards S, Worthley M, Arstall M, Beltrame JF. Randomised Placebo-Controlled Pilot Trial Evaluating the Anti-Anginal Efficacy of Ticagrelor in Patients with Angina with Nonobstructive Coronary Arteries and Coronary Slow Flow Phenomenon. J Clin Med 2024; 13:5235. [PMID: 39274447 PMCID: PMC11395883 DOI: 10.3390/jcm13175235] [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: 07/02/2024] [Revised: 08/07/2024] [Accepted: 08/22/2024] [Indexed: 09/16/2024] Open
Abstract
Background: The coronary slow flow phenomenon (CSFP) is an angiographic finding characterised by the delayed passage of contrast through the coronary arteries, despite the absence of obstructive coronary artery disease (defined as less than 50% narrowing of the vessel lumen). Patients with the CSFP experience recurrent angina, for which there are limited evidence-based therapies. Ticagrelor may serve as an effective anti-anginal therapy for these patients by increasing adenosine levels, which could alleviate coronary microvascular dysfunction and its associated angina due to its vasodilatory properties. This study aimed to determine the anti-anginal efficacy of ticagrelor 90 mg taken twice daily on spontaneous angina episodes in patients with refractory angina (i.e., episodes ≥3/week despite two anti-anginals) and documented CSFP. Methods: In a randomised, double-blind, placebo-controlled, cross-over trial, the anti-anginal efficacy of a 4-week ticagrelor therapy regimen was evaluated in 20 patients with refractory angina (mean age 61.5 ± 10.5 years; 40% women) who had documented slow coronary flow. The primary endpoint was the frequency of angina episodes, recorded using an angina diary. Secondary endpoints included the duration and severity of angina episodes, consumption of short-acting nitrates, and health status evaluations using the Seattle Angina Questionnaire (SAQ) and the Short Form-36 (SF-36) indices. Results: During the four weeks of therapy, ticagrelor did not significantly improve angina symptoms compared to the placebo (placebo 25.7 (16.7)) vs. ticagrelor 19.8 (18.1), p > 0.05). Furthermore, it did not impact other patient-related outcome measures, including angina severity, duration, frequency of prolonged angina episodes, nitrate consumption, or the SAQ/SF-36 health outcome indices. No serious adverse events related to the study drug were observed. Conclusions: In patients with documented CSFP who were unresponsive to standard anti-anginal therapy, ticagrelor did not reduce the frequency of spontaneous angina episodes or the consumption of nitrates. Further confirmation of the potential benefits of this therapy may be obtained through a larger clinical trial.
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Affiliation(s)
- Sivabaskari Pasupathy
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
- Flinders University, Adelaide, SA 5042, Australia
| | - Rosanna Tavella
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
| | - Christopher Zeitz
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
| | - Suzanne Edwards
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Matthew Worthley
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Margaret Arstall
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Northern Adelaide Local Health Network, Adelaide, SA 5112, Australia
| | - John F Beltrame
- School of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
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Andishmand A, Seyedhosseini S, Namayandeh SM, Adelzadeh E, Entezari A, Mirjalili SR. Sildenafil's effectiveness in the primary coronary slow flow phenomenon: a pilot randomised controlled clinical trial. Open Heart 2024; 11:e002772. [PMID: 39214536 DOI: 10.1136/openhrt-2024-002772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND On the one hand, the primary coronary slow flow phenomenon (CSFP) can cause recurrence of chest pain, prompting medical examinations and further healthcare costs, while on the other hand, it can lead to myocardial infarction, ventricular arrhythmia and sudden cardiac death. Nevertheless, there is not any agreement on the optimal treatment for primary CSFP, so we decided to examine the effectiveness of sildenafil in this context. METHODS This pilot study is a 12-week, triple-blind, randomised, placebo-controlled trial for receiving either 50 mg daily oral sildenafil or placebo. Twenty eligible patients aged 30-70 years from a tertiary hospital in Yazd were randomly allocated in a 1:1 ratio to two groups. The primary outcomes were the alterations in functional capacity (metabolic equivalents, METs), Duke treadmill score (DTS) and angina severity (Canadian Cardiovascular Society (CCS) class). The study protocol registration code is IRCT20220223054103N1. RESULTS The angina severity in the Sildenafil group improved, with all receivers achieving a state of being asymptomatic during regular physical activity (CCS I). Whereas just 40% of the recipients in the placebo group achieved the same level of improvement (p=0.011). Mean METs at baseline were 9.9 (SD: 3.1) and at week 12 were 13.1 (SD: 3.3) for sildenafil and 9.56 (SD: 2.1) and 9.63 (SD: 2.4) for placebo (difference favouring sildenafil with a median increase of 3.1 (IQR: 1.1 to 4.1, p=0.008)). Median DTS scores at baseline were 3 (IQR: 0 to 9) and at week 12 were 9.5 (IQR: 7.75 to 15) for sildenafil and 7 (IQR: -1.5 to 9.25) and 8 (IQR: 1.5 to 11.25) for placebo (difference favouring sildenafil with a median increase of 5.5 (IQR: 1 to 9.2, p=0.01)). CONCLUSIONS We suggest that a daily low dose of sildenafil could be a valuable therapeutic option for primary CSFP. TRIAL REGISTRATION NUMBER IRCT20220223054103N1.
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Affiliation(s)
- Abbas Andishmand
- Yazd Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Seyedmostafa Seyedhosseini
- Yazd Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Seyedeh Mahdieh Namayandeh
- Epidemiologist, Associated Professor, Afshar Research Development Center, Yazd, Iran
- Center for Healthcare Data Modeling, Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Elnaz Adelzadeh
- Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Amin Entezari
- Yazd Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Seyed Reza Mirjalili
- Yazd Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Harkin KL, Loftspring E, Beaty W, Joa A, Serrano-Gomez C, Farid A, Hausvater A, Reynolds HR, Smilowitz NR. Visual Estimates of Coronary Slow Flow Are Not Associated With Invasive Wire-Based Diagnoses of Coronary Microvascular Dysfunction. Circ Cardiovasc Interv 2024; 17:e013902. [PMID: 38583174 PMCID: PMC11187652 DOI: 10.1161/circinterventions.123.013902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Coronary slow flow (CSF) by invasive coronary angiography is frequently understood to be an indicator of coronary microvascular dysfunction (CMD) in patients with ischemia with nonobstructive coronary arteries. However, the relationship between visual estimates of CSF and quantitative wire-based invasive diagnosis of CMD is uncertain. METHODS We prospectively enrolled adults aged ≥18 years with stable ischemic heart disease who were referred for invasive coronary angiography. Individuals with ≥50% epicardial coronary artery stenosis were excluded. Invasive coronary angiography was reviewed for CSF, defined as ≥3 cardiac cycles to opacify distal vessels with contrast. Coronary function testing was performed in the left anterior descending coronary artery using bolus coronary thermodilution techniques to measure coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). Invasively determined CMD was defined as abnormal CFR (<2.5), abnormal IMR (≥25), or both. RESULTS Among 104 participants, the median age was 61.5 years and 79% were female. The median CFR was 3.6 (interquartile range, 2.5-4.7) and the median IMR was 21 (interquartile range, 13.3-28.0). Overall, 24.0% of participants had abnormal CFR, 34.6% had abnormal IMR, and 48.1% had a final diagnosis of invasively determined CMD. CSF was present in 23 participants (22.1%). The proportions of patients with CMD (56.5% versus 45.7%; P=0.36), abnormal CFR (17.4% versus 25.9%; P=0.40), and abnormal IMR (43.5% versus 32.1%; P=0.31) were not different in patients with versus without CSF. CONCLUSIONS Among patients with ischemia with nonobstructive coronary artery, CSF was not associated with abnormal CFR, IMR, or either abnormal CFR or IMR. CSF is not a reliable angiographic surrogate of abnormal CFR or IMR as determined by invasive, wire-based physiology testing. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03537586.
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Affiliation(s)
- Kenneth L Harkin
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Ethan Loftspring
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - William Beaty
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Amanda Joa
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Claudia Serrano-Gomez
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Ayman Farid
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Anaïs Hausvater
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
| | - Nathaniel R Smilowitz
- Sarah Ross Soter Center for Women's Cardiovascular Research (K.L.H., A.J., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine (E.L., W.B., C.S.-G., A.F., A.H., H.R.R., N.R.S.), New York University Grossman School of Medicine
- Veterans Affairs New York Harbor Health Care System, Department of Medicine, Section of Cardiology (N.R.S.)
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Sun L, Wang J, Lei J, Zhang Y, Zhang Y, Zhang Y, Xing S. Differential gene expression and miRNA regulatory network in coronary slow flow. Sci Rep 2024; 14:8419. [PMID: 38600259 PMCID: PMC11006858 DOI: 10.1038/s41598-024-58745-w] [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: 11/15/2023] [Accepted: 04/02/2024] [Indexed: 04/12/2024] Open
Abstract
Coronary slow flow (CSF) is characterized by slow progression of coronary angiography without epicardial stenosis. The aim of this study was to explore the potential biomarkers and regulatory mechanism for CSF. Peripheral blood mononuclear cells from 3 cases of CSF and 3 healthy controls were collected for high-throughput sequencing of mRNA and miRNA, respectively. The differentially expressed mRNAs (DE-mRNAs) and miRNAs (DE-miRNAs) was identified. A total of 117 DE-mRNAs and 32 DE-miRNAs were obtained and they were mainly enriched in immune and inflammatory responses. Twenty-six DE-mRNAs were the predicted target genes for miRNAs by RAID, and then the regulatory network of 15 miRNAs were constructed. In addition, through the PPI network, we identified the three genes (FPR1, FPR2 and CXCR4) with larger degrees as hub genes. Among them, FPR1 was regulated by hsa-miR-342-3p, hsa-let-7c-5p and hsa-miR-197-3p and participated in the immune response. Finally, we validated the differential expression of hub genes and key miRNAs between 20 CSF and 20 control. Moreover, we found that miR-342-3p has a targeted regulatory relationship with FPR1, and their expression is negatively correlated. Then we established a hypoxia/reoxygenation (H/R) HUVEC model and detected FPR1, cell proliferation and apoptosis. Transfection with miR-342-3p mimics can significantly promote the proliferation of HUVEC under H/R conditions. FPR1 were associated with CSF as a biomarker and may be regulated by miR-342-3p potential biomarkers.
