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Munneke AG, Lumens J, Arts T, Prinzen FW, Delhaas T. Myocardial perfusion and flow reserve in the asynchronous heart: mechanistic insight from a computational model. J Appl Physiol (1985) 2023; 135:489-499. [PMID: 37439238 PMCID: PMC10538979 DOI: 10.1152/japplphysiol.00181.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/08/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
The tight coupling between myocardial oxygen demand and supply has been recognized for decades, but it remains controversial whether this coupling persists under asynchronous activation, such as during left bundle branch block (LBBB). Furthermore, it is unclear whether the amount of local cardiac wall growth, following longer-lasting asynchronous activation, can explain differences in myocardial perfusion distribution between subjects. For a better understanding of these matters, we built upon our existing modeling framework for cardiac mechanics-to-perfusion coupling by incorporating coronary autoregulation. Regional coronary flow was regulated with a vasodilator signal based on regional demand, as estimated from regional fiber stress-strain area. Volume of left ventricular wall segments was adapted with chronic asynchronous activation toward a homogeneous distribution of myocardial oxygen demand per tissue weight. Modeling results show that 1) both myocardial oxygen demand and supply are decreased in early activated regions and increased in late-activated regions; 2) but that regional hyperemic flow remains unaffected; while 3) regional myocardial flow reserve (the ratio of hyperemic to resting myocardial flow) decreases with increases in absolute regional myocardial oxygen demand as well as with decreases in wall thickness. These findings suggest that septal hypoperfusion in LBBB represents an autoregulatory response to reduced myocardial oxygen demand. Furthermore, oxygen demand-driven remodeling of wall mass can explain asymmetric hypertrophy and the related homogenization of myocardial perfusion and flow reserve. Finally, the inconsistent observations of myocardial perfusion distribution can primarily be explained by the degree of dyssynchrony, the degree of asymmetric hypertrophy, and the imaging modality used.NEW & NOTEWORTHY This versatile modeling framework couples myocardial oxygen demand to oxygen supply and myocardial growth, enabling simulation of resting and hyperemic myocardial flow during acute and chronic asynchronous ventricular activation. Model-based findings suggest that reported inconsistencies in myocardial perfusion and flow reserve responses with asynchronous ventricular activation between patients can primarily be explained by the degree of dyssynchrony and wall mass remodeling, which together determine the heterogeneity in regional oxygen demand and, hence, supply with autoregulation.
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Affiliation(s)
- Anneloes G Munneke
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Theo Arts
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Carbone A, D'Andrea A, Sperlongano S, Tagliamonte E, Mandoli GE, Santoro C, Evola V, Bandera F, Morrone D, Malagoli A, D'Ascenzi F, Bossone E, Cameli M. Echocardiographic assessment of coronary microvascular dysfunction: Basic concepts, technical aspects, and clinical settings. Echocardiography 2021; 38:993-1001. [PMID: 33948990 PMCID: PMC8252466 DOI: 10.1111/echo.15059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023] Open
Abstract
Coronary flow reserve is the capacity of the coronary circulation to augment the blood flow in response an increase in myocardial metabolic demands and has a powerful prognostic significance in different clinical situations. It might assess with invasive and noninvasive technique. Transthoracic echocardiography Doppler is an emerging diagnostic technique, noninvasive, highly feasible, safe for patient and physician, without radiation, and able to detect macrovascular and microvascular anomalies in the coronary circulation. This review aims to describe the benefit and limits of echocardiographic assessment of coronary flow reserve.