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Affiliation(s)
- Lihua Sun
- Department of Cardiology, Zhongshan Boai Hospital Affiliated to South Medical University, No. 6, Chenggui Road, Zhongshan, 528405, Guangdong, China
| | - Juan Wang
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi, 830000, Xinjiang, China
| | - Jimin Lei
- Department of Cardiology, Zhongshan Boai Hospital Affiliated to South Medical University, No. 6, Chenggui Road, Zhongshan, 528405, Guangdong, China
| | - Ying Zhang
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi, 830000, Xinjiang, China
| | - Yue Zhang
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi, 830000, Xinjiang, China
| | - Yaling Zhang
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi, 830000, Xinjiang, China
| | - Shifeng Xing
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan West Road, Xinshi District, Urumqi, 830000, Xinjiang, China.
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Zhu Q, Wang S, Huang X, Zhao C, Wang Y, Li X, Jia D, Ma C. Understanding the pathogenesis of coronary slow flow: Recent advances. Trends Cardiovasc Med 2024; 34:137-144. [PMID: 36516963 DOI: 10.1016/j.tcm.2022.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/24/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Coronary slow flow is taken to be indicative of delayed filling of terminal vessels of the coronary arteries in the absence of coronary stenosis, as detected using coronary angiography. Patients suffering from coronary slow flow typically experience recurrent chest pain, thereby markedly affecting their quality of life. The etiology and pathogenesis of coronary slow flow, which is gradually attracting clinical attention, have yet to be sufficiently established, although it is currently believed that they may be associated with endothelial dysfunction in the coronary arteries, inflammatory response, abnormalities in microvascular reserve function, subclinical atherosclerosis, blood cell and platelet abnormalities, and genetic factors. In this review, we provide a brief overview of recent progress in research on the pathogenesis of coronary slow flow with a view toward elucidating the possible underlying pathogenesis and identify targets and directions for the treatment of this condition.
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Affiliation(s)
- Qing Zhu
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China
| | - Shitong Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China
| | - Xin Huang
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Cuiting Zhao
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China
| | - Yonghuai Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China
| | - Xinxin Li
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China
| | - Dalin Jia
- Department of Cardiology, The First Hospital of China Medical University, Shenyang, China
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, China; Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, China.
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Pasupathy S, Tavella R, Zeitz C, Edwards S, Worthley M, Arstall M, Beltrame JF. Anti-Anginal Efficacy of Zibotentan in the Coronary Slow-Flow Phenomenon. J Clin Med 2024; 13:1337. [PMID: 38592159 PMCID: PMC10931575 DOI: 10.3390/jcm13051337] [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: 01/03/2024] [Revised: 02/07/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Patients with coronary microvascular disorders often experience recurrent angina for which there are limited evidence-based therapies. These patients have been found to exhibit increased plasma levels of endothelin; thus, selective endothelin-A (Et-A) receptor blockers such as zibotentan may be an effective anti-anginal therapy in these patients. The study evaluated the impact of a 10 mg daily dose of zibotentan on spontaneous angina episodes in patients with the coronary slow-flow phenomenon who had refractory angina (i.e., experiencing angina at least three times/week despite current anti-anginal therapy). METHODS Using a randomized, double-blind, placebo-controlled, crossover trial design with 4-week treatment periods, 18 patients (63.2 ± 9.9 years, 33% females) were recruited. The primary endpoint was angina frequency as measured by an angina diary, with secondary endpoints including nitrate consumption, angina duration/severity and the Seattle Angina Questionnaire (SAQ) domains. RESULTS During the 4 weeks of therapy, angina frequency significantly improved with zibotentan therapy (placebo 41.4 (58.5) vs. zibotentan 29.2 (31.6), p < 0.05), and sublingual nitrate consumption significantly reduced (placebo 11.8 (15.2) vs. zibotentan 8.8 (12.9), p < 0.05. CONCLUSIONS Zibotentan improved the frequency of spontaneous angina episodes and reduced sublingual nitrate consumption in patients unresponsive to standard anti-anginal therapy.
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Affiliation(s)
- Sivabaskari Pasupathy
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
| | - Rosanna Tavella
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
| | - Christopher Zeitz
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Suzanne Edwards
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
| | - Matthew Worthley
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Margaret Arstall
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Northern Adelaide Local Health Network, Adelaide, SA 5112, Australia
| | - John F. Beltrame
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.P.); (R.T.); (C.Z.); (S.E.); (M.W.); (M.A.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, Adelaide, SA 5011, Australia
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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8
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Ipek G, Kamber T, Yilmaz H, Bolca O. Long-Term Change in Flow Rates in Patients with Coronary Slow Flow. Cardiology 2023; 148:500-505. [PMID: 37634497 DOI: 10.1159/000533802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Coronary slow flow (CSF) is a condition characterized by impaired blood flow rates in the coronary arteries. It can result in severe cardiovascular outcomes. There is no sufficient evidence regarding the certain etiology and reversibility of slow flow patterns and changes in frame counts with long-term management. METHODS We retrospectively enrolled 48 patients with chronic coronary syndrome and CSF who underwent a second angiography. A corrected coronary frame rate (CFR) >27 was defined as CSF. We created 3 groups according to the change in CSF status as the improved, not changed, and worsened groups. We compared the CFR and CSF status of the patients between the first and second angiographies within a median of 2.6 years. RESULTS We determined a nonsignificant change in cCFR in left anterior descending (LAD) artery (34.4 [18.9] vs. 31.59 [10.3], p = 0.35), circumflex (Cx) artery (42.84 [12.56] vs. 40.66 [13.2], p = 0.35), and right coronary artery (RCA) (57.80 [30.13] vs. 50.32 [19.5], p = 0.11). In the comparison of CSF status of LAD (75% vs. 63%, p = 0.27), Cx (96% vs. 83%, p = 0.09), RCA (94% vs. 94%, p = 1.0) between first and second angiographies, there was no significant change. In the comparison of the 3 groups according to the improvement of CSF status, there was no significant difference in demographic features, change in laboratory parameters, and time between the groups. CONCLUSION There was no significant change in the median CFR and CSF status in the overall group between the two angiographies after 3 years.
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Affiliation(s)
- Gokturk Ipek
- Cardiology Department, Siyami Ersek Cardiothoracic Surgery Center, Istanbul, Turkey
| | - Tugay Kamber
- Cardiology Department, Siyami Ersek Cardiothoracic Surgery Center, Istanbul, Turkey
| | - Hale Yilmaz
- Cardiology Department, Siyami Ersek Cardiothoracic Surgery Center, Istanbul, Turkey
| | - Osman Bolca
- Cardiology Department, Siyami Ersek Cardiothoracic Surgery Center, Istanbul, Turkey
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9
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Kei CY, Singh K, Dautov RF, Nguyen TH, Chirkov YY, Horowitz JD. Coronary "Microvascular Dysfunction": Evolving Understanding of Pathophysiology, Clinical Implications, and Potential Therapeutics. Int J Mol Sci 2023; 24:11287. [PMID: 37511046 PMCID: PMC10379859 DOI: 10.3390/ijms241411287] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Until recently, it has been generally held that stable angina pectoris (SAP) primarily reflects the presence of epicardial coronary artery stenoses due to atheromatous plaque(s), while acute myocardial infarction (AMI) results from thrombus formation on ruptured plaques. This concept is now challenged, especially by results of the ORBITA and ISCHEMIA trials, which showed that angioplasty/stenting does not substantially relieve SAP symptoms or prevent AMI or death in such patients. These disappointing outcomes serve to redirect attention towards anomalies of small coronary physiology. Recent studies suggest that coronary microvasculature is often both structurally and physiologically abnormal irrespective of the presence or absence of large coronary artery stenoses. Structural remodelling of the coronary microvasculature appears to be induced primarily by inflammation initiated by mast cell, platelet, and neutrophil activation, leading to erosion of the endothelial glycocalyx. This leads to the disruption of laminar flow and the facilitation of endothelial platelet interaction. Glycocalyx shedding has been implicated in the pathophysiology of coronary artery spasm, cardiovascular ageing, AMI, and viral vasculitis. Physiological dysfunction is closely linked to structural remodelling and occurs in most patients with myocardial ischemia, irrespective of the presence or absence of large-vessel stenoses. Dysfunction includes the impairment of platelet and vascular responsiveness to autocidal coronary vasodilators, such as nitric oxide, prostacyclin, and hydrogen sulphide, and predisposes both to coronary vasoconstriction and to a propensity for microthrombus formation. These findings emphasise the need for new directions in medical therapeutics for patients with SAP, as well as a wide range of other cardiovascular disorders.