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Affiliation(s)
- Andreina Carbone
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Simona Sperlongano
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Ercole Tagliamonte
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Evola
- Department of Clinical and Experimental Medicine, University of Palermo, Palermo, Italy
| | - Francesco Bandera
- Heart Failure Unit, Chair of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Health Science, University of Milan, Milan, Italy
| | - Doralisa Morrone
- Cardiothoracic Department, Cisanello Hospital, University of Pisa, Pisa, Italy
| | | | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Sbrana F, Pasanisi EM, Dal Pino B, Bigazzi F, Ripoli A, Sampietro T. Acute effect of lipoprotein apheresis on coronary flow velocity reserve evaluated by the cold pressure test. Eur J Prev Cardiol 2020; 28:e4-e6. [PMID: 34298553 DOI: 10.1177/2047487320931622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Francesco Sbrana
- Lipoapheresis Unit, Fondazione Toscana "Gabriele Monasterio", Italy
| | - Emilio M Pasanisi
- U.O. Cardiologia e Medicina Cardiovascolare, Fondazione Toscana "Gabriele Monasterio", Italy
| | | | - Federico Bigazzi
- Lipoapheresis Unit, Fondazione Toscana "Gabriele Monasterio", Italy
| | - Andrea Ripoli
- Deep Health Unit, Fondazione Toscana "Gabriele Monasterio", Italy
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Maman SR, Vargas AF, Ahmad TA, Miller AJ, Gao Z, Leuenberger UA, Proctor DN, Muller MD. Beta-1 vs. beta-2 adrenergic control of coronary blood flow during isometric handgrip exercise in humans. J Appl Physiol (1985) 2017; 123:337-343. [PMID: 28572492 DOI: 10.1152/japplphysiol.00106.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/23/2017] [Accepted: 05/31/2017] [Indexed: 12/26/2022] Open
Abstract
During exercise, β-adrenergic receptors are activated throughout the body. In healthy humans, the net effect of β-adrenergic stimulation is an increase in coronary blood flow. However, the role of vascular β1 vs. β2 receptors in coronary exercise hyperemia is not clear. In this study, we simultaneously measured noninvasive indexes of myocardial oxygen supply (i.e., blood velocity in the left anterior descending coronary artery; Doppler echocardiography) and demand [i.e., rate pressure product (RPP) = heart rate × systolic blood pressure) and tested the hypothesis that β1 blockade with esmolol improves coronary exercise hyperemia compared with nonselective β-blockade with propranolol. Eight healthy young men received intravenous infusions of esmolol, propranolol, and saline on three separate days in a single-blind, randomized, crossover design. During each infusion, subjects performed isometric handgrip exercise until fatigue. Blood pressure, heart rate, and coronary blood velocity (CBV) were measured continuously, and RPP was calculated. Changes in parameters from baseline were compared with paired t-tests. Esmolol (Δ = 3296 ± 1204) and propranolol (Δ = 2997 ± 699) caused similar reductions in peak RPP compared with saline (Δ = 5384 ± 1865). In support of our hypothesis, ΔCBV with esmolol was significantly greater than with propranolol (7.3 ± 2.4 vs. 4.5 ± 1.6 cm/s; P = 0.002). This effect was also evident when normalizing ΔCBV to ΔRPP. In summary, not only does selective β1 blockade reduce myocardial oxygen demand during exercise, but it also unveils β2-receptor-mediated coronary exercise hyperemia.NEW & NOTEWORTHY In this study, we evaluated the role of vascular β1 vs. β2 receptors in coronary exercise hyperemia in a single-blind, randomized, crossover study in healthy men. In response to isometric handgrip exercise, blood flow velocity in the left anterior descending coronary artery was significantly greater with esmolol compared with propranolol. These findings increase our understanding of the individual and combined roles of coronary β1 and β2 adrenergic receptors in humans.
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Affiliation(s)
- Stephan R Maman
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Alvaro F Vargas
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Tariq Ali Ahmad
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Amanda J Miller
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Zhaohui Gao
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Urs A Leuenberger
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - David N Proctor
- Department of Kinesiology, Noll Laboratory, The Pennsylvania State University, University Park, Pennsylvania; and
| | - Matthew D Muller
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania; .,Master of Science in Anesthesia Program, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Wittfeldt A, Jeppsson A, Gan LM. Effects of nitroglycerine on coronary flow velocity before and during adenosine provocation. Cardiovasc Ultrasound 2016; 14:48. [PMID: 27919286 PMCID: PMC5139021 DOI: 10.1186/s12947-016-0091-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography-assessed coronary flow velocity reserve (CFVR) evaluates coronary microvascular arterial function. Coronary flow velocity measurements at baseline and during hyperemia are used to calculate CFVR. Adenosine infusion induces hyperemia but it is not known if it causes a maximal response. We hypothesized that pre-treatment with nitroglycerine before adenosine provocation enhances hyperemia. METHODS Twenty-three healthy study subjects (mean age 27.5 ± 5.5, 35% women) underwent CFVR measurements before and after pretreatment with sublingual nitroglycerine (0.5 mg). Hyperemia was induced by adenosine infusion (140 μg/kg/min). In addition, the effect of nitroglycerin on left main coronary artery diameter was assessed. RESULTS Pretreatment with nitroglycerine increased median CFVR from 3.6 (range 2.8-4.3) to 5.0 (4.1-6.0), p = 0.002. The increase was caused by a marked reduction in baseline coronary flow velocity 17 (15-24) vs 27 (19-31) cm/s, p < 0.0001) while hyperemic velocity remained unchanged (90 (68-116) vs 93 (75-105) cm/s, p = 0.48). Nitroglycerin significantly dilated the left main coronary artery (from median 3.1 (2.7-3.6) mm to 3.8 (3.1-4.3) mm, p = 0.018). CONCLUSION Pretreatment with nitroglycerine dilates coronary arteries and increases coronary flow velocity reserve indicating that adenosine alone causes a submaximal hyperemia.
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Affiliation(s)
- Ann Wittfeldt
- Dept of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 41345, Gothenburg, Sweden. .,Department of Cardiology, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Anders Jeppsson
- Dept of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 41345, Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Li-Ming Gan
- Dept of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 41345, Gothenburg, Sweden.,AstraZeneca R & D, 43150, Molndal, Sweden
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Vargas Pelaez AF, Gao Z, Ahmad TA, Leuenberger UA, Proctor DN, Maman SR, Muller MD. Effect of adrenergic agonists on coronary blood flow: a laboratory study in healthy volunteers. Physiol Rep 2016; 4:4/10/e12806. [PMID: 27225628 PMCID: PMC4886172 DOI: 10.14814/phy2.12806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/30/2016] [Indexed: 12/20/2022] Open
Abstract
Myocardial oxygen supply and demand mismatch is fundamental to the pathophysiology of ischemia and infarction. The sympathetic nervous system, through α‐adrenergic receptors and β‐adrenergic receptors, influences both myocardial oxygen supply and demand. In animal models, mechanistic studies have established that adrenergic receptors contribute to coronary vascular tone. The purpose of this laboratory study was to noninvasively quantify coronary responses to adrenergic receptor stimulation in humans. Fourteen healthy volunteers (11 men and 3 women) performed isometric handgrip exercise to fatigue followed by intravenous infusion of isoproterenol. A subset of individuals also received infusions of phenylephrine (n = 6), terbutaline (n = 10), and epinephrine (n = 4); all dosages were based on fat‐free mass and were infused slowly to achieve steady‐state. The left anterior descending coronary artery was visualized using Doppler echocardiography. Beat‐by‐beat heart rate (HR), blood pressure (BP), peak diastolic coronary velocity (CBVpeak), and coronary velocity time integral were calculated. Data are presented as M ± SD. Isometric handgrip elicited significant increases in BP, HR, and CBVpeak (from 23.3 ± 5.3 to 34.5 ± 9.9 cm/sec). Isoproterenol raised HR and CBVpeak (from 22.6 ± 4.8 to 43.9 ± 12.4 cm/sec). Terbutaline and epinephrine evoked coronary hyperemia whereas phenylephrine did not significantly alter CBVpeak. Different indices of coronary hyperemia (changes in CBVpeak and velocity time integral) were significantly correlated (R = 0.803). The current data indicate that coronary hyperemia occurs in healthy humans in response to isometric handgrip exercise and low‐dose, steady‐state infusions of isoproterenol, terbutaline, and epinephrine. The contribution of β1 versus β2 receptors to coronary hyperemia remains to be determined. In this echocardiographic study, we demonstrate that coronary blood flow increases when β‐adrenergic receptors are stimulated (i.e., during exercise and different intravenous infusions). Our infusion paradigms and beat‐by‐beat imaging methodologies can be used in future studies to evaluate age‐, sex‐, and disease‐ differences in adrenergic control of coronary blood flow.