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Affiliation(s)
- Chun Yeung Kei
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
| | - Kuljit Singh
- Department of Medicine, Griffith University, Southport 4111, Australia
- Gold Coast University Hospital, Gold Coast 4215, Australia
| | - Rustem F Dautov
- Department of Medicine, University of Queensland, Woolloongabba 4102, Australia
- Prince Charles Hospital, Brisbane 4032, Australia
| | - Thanh H Nguyen
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Northern Adelaide Local Health Network, Adelaide 5000, Australia
| | - Yuliy Y Chirkov
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Basil Hetzel Institute for Translational Research, Adelaide 5011, Australia
| | - John D Horowitz
- Department of Medicine, University of Adelaide, Adelaide 5371, Australia
- Basil Hetzel Institute for Translational Research, Adelaide 5011, Australia
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10
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The Systemic Immune-Inflammation Index May Predict the Coronary Slow Flow Better Than High-Sensitivity C-Reactive Protein in Patients Undergoing Elective Coronary Angiography. Cardiol Res Pract 2022; 2022:7344639. [PMID: 36407283 PMCID: PMC9668456 DOI: 10.1155/2022/7344639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/28/2022] [Indexed: 11/10/2022] Open
Abstract
Methods A total of 197 patients (102 patients with CSF; 95 patients with normal coronary flow) were included in this retrospective study. Clinical and angiographic characteristics of patients were obtained from hospital records. Results Patients with CSF had higher SII, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), and high-sensitivity C-reactive protein (hsCRP) levels compared with the control group. Body mass index (p=0.022, OR 1.151, 95% CI 1.121–1.299), low-density lipoprotein (p=0.018, OR 1.028, 95% CI 1.005–1.052), hsCRP (p=0.044, OR 1.161, 95% CI 1.004–1.343), and SII (p < 0.001, OR 1.015, 95% CI 1.003–1.026) were independent predictors of CSF in the multivariable analysis. The optimal cutoff value of SII in predicting CSF was >877 in ROC curve analysis (p < 0.001, AUC = 0.892, 95% CI 0.848–0.936). This cutoff value of SII predicted the CSF with a sensitivity of 71.5% and specificity of 92.4%. Spearman correlation analysis showed a positive correlation between the mean TFC value and PLR, NLR, hsCRP, and SII. Conclusions SII may be used as a better indicator for the prediction of CSF than hsCRP.
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11
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Horowitz JD, Nguyen TH. Takotsubo Syndrome: Severe Early Coronary Vasculitis Predicts Slow Recovery. JACC Cardiovasc Imaging 2022; 15:1796-1798. [PMID: 36202459 DOI: 10.1016/j.jcmg.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 06/16/2023]
Affiliation(s)
- John D Horowitz
- Basil Hetzel Institute for Translational Research, University of Adelaide, Woodville, South Australia, Australia.
| | - Thanh Ha Nguyen
- Basil Hetzel Institute for Translational Research, University of Adelaide, Woodville, South Australia, Australia; Northern Adelaide Local Health Service, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
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12
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Zhang W, Dai J, Shen L, Jiang Y, Zheng X, Xu K, Yang X, Wang X, Hao Z, Zhao Y, Wang D, Jiang L, Qiu X, Shen L, He B. Alprostadil vs. isosorbide dinitrate in ameliorating angina episodes in patients with coronary slow flow phenomenon: A randomized controlled trial. Front Cardiovasc Med 2022; 9:965364. [PMID: 36158840 PMCID: PMC9493040 DOI: 10.3389/fcvm.2022.965364] [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: 06/09/2022] [Accepted: 08/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background The optimum therapy for coronary slow flow phenomenon (CSFP) stays debatable. This study compared the effectiveness of alprostadil with isosorbide dinitrate in alleviating angina episodes in CSFP patients. Methods In this prospective, randomized controlled study, 102 patients with CSFP without severe coronary artery stenosis that exhibited stable angina were allocated randomly in a ratio of 1:1 to either the alprostadil group (40 μg, three times per day, n = 51) or the isosorbide dinitrate group (5 mg, three times per day, n = 51). Frequency of angina events, intensity of suffering, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were evaluated at baseline and one month after. Additionally, the Seattle Angina Questionnaire (SAQ) was assessed. Results Baseline characteristics were comparable between the two groups. At 1-month follow-up, patients administered with alprostadil experienced fewer angina episodes [episodes per week, 1 (2) vs. 2 (2), P < 0.001] and less pain intensity [self-evaluated pain score, 2 (3) vs. 3 (4), P < 0.001] than those with isosorbide dinitrate. In the alprostadil group, 78.4% of patients were classified as CCS class I, significantly higher than the 47.1% seen in the isosorbide dinitrate group (P = 0.001). Furthermore, treatment of alprostadil led to a significant improvement in the SAQ score (7.09 U, 95% CI: 4.22–9.96, P < 0.001) compared to isosorbide dinitrate. Additionally, fewer patients suffered headaches when receiving alprostadil (7.8% vs. 19.6%, P = 0.084). Conclusion Alprostadil was more effective in ameliorating angina symptoms in CSFP patients than isosorbide dinitrate. Clinical trial registration [www.chictr.org.cn], identifier [ChiCTR2000033233].
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Affiliation(s)
- Weifeng Zhang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jinjie Dai
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lan Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center, Shanghai Jiao Tong University, Shanghai, China
| | - Yue Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaowen Zheng
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoxiao Yang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaolei Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ziyong Hao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Zhao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Dong Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lisheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xingbiao Qiu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Linghong Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Ben He,
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13
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Askin L, Tanrıverdi O. Evaluation of index of cardio-electrophysiological balance in patients with coronary slow flow. Acta Cardiol 2022; 77:337-341. [PMID: 34218730 DOI: 10.1080/00015385.2021.1945232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Coronary slow flow (CSF) is defined as the late progression of applied contrast through coronary arteries. The cardiac electrophysiological balance index (iCEB) reflects the balance between ventricular depolarisation and repolarisation and provides more information about ventricular arrhythmogenesis (VA) than other electrocardiography (ECG) parameters (QT, corrected QT [QTc], etc.). AIM We aimed to evaluate iCEB in patients with CSF. METHODS We divided the study population into two groups as CSF and control. The CSF group consisted of 100 patients (33 female, 67 male, mean age 52.2 ± 2.6), while the control group consisted of the same number of age and sex-matched patients (35 female, 65 male, mean age 51.7 ± 1.4). ECG parameters of the study population (QRS duration, QT, T wave peak-to-end (Tp-e) intervals, iCEB (QT/QRS), and iCEBc (heart rate QTc/QRS) rates were calculated and compared between CSF and control groups. RESULTS Intervals (QT and QTc intervals) and Tp-e/QTc ratio were greater in the CSF group compared with controls [422.1 ± 12.8 vs. 349.4 ± 14.3 bpm, respectively, p < .001; 457.0 ± 12.2 vs. 378.1 ± 12.3 bpm, respectively, p < .001, and 0.19 vs. 0.12, respectively, p < .001]. ICEB and iCEBc were significantly greater than controls [(4.9 ± 0.4 vs. 4.2 ± 0.4, respectively, p < .001), (5.7 ± 0.3 vs. 4.4 ± 0.3, respectively, p < .001)]. CONCLUSIONS ICEB and iCEBc were significantly increased in patients with CSF. This may suggest that CSF may predispose to malign arrhythmias.
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Affiliation(s)
- Lutfu Askin
- Department of Cardiology, Adiyaman Education and Research Hospital, Adiyaman, Turkey
| | - Okan Tanrıverdi
- Department of Cardiology, Adiyaman Education and Research Hospital, Adiyaman, Turkey
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14
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Aparicio A, Cuevas J, Morís C, Martín M. Slow Coronary Blood Flow: Pathogenesis and Clinical Implications. Eur Cardiol 2022; 17:e08. [PMID: 35356630 PMCID: PMC8941644 DOI: 10.15420/ecr.2021.46] [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: 08/31/2021] [Accepted: 12/05/2021] [Indexed: 11/04/2022] Open
Abstract
Coronary slow flow (CSF) phenomenon, also known as cardiac syndrome Y, is defined as the delayed opacification of the coronary vasculature at the distal level. Different hypotheses and theories have been postulated about its substrate and mechanism, such as microvascular and endothelial dysfunction. Several studies have confirmed that CSF is a cause of ischaemia detected by non-invasive testing. Clinically, it can present as angina pectoris, acute coronary syndrome and sudden cardiac death. It has an incidence of 1–5% in patients undergoing coronary angiography and has been most frequently found in young men who are smokers with metabolic syndrome. There are no established treatments for CSF and further studies are still necessary.
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Affiliation(s)
- Andrea Aparicio
- Area de Gestión Clínica del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Javier Cuevas
- Area de Gestión Clínica del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - César Morís
- Area de Gestión Clínica del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - María Martín
- Area de Gestión Clínica del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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15
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Fabin N, Bergami M, Cenko E, Bugiardini R, Manfrini O. The Role of Vasospasm and Microcirculatory Dysfunction in Fluoropyrimidine-Induced Ischemic Heart Disease. J Clin Med 2022; 11:jcm11051244. [PMID: 35268333 PMCID: PMC8910913 DOI: 10.3390/jcm11051244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 12/10/2022] Open
Abstract
Cardiovascular diseases and cancer are the leading cause of morbidity and mortality globally. Cardiotoxicity from chemotherapeutic agents results in substantial morbidity and mortality in cancer survivors and patients with active cancer. Cardiotoxicity induced by 5-fluorouracil (5-FU) has been well established, yet its incidence, mechanisms, and manifestation remain poorly defined. Ischemia secondary to coronary artery vasospasm is thought to be the most frequent cardiotoxic effect of 5-FU. The available evidence of 5-FU-induced epicardial coronary artery spasm and coronary microvascular dysfunction suggests that endothelial dysfunction or primary vascular smooth muscle dysfunction (an endothelial-independent mechanism) are the possible contributing factors to this form of cardiotoxicity. In patients with 5-FU-related coronary artery vasospasm, termination of chemotherapy and administration of nitrates or calcium channel blockers may improve ischemic symptoms. However, there are variable results after administration of nitrates or calcium channel blockers in patients treated with 5-FU presumed to have myocardial ischemia, suggesting mechanisms other than impaired vasodilatory response. Clinicians should investigate whether chest pain and ECG changes can reasonably be attributed to 5-FU-induced cardiotoxicity. More prospective data and clinical randomized trials are required to understand and mitigate potentially adverse outcomes from 5-FU-induced cardiotoxicity.
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16
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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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17
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Khedr A, Neupane B, Proskuriakova E, Jada K, Kakieu Djossi S, Mostafa JA. Pharmacologic Management of Coronary Artery Ectasia. Cureus 2021; 13:e17832. [PMID: 34660041 PMCID: PMC8502747 DOI: 10.7759/cureus.17832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/08/2021] [Indexed: 01/24/2023] Open
Abstract
Coronary artery ectasia (CAE) is a rare form of aneurysmal coronary heart disease. It is defined as a dilatation of the coronary artery by more than one-third of its length and with a diameter 1.5 times of a normal coronary artery adjacent to it. This condition increases the risk of angina pectoris and acute coronary syndrome. Hence, we discuss the pharmacologic options for primary and secondary prevention of CAE complications. Antiplatelets such as aspirin are considered the mainstay of treatment in patients with CAE. Anticoagulants such as warfarin are warranted on a case-by-case basis to prevent thrombus formation depending on the presence of concomitant obstructive coronary artery disease and the patient’s risk of bleeding. Since atherosclerosis is the most common cause of CAE, statins are indicated in all patients for primary prevention. Angiotensin-converting enzyme (ACE) inhibitors may be indicated, especially in hypertensive patients, due to their anti-inflammatory properties. Beta-blockers may be indicated due to their antihypertensive and anti-ischemic effects. Calcium (Ca) channel blockers may be needed to prevent coronary vasospasm. Nitrates are generally contraindicated as they may lead to worsening of symptoms. Other antianginal medications such as trimetazidine can improve exercise tolerance with no reported adverse events in these patients.
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Affiliation(s)
- Anwar Khedr
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bandana Neupane
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ekaterina Proskuriakova
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Keji Jada
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Jihan A Mostafa
- Psychiatry, Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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18
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Nguyen TH, Ong GJ, Girolamo OC, De Menezes Caceres' V, Muminovic A, Chirkov YY, Horowitz JD. Angina due to coronary artery spasm (variant angina): diagnosis and intervention strategies. Expert Rev Cardiovasc Ther 2021; 19:917-927. [PMID: 34633245 DOI: 10.1080/14779072.2021.1991314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Since Prinzmetal first described a 'variant' form of angina pectoris, with predominantly resting episodes of pain and cyclic severity variations, it has gradually become apparent that this clinical presentation is caused by episodes of coronary artery spasm (CAS) involving focal or diffuse changes in large and/or small coronary arteries in the presence or absence of 'fixed' coronary artery stenoses. However, most clinicians have only limited understanding of this group of disorders. AREAS COVERED We examine the clinical presentation of CAS, associated pathologies outside the coronary vasculature, impediments to making the diagnosis, provocative diagnostic tests, available and emerging treatments, and the current understanding of pathogenesis. EXPERT OPINION CAS is often debilitating and substantially under-diagnosed and occur mainly in women. Many patients presenting with CAS crises have non-diagnostic ECGs and normal serum troponin concentrations, but CAS can be suspected on the basis of history and association with migraine, Raynaud's phenomenon and Kounis syndrome. Definitive diagnosis requires provocative testing at coronary angiography. Treatment still centers around the use of calcium antagonists, but with greater understanding of pathogenesis, new management options are emerging.
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Affiliation(s)
- Thanh Ha Nguyen
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Gao-Jing Ong
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Olivia C Girolamo
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Viviane De Menezes Caceres'
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Armin Muminovic
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - Yuliy Y Chirkov
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
| | - John D Horowitz
- Department of Cardiology, Central Adelaide Local Health Network, University of Adelaide, Basil Hetzel Institute for Translational Research, Adelaide, Australia
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19
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Masi S, Rizzoni D, Taddei S, Widmer RJ, Montezano AC, Lüscher TF, Schiffrin EL, Touyz RM, Paneni F, Lerman A, Lanza GA, Virdis A. Assessment and pathophysiology of microvascular disease: recent progress and clinical implications. Eur Heart J 2021; 42:2590-2604. [PMID: 33257973 PMCID: PMC8266605 DOI: 10.1093/eurheartj/ehaa857] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/23/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022] Open
Abstract
The development of novel, non-invasive techniques and standardization of protocols to assess microvascular dysfunction have elucidated the key role of microvascular changes in the evolution of cardiovascular (CV) damage, and their capacity to predict an increased risk of adverse events. These technical advances parallel with the development of novel biological assays that enabled the ex vivo identification of pathways promoting microvascular dysfunction, providing novel potential treatment targets for preventing cerebral-CV disease. In this article, we provide an update of diagnostic testing strategies to detect and characterize microvascular dysfunction and suggestions on how to standardize and maximize the information obtained from each microvascular assay. We examine emerging data highlighting the significance of microvascular dysfunction in the development CV disease manifestations. Finally, we summarize the pathophysiology of microvascular dysfunction emphasizing the role of oxidative stress and its regulation by epigenetic mechanisms, which might represent potential targets for novel interventions beyond conventional approaches, representing a new frontier in CV disease reduction.
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Affiliation(s)
- Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Institute of Cardiovascular Science, University College London, London, UK
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Division of Medicine, Istituto Clinico Città di Brescia, Brescia, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Robert Jay Widmer
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Augusto C Montezano
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Thomas F Lüscher
- Heart Division, Royal Brompton and Harefield Hospital and Imperial College, London, UK.,Center for Molecular Cardiology, University of Zürich, Zürich, Switzerland
| | - Ernesto L Schiffrin
- Department of Medicine and Lady Davis Institute, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Rhian M Touyz
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Francesco Paneni
- Center for Molecular Cardiology, University of Zürich, Zürich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zürich, Switzerland.,Department of Research and Education, University Hospital Zurich, Zürich, Switzerland
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Gaetano A Lanza
- Department of Cardiovascular and Thoracic Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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20
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Chalikias G, Tziakas D. Slow Coronary Flow: Pathophysiology, Clinical Implications, and Therapeutic Management. Angiology 2021; 72:808-818. [PMID: 33779300 DOI: 10.1177/00033197211004390] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coronary slow flow (CSF) is an angiographic phenomenon with specific epidemiologic characteristics, associated clinical presentation, and prognosis. Although patients with CSF are diagnosed as having "normal coronary arteries," it seems appropriate to consider CSF as a distinct disease entity requiring specific treatment. The patient with CSF is usually male, smoker, obese, with a constellation of risk factors suggestive of metabolic syndrome. Unstable angina is the most common clinical presentation, with recurrent episodes of chest pain at rest associated with electrocardiographic changes often requiring readmission and reevaluation. Regarding definition and diagnosis, interventionists should first exclude possible "secondary" causes of CSF, use objective means for definition and then differentiate from other similar conditions such as microvascular angina. Although the phenomenon is generally benign, patients with CSF are severely symptomatic with recurrent episodes of chest pain and poor quality of life. Furthermore, acute presentation of the phenomenon is commonly life-threatening with ventricular tachyarrhythmias, conduction abnormalities, or cardiogenic shock. Acute treatment of CSF includes, but is not restricted to, intracoronary infusion of dipyridamole, adenosine, or atropine. Chronic management of patients with CSF encompasses dipyridamole, diltiazem, nebivolol, telmisartan, and/or atorvastatin associated with amelioration of angina symptoms, improved quality of life, and good prognosis.
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Affiliation(s)
- George Chalikias
- Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Tziakas
- Cardiology Department, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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21
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Huang Q, Zhang F, Chen S, Dong Z, Liu W, Zhou X. Clinical characteristics in patients with coronary slow flow phenomenon: A retrospective study. Medicine (Baltimore) 2021; 100:e24643. [PMID: 33578588 PMCID: PMC10545414 DOI: 10.1097/md.0000000000024643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/23/2020] [Accepted: 01/15/2021] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Coronary slow flow phenomenon (CSFP) is a coronary artery disease in which coronary angiography shows no obvious stenosis, but there is a delay in blood flow perfusion. The etiopathogenic mechanisms of CSFP are still unclear. The aim of the present study was to investigate the role of clinical characteristics in patients with CSFP, and to provide a reference for exploring the potential mechanisms of CSFP. Patients with angiographically normal epicardial arteries were enrolled (145 patients with CSFP and 145 normal controls). Collected clinical information and laboratory indexes, which measured by peripheral venous blood samples before coronary angiography. Logistic regression analysis was performed for statistical analysis. The present study found 19 clinical and laboratory indexes with statistical differences between the two groups in univariate analysis. Multivariate analysis showed that monocyte count, haemoglobin, serum creatinine and globulin were independent predictors of CSFP. Moreover, the monocyte count, haemoglobin, creatinine and globulin levels were significantly higher in the CSFP patients than the controls, with positive associations between these parameters and the extent of CSFP. In addition, ROC analysis showed the diagnostic value of the above indexes for CSFP.
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Affiliation(s)
- Qiaojuan Huang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University
| | - Fan Zhang
- Department of Epidemiology, School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Siyu Chen
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University
| | - Zhaoying Dong
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University
| | - Weiwei Liu
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University
| | - Xiaoli Zhou
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University
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22
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Smith JF, Lemmey HA, Borysova L, Hiley CR, Dora KA, Garland CJ. Endothelial Nitric Oxide Suppresses Action-Potential-Like Transient Spikes and Vasospasm in Small Resistance Arteries. Hypertension 2020; 76:785-794. [PMID: 32713276 PMCID: PMC7418934 DOI: 10.1161/hypertensionaha.120.15491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/27/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022]
Abstract
Endothelial dysfunction in small arteries is a ubiquitous, early feature of cardiovascular disease, including hypertension. Dysfunction reflects reduced bioavailability of endothelium-derived nitric oxide (NO) and depressed endothelium-dependent hyperpolarization that enhances vasoreactivity. We measured smooth muscle membrane potential and tension, smooth muscle calcium, and used real-time quantitative polymerase chain reaction in small arteries and isolated tubes of endothelium to investigate how dysfunction enhances vasoreactivity. Rat nonmyogenic mesenteric resistance arteries developed vasomotion to micromolar phenylephrine (α1-adrenoceptor agonist); symmetrical vasoconstrictor oscillations mediated by L-type voltage-gated Ca2+ channels (VGCCs). Inhibiting NO synthesis abolished vasomotion so nanomolar phenylephrine now stimulated rapid, transient depolarizing spikes in the smooth muscle associated with chaotic vasomotion/vasospasm. Endothelium-dependent hyperpolarization block also enabled phenylephrine-vasospasm but without spikes or chaotic vasomotion. Depolarizing spikes were Ca2+-based and abolished by either T-type or L-type VGCCs blockers with depressed vasoconstriction. Removing NO also enabled transient spikes/vasoconstriction to Bay K-8644 (L-type VGCC activator). However, these were abolished by the L-type VGCC blocker nifedipine but not T-type VGCC block. Phenylephrine also initiated T-type VGCC-transient spikes and enhanced vasoconstriction after NO loss in nonmyogenic arteries from spontaneously hypertensive rats. In contrast to mesenteric arteries, myogenic coronary arteries displayed transient spikes and further vasoconstriction spontaneously on loss of NO. T-type VGCC block abolished these spikes and additional vasoconstriction but not myogenic tone. Therefore, in myogenic and nonmyogenic small arteries, reduced NO bioavailability engages T-type VGCCs, triggering transient depolarizing spikes in normally quiescent vascular smooth muscle to cause vasospasm. T-type block may offer a means to suppress vasospasm without inhibiting myogenic tone mediated by L-type VGCCs.