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Affiliation(s)
- Alvaro F Vargas Pelaez
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Zhaohui Gao
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Tariq A Ahmad
- Division of General Internal Medicine, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Urs A Leuenberger
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - David N Proctor
- Department of Kinesiology, Noll Laboratory, The Pennsylvania State University, University Park, Pennsylvania
| | - Stephan R Maman
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Matthew D Muller
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, Pennsylvania
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7
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Ross AJ, Gao Z, Luck JC, Blaha CA, Cauffman AE, Aziz F, Radtka JF, Proctor DN, Leuenberger UA, Sinoway LI, Muller MD. Coronary Exercise Hyperemia Is Impaired in Patients with Peripheral Arterial Disease. Ann Vasc Surg 2016; 38:260-267. [PMID: 27575303 DOI: 10.1016/j.avsg.2016.05.135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/23/2016] [Accepted: 05/27/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is an atherosclerotic vascular disease that affects over 200 million people worldwide. The hallmark of PAD is ischemic leg pain and this condition is also associated with an augmented blood pressure response to exercise, impaired vascular function, and high risk of myocardial infarction and cardiovascular mortality. In this study, we tested the hypothesis that coronary exercise hyperemia is impaired in PAD. METHODS Twelve patients with PAD and no overt coronary disease (65 ± 2 years, 7 men) and 15 healthy control subjects (64 ± 2 years, 9 men) performed supine plantar flexion exercise (30 contractions/min, increasing workload). A subset of subjects (n = 7 PAD, n = 8 healthy) also performed isometric handgrip exercise (40% of maximum voluntary contraction to fatigue). Coronary blood velocity in the left anterior descending artery was measured by transthoracic Doppler echocardiography; blood pressure and heart rate were monitored continuously. RESULTS Coronary blood velocity responses to 4 min of plantar flexion exercise (PAD: Δ2.4 ± 1.2, healthy: Δ6.0 ± 1.6 cm/sec, P = 0.039) and isometric handgrip exercise (PAD: Δ8.3 ± 4.2, healthy: Δ16.9 ± 3.6, P = 0.033) were attenuated in PAD patients. CONCLUSION These data indicate that coronary exercise hyperemia is impaired in PAD, which may predispose these patients to myocardial ischemia.
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Affiliation(s)
- Amanda J Ross
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Zhaohui Gao
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Jonathan Carter Luck
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Cheryl A Blaha
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Aimee E Cauffman
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Faisal Aziz
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - John F Radtka
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - David N Proctor
- Department of Kinesiology, Noll Laboratory, The Pennsylvania State University, State College, PA
| | - Urs A Leuenberger
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Lawrence I Sinoway
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA
| | - Matthew D Muller
- Penn State Heart and Vascular Institute, Penn State University College of Medicine, Hershey, PA.
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Heinonen I, Luotolahti M, Vuolteenaho O, Nikinmaa M, Saraste A, Hartiala J, Koskenvuo J, Knuuti J, Arjamaa O. Circulating N-terminal brain natriuretic peptide and cardiac function in response to acute systemic hypoxia in healthy humans. J Transl Med 2014; 12:189. [PMID: 24989366 PMCID: PMC4086279 DOI: 10.1186/1479-5876-12-189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 06/09/2014] [Indexed: 11/22/2022] Open
Abstract
Background As it remains unclear whether hypoxia of cardiomyocytes could trigger the release of brain natriuretic peptide (BNP) in humans, we investigated whether breathing normobaric hypoxic gas mixture increases the circulating NT-proBNP in healthy male subjects. Methods Ten healthy young men (age 29 ± 5 yrs, BMI 24.7 ± 2.8 kg/m2) breathed normobaric hypoxic gas mixture (11% O2/89% N2) for one hour. Venous blood samples were obtained immediately before, during, and 2 and 24 hours after hypoxic exposure. Cardiac function and flow velocity profile in the middle left anterior descending coronary artery (LAD) were measured by Doppler echocardiography. Results Arterial oxygen saturation decreased steadily from baseline value of 99 ± 1% after the initiation hypoxia challenge and reached steady-state level of 73 ± 6% within 20–30 minutes. Cardiac output increased from 6.0 ± 1.2 to 8.1 ± 1.6 L/min and ejection fraction from 67 ± 4% to 75 ± 6% (both p < 0.001). Peak diastolic flow velocity in the LAD increased from 0.16 ± 0.04 to 0.28 ± 0.07 m/s, while its diameter remained unchanged. In the whole study group, NT-proBNP was similar to baseline (60 ± 32 pmol/ml) at all time points. However, at 24 h, concentration of NT-proBNP was higher (34 ± 18%) in five subjects and lower (17 ± 17%), p = 0.002 between the groups) in five subjects than at baseline. Conclusion In conclusion, there is no consistent increase in circulating NT-proBNP in response to breathing severely hypoxic normobaric gas mixture in healthy humans, a possible reason being that the oxygen flux to cardiac myocytes does not decrease because of increased coronary blood flow. However, the divergent individual responses as well as responses in different cardiac diseases warrant further investigations.