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Affiliation(s)
- Josh F. Smith
- Department of Pharmacology, Universityxs of Oxford (J.F.S., H.A.L.L., L.B, K.A.D., C.J.G.)
| | - Hamish A.L. Lemmey
- Department of Pharmacology, Universityxs of Oxford (J.F.S., H.A.L.L., L.B, K.A.D., C.J.G.)
| | - Lyudmyla Borysova
- Department of Pharmacology, Universityxs of Oxford (J.F.S., H.A.L.L., L.B, K.A.D., C.J.G.)
| | - C. Robin Hiley
- From the Deptartment of Pharmacology, University of Cambridge (C.R.H.)
| | - Kim A. Dora
- Department of Pharmacology, Universityxs of Oxford (J.F.S., H.A.L.L., L.B, K.A.D., C.J.G.)
| | - Christopher J. Garland
- Department of Pharmacology, Universityxs of Oxford (J.F.S., H.A.L.L., L.B, K.A.D., C.J.G.)
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Jovanovic I, Tesic M, Giga V, Dobric M, Boskovic N, Vratonjic J, Orlic D, Gudelj O, Tomasevic M, Dikic M, Nedeljkovic I, Trifunovic D, Nedeljkovic MA, Dedic S, Beleslin B, Djordjevic-Dikic A. Impairment of coronary flow velocity reserve and global longitudinal strain in women with cardiac syndrome X and slow coronary flow. J Cardiol 2020; 76:1-8. [PMID: 32387219 DOI: 10.1016/j.jjcc.2020.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/19/2020] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Microvascular dysfunction (MVD) is associated with adverse prognosis and may account for abnormal stress tests and angina symptoms in women with cardiac syndrome X (CSX). The aim of our study was to assess MVD by coronary flow velocity reserve (CFVR) and left ventricular (LV) contractile function by LV global longitudinal strain (LVGLS) in CSX patients with respect to presence of slow coronary flow (SCF). It was of additional importance to evaluate clinical status of CSX patients using Seattle Angina Questionnaire. METHODS AND RESULTS Study population included 70 women with CSX (mean age 61 ± 7 years) and 34 age-matched controls. CSX group was stratified into two subgroups depending on SCF presence: CSX-Thrombolysis In Myocardial Infarction (TIMI) 3- normal flow subgroup (n = 38) and CSX-TIMI 2- SCF subgroup (n = 32) as defined by coronary angiography. LVGLS measurements and CFVR of left anterior descending (LAD) and posterior descending (PD) artery were performed. CFVR-LAD and PD were markedly impaired in CSX group compared to controls (2.34 ± 0.25 vs 3.05 ± 0.21, p < 0.001; 2.32 ± 0.24 vs 3.01 ± 0.13, p < 0.001), and furthermore decreased in CSX-TIMI 2 patients. Resting, peak, and ΔLVGLS were all significantly impaired in CSX group compared to controls (for all p < 0.001), and furthermore reduced in CSX-TIMI 2 subgroup. Strongest correlation was found between peak LVGLS and CFVR LAD (r = -0.784, p < 0.001) and PD (r = -0.772, p < 0.001). CSX-TIMI 2 subgroup had more frequent angina symptoms and more impaired quality of life. CONCLUSIONS MVD in CSX patients is demonstrated by reduction in CFVR and LVGLS values. SCF implies more profound impairment of microvascular and LV systolic function along with worse clinical presentation.
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Affiliation(s)
- Ivana Jovanovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia.
| | - Milorad Tesic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Dobric
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Orlic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ognjen Gudelj
- Clinic for Cardiology, Military Medical Academy, Belgrade, Serbia
| | - Miloje Tomasevic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Miodrag Dikic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Trifunovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan A Nedeljkovic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Dedic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Belgrade, Serbia
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Seyyed-Mohammadzad MH, Rashtchizadeh S, Khademvatani K, Afsargharehbagh R, Nasiri A, Sepehrvand N. Ventricular Dysfunction in Patients with Coronary Slow-Flow Phenomenon: A Single-center Case-control Study. Heart Views 2020; 21:60-64. [PMID: 33014297 PMCID: PMC7507914 DOI: 10.4103/heartviews.heartviews_119_18] [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: 11/22/2018] [Accepted: 08/19/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Coronary slow-flow phenomenon (CSFP), characterized by delayed distal vessel opacification of contrast, in the absence of significant epicardial coronary stenosis, has effects on exercise capacity and clinical outcomes. The aim of this study was to explore the systolic and diastolic function of patients with CSFP and to compare it with a group of controls with normal coronary anatomy and flow. Materials and Methods: In this case–control study, 45 consecutive CSFP patients and 45 age-, body mass index-, and presentation season-matched controls with normal coronary arteries and normal coronary flows were enrolled from Seyyedoshohada Heart Center from March 2015 to March 2016. A transthoracic echocardiography was done by a blinded echocardiographer using both conventional and tissue Doppler imaging techniques. Results: Patients with CSFP were more likely to be male (P = 0.006) and smoker (P = 0.02) compared to controls. Other risk factors were not different between the two groups. There were no differences between groups in terms of the peak early (E) and late (A) diastolic velocities, deceleration time, early (E’) and late (A’) peak diastolic velocities at the mitral annulus, and the systolic mitral annular velocity (S’). Global longitudinal strain and peak systolic strain rates was lower in patients with CSFP compared to controls (−16.7% ±2.4% vs. −18.9% ±1.6%, P < 0.001 and 1.10 ± 0.1 vs. 1.24 ± 0.3, P = 0.008, respectively). Conclusion: Patients with CSFP showed signs of the left ventricular systolic dysfunction in tissue Doppler echocardiography, which underlines the importance of close follow-up in these patients. Patients with CSFP should be screened for ventricular function preferably by tissue Doppler echocardiography.
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Affiliation(s)
| | - Sanam Rashtchizadeh
- Department of Cardiology, Seyyedoshohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Kamal Khademvatani
- Department of Cardiology, Seyyedoshohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Roghaiyeh Afsargharehbagh
- Department of Cardiology, Seyyedoshohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Aliakbar Nasiri
- Department of Anesthesiology, Urmia University of Medical Sciences, Urmia, Iran
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Ong P, Safdar B, Seitz A, Hubert A, Beltrame JF, Prescott E. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116:841-855. [DOI: 10.1093/cvr/cvz339] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.
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Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - Astrid Hubert
- Department of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany
| | - John F Beltrame
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Adelaide, Australia
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Chen F, Zheng M, Li X, Peng Y, Chen M. ST-Segment Elevation Myocardial Infarction Related to Potential Spontaneous Coronary Thrombosis in Pheochromocytoma Crisis. Front Endocrinol (Lausanne) 2020; 11:140. [PMID: 32256452 PMCID: PMC7093383 DOI: 10.3389/fendo.2020.00140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/02/2020] [Indexed: 02/05/2023] Open
Abstract
Pheochromocytoma crisis is a rare and possibly fatal emergency. Hypersecreted catecholamines may result in myocardial injury via its direct toxic effect on cardiomyocytes or mediating vasoconstriction which will reduce coronary blood flow in this special setting. Interestingly, several case studies have reported the occurrence of ST-segment elevation myocardial infarction in patients with pheochromocytoma crisis. However, no one found the angiographic evidence of occlusive thrombus in the infarct-related coronary artery. Additionally, pheochromocytoma can induce hypercoagulability and promote thrombosis, but spontaneous coronary thrombosis has never been reported in this condition. Here, we report an unusual case of pheochromocytoma crisis presenting with STEMI due to spontaneous coronary thrombosis.
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Dorobantu M, Calmac L. Coronary Microcirculatory Dysfunction Evaluation in Chronic Angina. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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28
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Clinical Profile and Outcome in Patients with Coronary Slow Flow Phenomenon. Cardiol Res Pract 2019; 2019:9168153. [PMID: 31205785 PMCID: PMC6530115 DOI: 10.1155/2019/9168153] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/10/2019] [Accepted: 04/23/2019] [Indexed: 01/20/2023] Open
Abstract
The coronary slow flow phenomenon (CSFP) is a poorly recognized clinical entity characterized by delayed distal vessel opacification in the absence of epicardial coronary stenosis and presently lack of specific data on the clinical profile and outcome. We investigated a cohort of 429 patients who fulfilled the criteria for CSFP to explore the clinical feature, outcome, and risk factor of prognosis. Two teams (clinical center and core lab) were blind to patient data for the assessment of coronary angiograph using corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC). The study cohort consisted of 429 patients (294 men, 68.5%), aged from 30 to 78 years (mean, 54 years). Two hundred patients (46.6%) out of 429 patients had a history of hypertension, 72 (16.8%) had diabetes mellitus, and 222 (51.7%) had dyslipidemia. All the rates of agreement between two teams in evaluating whether normal flow (CTFC ≤ 27 frames) or slow flow (CTFC > 27 frames) were moderate (0.40 < κ < 0.75) for the three arteries. Follow-up (mean, 3.8 years) was done for 421 patients (98.1%). The major adverse cardiovascular events (MACE) occurred in 39 patients (9.3%) out of 421 patients. Multivariate analysis showed that the risk of MACE approximately doubles with age >50 years (hazard ratio (HR) = 2.2, 95% CI: 1.0 to 4.9, and P=0.042), hypertension (HR = 2.1, 95% CI: 1.1 to 4.2, and P=0.021), and dyslipidemia (HR = 2.0, 95% CI: 1.0 to 3.9, and P=0.042). CSFP affects predominantly patients at middle age and above but can occur in any age group; CSFP should be more concerned, particularly in patients >50 years old with hypertension and dyslipidemia.
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Sheikh AR, Zeitz CJ, Rajendran S, Di Fiore DP, Tavella R, Beltrame JF. Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease - A pilot study. Int J Cardiol 2019; 267:16-21. [PMID: 29957255 DOI: 10.1016/j.ijcard.2018.04.077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/15/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coronary haemodynamic testing frequently identifies abnormal pathophysiological parameters in patients with angina and non-obstructed coronaries on angiography (NoCAD) but the clinical utility of these measures has received limited attention. OBJECTIVE This study aims to identify the clinical and coronary haemodynamic determinants of recurrent chest pain at one month in patients with NoCAD. METHODS Patients with angina, NoCAD (<50% stenosis) and normal LV systolic function underwent invasive coronary haemodynamic testing involving: (1) angiographic TIMI frame and opacification rate, (2) microvascular functional measures including coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR), (3) coronary endothelial function assessment with low dose intracoronary acetylcholine (IC-ACh) infusions (0.18 μg/min & 1.8 μg/min over 2 min), and (4) Provocative spasm testing with high dose IC-ACh boluses (25, 50 and 100 μg). Clinical and health status were assessed at baseline and one month. RESULTS In the 49 NoCAD patients (78% female, mean age of 54 ± 11) undergoing comprehensive coronary haemodynamic testing, 33 (67%) continued to experience chest pain at one month. Determinants of recurrent chest pain on univariate analysis included baseline chest pain status or a HMR > 1.9. Multivariate logistic regression analysis identified frequent angina at baseline (OR: 68.9 [4.1, 1165.0], p = 0.003), previous unstable angina admission (OR: 43.9 [3.5, 547.9], p = 0.003) and a HMR > 1.9 (OR: 15.6 [2.1, 114.0], p = 0.007) as independent predictors of recurrent chest pain. CONCLUSION In this small pilot study, an abnormal HMR was the only coronary haemodynamic parameter that was a determinant of ongoing angina at short-term follow-up.
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Affiliation(s)
- Abdul R Sheikh
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - Christopher J Zeitz
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Cardiology Unit, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - Sharmalar Rajendran
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Cardiology Unit, Lyell McEwin Hospital, Northern Adelaide Local Health Network, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - David P Di Fiore
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - Rosanna Tavella
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia
| | - John F Beltrame
- Discipline of Medicine, University of Adelaide, Adelaide, South Australia 5005, Australia; Cardiology Department, The Queen Elizabeth & Royal Adelaide Hospitals, Central Adelaide Local Health Network, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, 37 Woodville Road, Woodville South, South Australia 5011, Australia.
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Sheng X, Ding S, Ge H, Sun Y, Kong L, He J, Pu J, He B. Intracoronary infusion of alprostadil and nitroglycerin with targeted perfusion microcatheter in STEMI patients with coronary slow flow phenomenon. Int J Cardiol 2018; 265:6-11. [DOI: 10.1016/j.ijcard.2018.04.119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/02/2018] [Accepted: 04/24/2018] [Indexed: 11/26/2022]
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Alvarez C, Siu H. Coronary Slow-Flow Phenomenon as an Underrecognized and Treatable Source of Chest Pain: Case Series and Literature Review. J Investig Med High Impact Case Rep 2018; 6:2324709618789194. [PMID: 30038914 PMCID: PMC6050810 DOI: 10.1177/2324709618789194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/10/2018] [Accepted: 06/23/2018] [Indexed: 01/08/2023] Open
Abstract
Background. Coronary slow-flow phenomenon (CSFP) is characterized by delayed distal vessel opacification of contrast, in the absence of significant epicardial coronary stenosis. CSFP has been reported as a cause of chest pain and abnormal noninvasive ischemic tests and is often underrecognized. Material and Methods. Charts and angiographic records from our institution were reviewed to identify 15 consecutive patients who were diagnosed with CSFP from January 2016 to January 2017. Results. Of the 15 patients (4 females and 11 males) studied, the mean age was 59.1 years (range = 45-86 years); all had left ventricular ejection fraction >45% and without significant valvular stenosis/regurgitation. The indication for coronary angiography for all 15 patients was chest pain with abnormal noninvasive tests. Of the 11 patients who underwent previous coronary angiograms, all revealed prior evidence of CSFP. None of these patients were on calcium channel blockers (CCBs) or long-acting nitroglycerin agents before angiography. Intracoronary CCBs were effectively utilized to alleviate the angiographic finding (improvement in Thrombolysis in Myocardial Infarction frame count) in all 15 patients. Oral CCBs were started with subsequent improvement in all 15 patients (mean follow-up time = 13.6 months). Conclusion. Coronary slow-flow should be a diagnostic consideration in patients presenting with chest pain and abnormal noninvasive ischemic testing with nonobstructive epicardial vessels. CSFP remains underrecognized, and the specific standard of care for treatment has not been established. In each of the 15 cases, intracoronary nifedipine resolved the angiographic manifestation of coronary slow-flow. Furthermore, in follow-up, all patients improved symptomatically from their chest pain after oral CCBs were initiated.
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Affiliation(s)
| | - Henry Siu
- St. Francis Medical Center, Trenton, NJ, USA.,Thomas Jefferson University, Philadelphia, PA, USA
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Sanghvi S, Mathur R, Baroopal A, Kumar A. Clinical, demographic, risk factor and angiographic profile of coronary slow flow phenomenon: A single centre experience. Indian Heart J 2018; 70 Suppl 3:S290-S294. [PMID: 30595277 PMCID: PMC6310702 DOI: 10.1016/j.ihj.2018.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/06/2018] [Accepted: 06/04/2018] [Indexed: 11/27/2022] Open
Abstract
Background The coronary slow flow phenomenon (CSFP) is an angiographic finding characterized by delayed distal vessel opacification in the absence of significant epicardial coronary stenosis. Although it is well-known to interventional cardiologists for approximately four decades, the etiopathogenesis still remains unclear. Aims and objectives In this study, we aimed to determine the clinical, demographic, risk factor and angiographic profile of patients with CSFP. Methods Clinical, demographic, risk factor and angiographic profile were recorded in all consecutive patients who had undergone coronary angiography between September 2016 and March 2017 and showed features of CSFP and a control group who showed normal coronary flow (NCF). The CSFP was diagnosed on the basis of the corrected thrombolysis in myocardial infarction frame count. Results CSFP was significantly more prevalent in male patients. Among the traditional risk factors, there was significantly more prevalence of hypertension (31.25% versus 6.67%, p < 0.001), dyslipidemia (40% versus 7.5%, p < 0.001) and history of tobacco use (47.5% versus 10.0%, p < 0.001) in CSFP patients as compared to NCF patients. On multivariable regression analysis hypertension, dyslipidemia, history of smoking and tobacco chewing were found to have independent association with CSFP. Acute coronary syndrome (ACS) was the most common mode of presentation in CSFP patients. Conclusion CSFP was relatively common among patients who presented with ACS. Hypertension, dyslipidemia, smoking and tobacco chewing can be considered independent risk factors for this phenomenon. Therefore, CSFP should be considered as a pathological entity and not an entirely benign condition.
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Affiliation(s)
- Sanjeev Sanghvi
- Department of Cardiology, DR. S.N. Medical College, Jodhpur, India
| | - Rohit Mathur
- Department of Cardiology, DR. S.N. Medical College, Jodhpur, India
| | - Anil Baroopal
- Department of Cardiology, DR. S.N. Medical College, Jodhpur, India.
| | - Aditya Kumar
- Department of Cardiology, DR. S.N. Medical College, Jodhpur, India
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Tamargo J, Ruilope LM. Investigational calcium channel blockers for the treatment of hypertension. Expert Opin Investig Drugs 2016; 25:1295-1309. [DOI: 10.1080/13543784.2016.1241764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J Tamargo
- Department of Pharmacology, School of Medicine, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain. CIBER of Cardiovascular Diseases
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Abstract
INTRODUCTION Angina pectoris, or symptomatic myocardial ischaemia, reflects an impairment of coronary blood flow, and usually a deficiency of available myocardial energetics. Treatment options vary with the precise cause, which may vary with regards to the roles of increased myocardial oxygen demand versus reduced supply. Traditionally, organic nitrates, β-adrenoceptor antagonists, and non-dihydropyridine calcium antagonists were the only commonly used prophylactic anti-anginal agents. However, many patients failed to respond adequately to such therapy, and/or were unsuitable for their use. Areas covered: A number of 'new' agents have been shown to represent ancillary forms of prophylactic anti-anginal therapy and are particularly useful in patients who are relatively unsuitable for either percutaneous or surgical revascularisation. These include modulators of myocardial metabolic efficiency, such as perhexiline, trimetazidine and ranolazine, as well as high dose allopurinol, nicorandil and ivabradine. The advantages and disadvantages of these various agents are summarized. Expert opinion: 'Optimal' medical treatment of angina pectoris now includes use of agents primarily intended to reduce risk of infarction (e.g. statins, aspirin, ACE inhibitors). In patients whose angina persists despite the use of 'standard' anti-anginal therapy, and who are not ideal for invasive revascularization options, a number of emerging drugs offer prospects of symptomatic relief.