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Affiliation(s)
- Ilkka Heinonen
- Turku PET Centre, University of Turku and Turku University Hospital, PO Box 52, FI-20521 Turku, Finland.
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Varho V, Karjalainen PP, Ylitalo A, Airaksinen JK, Mikkelsson J, Sia J, Pietilä M, Kiviniemi TO. Transthoracic echocardiography for non-invasive assessment of coronary vasodilator function after DES implantation. Eur Heart J Cardiovasc Imaging 2014; 15:1029-34. [PMID: 24755162 DOI: 10.1093/ehjci/jeu059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS Coronary vasodilator dysfunction has been reported after drug-eluting stent (DES) implantation. Recent ESC guidelines suggest that transthoracic echocardiography (TTE) may be considered for assessment of coronary flow reserve (CFR) and microvascular disease in patients with stable angina, but its reliability has not been tested in patients with DES. We sought to assess the agreement between TTE (CFRTTE) and invasive thermodilution-derived CFR (CFRThermodilution) as well as their association with index of microcirculatory resistance (IMR) in mid-term follow-up after percutaneous coronary intervention for acute coronary syndrome. METHODS AND RESULTS CFRTTE and CFRThermodilution were assessed 3 months after DES implantation in the left anterior descending artery in 24 patients. Patients with haemodynamically significant epicardial stenosis (fractional flow reserve <0.75) were excluded. Correlation between the two methods was good (r = 0.71, P < 0.001), but CFRThermodilution (mean ± SD) tended to be higher (3.17 ± 1.00 vs. 2.87 ± 0.72; mean difference 0.29, 95% confidence interval -0.06 to 0.59). In Bland-Altman analysis, there was a trend towards a greater difference in the range of higher invasive values. Nevertheless, TTE was successful in discriminating moderately impaired CFR (≤2.5) (P = 0.001) and severely impaired CFR (≤2.0) (P < 0.001) when compared with an invasive method. No association between either CFR measurements vs. IMR measurement was detected, suggesting that in addition to microcirculatory function, CFR also accounts for epicardial vasodilator function in the absence of haemodynamically significant stenosis. CONCLUSION TTE is a feasible and reliable method for the assessment of CFR and vasodilator dysfunction after DES implantation. Values obtained with this method successfully find abnormal CFR confirmed with the invasive thermodilution method.
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Affiliation(s)
- Ville Varho
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | | | - Antti Ylitalo
- Department of Cardiology, Satakunta Central Hospital, Pori, Finland
| | - Juhani K Airaksinen
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | - Jussi Mikkelsson
- Department of Cardiology, Satakunta Central Hospital, Pori, Finland
| | - Jussi Sia
- Department of Cardiology, Central Ostrobothnia Central Hospital, Kokkola, Finland
| | - Mikko Pietilä
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | - Tuomas O Kiviniemi
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
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10
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Karjalainen P. Neointimal coverage and vasodilator response to titanium-nitride-oxide-coated bioactive stents and everolimus-eluting stents in patients with acute coronary syndrome: insights from the BASE-ACS trial. Int J Cardiovasc Imaging 2013; 29:1693-703. [DOI: 10.1007/s10554-013-0285-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 08/24/2013] [Indexed: 10/26/2022]
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Lanza GA, Camici PG, Galiuto L, Niccoli G, Pizzi C, Di Monaco A, Sestito A, Novo S, Piscione F, Tritto I, Ambrosio G, Bugiardini R, Crea F, Marzilli M. Methods to investigate coronary microvascular function in clinical practice. J Cardiovasc Med (Hagerstown) 2013; 14:1-18. [DOI: 10.2459/jcm.0b013e328351680f] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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12
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Kiviniemi TO, Yegutkin GG, Toikka JO, Paul S, Aittokallio T, Janatuinen T, Knuuti J, Rönnemaa T, Koskenvuo JW, Hartiala JJ, Jalkanen S, Raitakari OT. Pravastatin-induced improvement in coronary reactivity and circulating ATP and ADP levels in young adults with type 1 diabetes. Front Physiol 2012; 3:338. [PMID: 22934084 PMCID: PMC3429103 DOI: 10.3389/fphys.2012.00338] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/01/2012] [Indexed: 12/20/2022] Open
Abstract