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Affiliation(s)
- Cher-Rin Chong
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia.,b Pharmacy Department , Queen Elizabeth Hospital , Woodville South , SA , Australia
| | - Gao J Ong
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia
| | - John D Horowitz
- a Cardiology and Clinical Pharmacology Departments, Basil Hetzel Institute , Queen Elizabeth Hospital, University of Adelaide , Adelaide , SA , Australia
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Dogan A, Oylumlu M, Kilit C, Özgeyik M. ST elevation myocardial infarction caused by coronary slow flow: Case report and brief review of the literature. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2016. [DOI: 10.1016/j.ijcac.2015.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Harraz OF, Visser F, Brett SE, Goldman D, Zechariah A, Hashad AM, Menon BK, Watson T, Starreveld Y, Welsh DG. CaV1.2/CaV3.x channels mediate divergent vasomotor responses in human cerebral arteries. ACTA ACUST UNITED AC 2016; 145:405-18. [PMID: 25918359 PMCID: PMC4411256 DOI: 10.1085/jgp.201511361] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The regulation of arterial tone is critical in the spatial and temporal control of cerebral blood flow. Voltage-gated Ca(2+) (CaV) channels are key regulators of excitation-contraction coupling in arterial smooth muscle, and thereby of arterial tone. Although L- and T-type CaV channels have been identified in rodent smooth muscle, little is known about the expression and function of specific CaV subtypes in human arteries. Here, we determined which CaV subtypes are present in human cerebral arteries and defined their roles in determining arterial tone. Quantitative polymerase chain reaction and Western blot analysis, respectively, identified mRNA and protein for L- and T-type channels in smooth muscle of cerebral arteries harvested from patients undergoing resection surgery. Analogous to rodents, CaV1.2 (L-type) and CaV3.2 (T-type) α1 subunits were expressed in human cerebral arterial smooth muscle; intriguingly, the CaV3.1 (T-type) subtype present in rodents was replaced with a different T-type isoform, CaV3.3, in humans. Using established pharmacological and electrophysiological tools, we separated and characterized the unique profiles of Ca(2+) channel subtypes. Pressurized vessel myography identified a key role for CaV1.2 and CaV3.3 channels in mediating cerebral arterial constriction, with the former and latter predominating at higher and lower intraluminal pressures, respectively. In contrast, CaV3.2 antagonized arterial tone through downstream regulation of the large-conductance Ca(2+)-activated K(+) channel. Computational analysis indicated that each Ca(2+) channel subtype will uniquely contribute to the dynamic regulation of cerebral blood flow. In conclusion, this study documents the expression of three distinct Ca(2+) channel subtypes in human cerebral arteries and further shows how they act together to orchestrate arterial tone.
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Affiliation(s)
- Osama F Harraz
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada Department of Pharmacology and Toxicology, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
| | - Frank Visser
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Suzanne E Brett
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Daniel Goldman
- Department of Medical Biophysics, University of Western Ontario, London, Ontario N6A 5C1, Canada
| | - Anil Zechariah
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Ahmed M Hashad
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Bijoy K Menon
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Tim Watson
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Yves Starreveld
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Donald G Welsh
- Department of Physiology and Pharmacology, Hotchkiss Brain and Libin Cardiovascular Institutes, and Molecular Core Facility, Hotchkiss Brain Institute, and Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada
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Lanza GA. Angina Pectoris and Myocardial Ischemia in the Absence of Obstructive Coronary Artery Disease: Role of Diagnostic Tests. Curr Cardiol Rep 2016; 18:15. [DOI: 10.1007/s11886-015-0688-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tavella R, Cutri N, Tucker G, Adams R, Spertus J, Beltrame JF. Natural history of patients with insignificant coronary artery disease. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:117-124. [DOI: 10.1093/ehjqcco/qcv034] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Indexed: 02/02/2023]
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Lanza GA, Careri G, Stazi A, Villano A, De Vita A, Aurigemma C, Crea F. Clinical Spectrum and Outcome of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome and No Obstructive Coronary Atherosclerosis. Circ J 2016; 80:1600-6. [DOI: 10.1253/circj.cj-16-0145] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Giulia Careri
- Institute of Cardiology, Università Cattolica del Sacro Cuore
| | | | - Angelo Villano
- Institute of Cardiology, Università Cattolica del Sacro Cuore
| | - Antonio De Vita
- Institute of Cardiology, Università Cattolica del Sacro Cuore
| | | | - Filippo Crea
- Institute of Cardiology, Università Cattolica del Sacro Cuore
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Dahhan A. Coronary artery ectasia in atherosclerotic coronary artery disease, inflammatory disorders, and sickle cell disease. Cardiovasc Ther 2015; 33:79-88. [PMID: 25677643 DOI: 10.1111/1755-5922.12106] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Coronary artery ectasia (CAE) or aneurysm is usually defined as dilation ≥1.5-fold the normal vessel diameter. It has an incidence of 1.4-5.3% and is associated with a wide variety of etiologies-mainly congenital, atherosclerotic, and inflammatory ones. CAE is very common in sickle cell disease, and possibly sickle cell trait, with an incidence of 17.7%. It is likely related to the inflammatory process associated with hemoglobin S. Prognosis depends mainly on the underlying etiology. Atherosclerotic CAE does not carry additional risks compared to atherosclerotic coronary artery disease (ACAD) without ectasia. However, isolated CAE in the absence of ACAD carries an increased risk of myocardial infarction (MI) due to vasospasm, slower coronary blood flow, and thrombosis, typically within the dilated segments. Due to lack of studies and guidelines, management recommendations are based on personal experiences. Therapy should be tailored to each individual case after assessment of severity, history of complications, underlying etiology, and comorbidities. Treatment of underlying condition and avoidance of exacerbating factors are essential. Medical therapy in general may include antiplatelets, β-blockers, angiotensin-converting enzyme inhibitors statins, and dihydropyridine calcium channel blockers. In severe CAE or history of MI, the addition of anticoagulation therapy after assessing bleeding risk may be warranted. In acute MI, the large thrombus burden in the dilated segment makes the percutaneous approach very challenging. Aspiration attempts can result in distal thromboembolization. Survival is better in bypass grafting than with medical therapy. Nonetheless, bypass grafting does not improve survival in atherosclerotic CAE. Depending on the physical characteristics of aneurysm, different surgical approaches can be sought; however, the ideal one is unclear.
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Affiliation(s)
- Ali Dahhan
- Department of Internal Medicine, University of Iowa, Carver College of Medicine, Iowa City, IA, USA
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Cetin MS, Ozcan Cetin EH, Canpolat U, Aydın S, Temizhan A, Topaloglu S, Aras D, Aydogdu S. An overlooked parameter in coronary slow flow phenomenon: whole blood viscosity. Biomark Med 2015; 9:1311-21. [PMID: 26612589 DOI: 10.2217/bmm.15.92] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: We aimed to assess the relationship between coronary slow flow phenomenon (CSFP) and whole blood viscosity (WBV). Materials & methods: Two hundred patients with CSFP and 200 subjects with normal coronary arteries as control group were enrolled. WBV was calculated from hematocrit and plasma protein concentration at low shear rate (LSR) (0.5 s-1) and high shear rate (HSR) (208 s-1) by a validated equation. Results: CSFP patients had significantly higher WBV for LSR and HSR. The mean corrected TIMI frame count was highest in the highest tertile group for both shear rates. Corrected TIMI frame count revealed a significant relationship with WBV for LSR (r = 0.562) and HSR (r = 0.611). At multivariate analysis, WBV at LSR and HSR were independent predictors of CSFP. Conclusion: WBV seemed to have a significant and an independent predictor of CSFP.
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Affiliation(s)
- Mehmet Serkan Cetin
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | | | - Ugur Canpolat
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Selahattin Aydın
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Ahmet Temizhan
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Serkan Topaloglu
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Dursun Aras
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Sinan Aydogdu
- Turkey Yuksek Ihtisas Education & Research Hospital, Cardiology Clinic, Ankara, Turkey
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Chen Z, Chen X, Li S, Huo X, Fu X, Dong X. Nicorandil improves myocardial function by regulating plasma nitric oxide and endothelin-1 in coronary slow flow. Coron Artery Dis 2015; 26:114-20. [PMID: 25325437 PMCID: PMC4323571 DOI: 10.1097/mca.0000000000000179] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary slow flow (CSF) is a special coronary microvascular disorder. The pathogenesis and effective therapeutics of CSF remain unclear. This study aimed to evaluate the global and regional functions of the left ventricle (LV) and investigate the efficacy of nicorandil in patients with CSF. PATIENTS AND METHODS Thirty-six patients with CSF in the left anterior descending (LAD) branch and 20 patients with normal coronary arteries were included. Global and regional functions of the LV supplied by LAD were measured using conventional Doppler echocardiography and two-dimensional speckle tracking echocardiography, respectively, within 24 h after coronary angiography. Concentrations of plasma nitric oxide (NO) and endothelin-1 (ET-1) were detected using colorimetry and radioimmunoassay, respectively. The function of the LV and the levels of NO and ET-1 were also investigated before and 90 days after treatment with 15 mg/day of nicorandil. RESULTS Compared with the control group, the early diastolic peak velocity (E), E/A ratio, and plasma NO levels were lower, whereas the late diastolic peak flow velocity (A) and plasma ET-1 levels were significantly higher in the CSF group (P<0.05). The longitudinal strain rate peak of the LV was reduced significantly in CSF patients (P<0.001). After treatment, 75% (27/36) of CSF patients were free of chest pain. The values of E peak, E/A ratio, longitudinal strain rate peak, and plasma NO level were increased (P<0.001), whereas the ET-1 level was decreased in CSF patients (P<0.001). CONCLUSION Nicorandil may improve chest pain symptoms and the impaired function of the LV, possibly by increasing plasma NO and reducing ET-1 in CSF.
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Affiliation(s)
- Zuoyuan Chen
- Departments of aCardiology bCardiac Ultrasound, The Affiliated Hospital of Qingdao University cDepartment of Internal Medicine, Qingdao Commercial Hospital dDepartment of Cardiology, Qingdao Fifth People's Hospital, Qingdao eDepartment of Cardiology, Dezhou People's Hospital, Dezhou, Shandong, China
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Wang Y, Ma C, Zhang Y, Guan Z, Liu S, Li Y, Yang J. Assessment of left and right ventricular diastolic and systolic functions using two-dimensional speckle-tracking echocardiography in patients with coronary slow-flow phenomenon. PLoS One 2015; 10:e0117979. [PMID: 25706989 PMCID: PMC4338029 DOI: 10.1371/journal.pone.0117979] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 01/03/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Coronary slow-flow phenomenon (CSFP) is an angiographic diagnosis characterised by a low rate of flow of contrast agent in the normal or near-normal epicardial coronary arteries. Many of the patients with CSFP may experience recurrent acute coronary syndromes. However, current clinical practice tends to underestimate the impact of CSFP due to the yet unknown effect on the cardiac function. This study was performed to evaluate left ventricular (LV) and right ventricular (RV) diastolic and systolic functions, using two-dimensional (2D) longitudinal strain and strain rate, in patients with CSFP, and to determine the relationships between the thrombolysis in myocardial infarction (TIMI) frame count (TFC) and LV and RV diastolic and systolic functions. METHODS Sixty-three patients with CSFP and 45 age- and sex-matched controls without CSFP were enrolled in the study. Diagnosis of CSFP was made by TFC. LV and RV diastolic and systolic functions were assessed by 2D speckle-tracking echocardiography. RESULTS LV peak early diastolic longitudinal strain rate (LSRe) was lower in patients with CSFP than in controls (P = 0.01). LV peak systolic longitudinal strain (LS) and LV peak systolic longitudinal strain rate (LSRs) were lower in patients with CSFP than in controls (P = 0.004 and P = 0.03, respectively). There was no difference in LV ejection fraction. RV peak early diastolic longitudinal strain rate (RSRe) was lower in patients with CSFP than in controls (P = 0.03). There were no differences in RV peak systolic longitudinal strain (RS), RV peak systolic longitudinal strain rate (RSRs), or RV fractional area change among the groups. The mean TFC correlated negatively with LSRe and RSRe in patients with CSFP (r = -0.26, P = 0.04 and r = -0.32, P = 0.01, respectively). CONCLUSIONS LV diastolic and systolic functions were impaired in patients with CSFP. CSFP also affected RV diastolic function, but not RV systolic function.
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Affiliation(s)
- Yonghuai Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
- * E-mail:
| | - Yan Zhang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Zhengyu Guan
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Shuang Liu
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Yuling Li
- Department of Cardiology, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Jun Yang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
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Sani HD, Eshraghi A, Nezafati MH, Vojdanparast M, Shahri B, Nezafati P. Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients With Slow Coronary Flow Phenomenon: A Randomized Clinical Trial. J Cardiovasc Pharmacol Ther 2015; 20:401-6. [PMID: 25701829 DOI: 10.1177/1074248415571457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/22/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with the coronary slow flow phenomenon frequently experience angina episodes. The present study aimed to compare the efficacy of nicorandil versus nitroglycerin for alleviation of angina symptoms in slow flow patients. METHODS In a single-center, single-blind, parallel-design, comparator-controlled, randomized clinical trial (NCT02254252), 54 patients with slow flow and normal or near-normal coronary angiography who presented with frequent angina episodes were randomly assigned to 1-month treatment with nicorandil 10 mg, 2 times a day (n = 27) or sustained-release glyceryltrinitrate 6.4 mg 2 times a day (n =27). Frequency of angina episodes, pain intensity, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were assessed at baseline and after 1 month of treatment. RESULTS In all, 25 patients in the nicorandil arm and 24 patients in the nitroglycerin arm were analyzed. After 1 month, patients treated with nicorandil had fewer angina episodes (adjusted mean number of episodes per week, nicorandil versus nitroglycerin; 1.68 ± 0.15 vs 2.29 ± 0.15, P = .007, effect size = 14.6%). Patients also reported greater reductions in pain intensity with nicorandil versus nitroglycerin (adjusted mean of self-reported pain score; 3.03 ± 0.29 vs 3.89 ± 0.30, P = .046, effect size = 8.4%). A significantly higher proportion of patients in the nicorandil arm were categorized in CCS class I (76% vs 33.3%, P = .004) or class II (16.0% vs 45.8%, P = .032). CONCLUSION In slow flow patients, nicorandil provides better symptomatic relief of angina than nitroglycerin.
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Affiliation(s)
- Hashem Danesh Sani
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Hassan Nezafati
- Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Vojdanparast
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bahram Shahri
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pouya Nezafati
- Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
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Taşolar H, Eyyüpkoca F, Aktürk E, Karakuş Y, Cansel M, Yağmur J, Ozyalin F, Altun B, Pekdemir H. Endothelial nitric oxide synthase levels and their response to exercise in patients with slow coronary flow. Cardiovasc J Afr 2014; 24:355-9. [PMID: 24337211 PMCID: PMC3896107 DOI: 10.5830/cvja-2013-072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/18/2013] [Indexed: 11/06/2022] Open
Abstract
Background Endothelial dysfunction plays a key role in the aetiopathogenesis of slow coronary flow (SCF) even if there is no obstructive epicardial lesion. Reduced plasma levels of endothelial nitric oxide synthase (eNOS) are an important indicator of endothelial dysfunction. We aimed to determine plasma levels of eNOS and their relationship with exercise in patients with SCF. Methods Twenty-two patients with SCF in at least one coronary artery and 17 healthy individuals were included in this study. The TIMI frame count method was used to determine SCF. Plasma levels of eNOS before and after effort were determined in the patient and control groups. Results Basal eNOS levels in the patient group were lower than in the control group (p = 0.040), and plasma eNOS levels after exercise decreased more significantly in the patient group compared to the control group (p = 0.002). Median decreases of eNOS in response to exercise were higher in the SCF group than in the control group (p < 0.001), and the decrease observed in the control group was not statistically significant (p = 0.35). There were significantly negative correlations between TIMI frame count and plasma levels of eNOS at baseline and after exercise (r = –0.51, p = 0.015, r = –0.58, p = 0.005, respectively). Moreover, there was also a positive correlation between the rate–pressure product and plasma levels of eNOS after exercise in patients with SCF (r = 0.494, p = 0.019). Conclusion Our findings indicate an important pathophysiological relationship between the severity of SCF in which endothelial dysfunction plays a role in its pathogenesis and the level of circulating plasma levels of eNOS.
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Affiliation(s)
- Hakan Taşolar
- Department of Cardiology, Adiyaman University, Training and Research Hospital, Adiyaman, Turkey
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Coca A, Mazón P, Aranda P, Redón J, Divisón JA, Martínez J, Calvo C, Galcerán JM, Barrios V, Coll ARCI. Role of dihydropyridinic calcium channel blockers in the management of hypertension. Expert Rev Cardiovasc Ther 2014; 11:91-105. [DOI: 10.1586/erc.12.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Wang X, Nie SP. The coronary slow flow phenomenon: characteristics, mechanisms and implications. Cardiovasc Diagn Ther 2013; 1:37-43. [PMID: 24282683 DOI: 10.3978/j.issn.2223-3652.2011.10.01] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 10/10/2011] [Indexed: 11/14/2022]
Abstract
The coronary slow flow phenomenon (CSFP) is an important, angiographic entity characterized by delayed progression of the injected contrast medium through the coronary tree. It is a frequent finding, typically observed in patients presenting with acute coronary syndromes. Although it is well known to interventional cardiologists for approximately four decades, the pathogenic mechanisms remain unclear. The clinical implications are significant, with over 80% of patients experiencing recurrent chest pain, resulting in considerable impairment in quality of life. This article will address in detail the characteristics, possible mechanisms, and clinical implications of this entity to provide further insight into its clinical significance and management strategies.
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Affiliation(s)
- Xiao Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Khouzam RN, Kabra R, Soufi MK. Marijuana, bigeminal premature ventricular contractions and sluggish coronary flow: Are they related? J Cardiol Cases 2013; 8:121-124. [PMID: 30546761 PMCID: PMC6281510 DOI: 10.1016/j.jccase.2013.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/19/2013] [Accepted: 06/28/2013] [Indexed: 10/26/2022] Open
Abstract
Premature ventricular contractions (PVCs) and slow coronary flow phenomenon (SCFP) are primarily separate entities. Each one of them has different characteristics and a diverse spectrum of presentation. However, and despite many suggested theories, a comprehensive understanding of the etiology of both of them is still a matter of debate. PVCs, which can be triggered by consuming cannabis (marijuana), and through decreasing the diastolic time (DT), can affect the slow blood flow found in SCFP even more and worsen the clinical picture in patients who have PVCs and SCFP. In this paper, we present a patient who uses marijuana and has PVCs and SCFP, try to address different aspects of PVCs and SCFP, pinpoint any suspected interaction between both of them and the role of marijuana in this context. .
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Affiliation(s)
- Rami N. Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, 6283 Common Oaks Crt # 106, Memphis, TN 38120, USA
| | - Rajesh Kabra
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, 6283 Common Oaks Crt # 106, Memphis, TN 38120, USA
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Di Fiore DP, Beltrame JF. Chest pain in patients with 'normal angiography': could it be cardiac? INT J EVID-BASED HEA 2013; 11:56-68. [PMID: 23448331 DOI: 10.1111/1744-1609.12002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Approximately 20% of patients undergoing diagnostic angiography for the evaluation of chest pain are found to have a normal coronary angiogram. Although this finding is generally associated with a low risk of cardiac events, approximately half will continue to experience chest pain over the next 12 months. Therefore, the finding of normal angiography warrants further evaluation of the potential causes for the presenting chest pain if we are to improve the disability suffered by these patients. In this review, the potential non-cardiac and cardiac causes for the chest pain in patients with normal angiography are briefly discussed with an in-depth focus on coronary vasomotor disorders including coronary artery spasm (variant angina) and microvascular disorders such as syndrome X, microvascular angina, the coronary slow flow phenomenon and microvascular spasm.
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Affiliation(s)
- David P Di Fiore
- The Queen Elizabeth Hospital, Discipline of Medicine, The University of Adelaide, Woodville South, South Australia, Australia
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