Aims: Extracellular ATP and ADP regulate diverse inflammatory, prothrombotic and vasoactive responses in the vasculature. Statins have been shown to modulate their signaling pathways in vitro. We hypothesized that altered intravascular nucleotide turnover modulates vasodilation in patients with type 1 diabetes (T1DM), and this can be partly restored with pravastatin therapy. Methods: In this randomized double blind study, plasma ATP and ADP levels and echocardiography-derived coronary flow velocity response to cold pressor test (CPT) were concurrently assessed in 42 normocholesterolemic patients with T1DM (age 30 ± 6 years, LDL cholesterol 2.5 ± 0.6 mmol/L) before and after four-month treatment with pravastatin 40 mg/day or placebo (n = 22 and n = 20, respectively), and in 41 healthy control subjects. Results: Compared to controls, T1DM patients had significantly higher concentrations of ATP (p < 0.01) and ADP (p < 0.01) and these levels were partly restored after treatment with pravastatin (p = 0.002 and p = 0.007, respectively), but not after placebo (p = 0.06 and p = 0.14, respectively). Coronary flow velocity acceleration was significantly lower in T1DM patients compared to control subjects, and it increased from pre- to post-intervention in the pravastatin (p = 0.02), but not in placebo group (p = 0.15). Conclusions: Pravastatin treatment significantly reduces circulating ATP and ADP levels of T1DM patients, and concurrently improves coronary flow response to CPT. This study provides a novel insight in purinergic mechanisms involved in pleiotropic effects of pravastatin.
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Affiliation(s)
- Tuomas O Kiviniemi
- Department of Clinical Physiology, Turku University Hospital Turku, Finland
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Effects of type 2 diabetes mellitus on coronary microvascular function and myocardial perfusion in patients without obstructive coronary artery disease. Eur J Nucl Med Mol Imaging 2012; 39:1199-206. [PMID: 22526959 DOI: 10.1007/s00259-012-2117-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 03/11/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE We assessed the impact of type 2 diabetes, in the presence of other major cardiovascular risk factors, on coronary microvascular function and myocardial perfusion in patients without obstructive coronary artery disease (CAD). METHODS In this prospective study, 23 patients with type 2 diabetes and 26 nondiabetic patients matched for age, sex and other cardiovascular risk factors underwent a cold pressure test (CPT) and dipyridamole transthoracic echocardiography to determine their coronary flow (CF) ratio. Within 2 weeks, all diabetic patients also underwent dipyridamole-rest myocardial perfusion single-photon emission (MPS) CT. None of the patients with or without diabetes had significant CAD on invasive coronary angiography. RESULTS The CPT-CF ratio was significantly lower in diabetic patients than in nondiabetic patients (1.46 ± 0.26 vs. 1.71 ± 0.32, p = 0.006) and was correlated significantly with fasting glycaemia (r = -0.35, p = 0.01), but not with glycated haemoglobin. The dipyridamole-CF ratio was also lower in diabetic patients than in nondiabetic patients (2.38 ± 0.74 vs. 2.75 ± 0.49, p = 0.04). On MPS imaging, 5 diabetic patients (22%) had stress-induced ischaemia and the remaining 18 (78%) had normal myocardial perfusion. The dipyridamole-CF ratio was not different in patients with and without reversible defects (2.3 ± 1.1 vs. 2.4 ± 0.6, p = 0.97). CONCLUSION Coronary microvascular function is impaired in type 2 diabetic patients without significant CAD, compared to nondiabetic patients with similar other cardiovascular risk factors. In the majority of diabetic patients, microvascular dysfunction is associated with normal myocardial perfusion.
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Changes in blood pressure and systemic vascular resistance do not predict microvascular structure during treatment of mild essential hypertension. J Hypertens 2012; 30:794-801. [DOI: 10.1097/hjh.0b013e328350e4ff] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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15
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Malmberg M, Vähäsilta T, Saraste A, Koskenvuo JW, Pärkkä JP, Leino K, Laitio T, Stark C, Heikkilä A, Saukko P, Savunen T. Intracoronary Levosimendan during Ischemia Prevents Myocardial Apoptosis. Front Physiol 2012; 3:17. [PMID: 22347864 PMCID: PMC3278776 DOI: 10.3389/fphys.2012.00017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 01/25/2012] [Indexed: 11/30/2022] Open
Abstract
Background: Levosimendan is a calcium sensitizer that has been shown to prevent myocardial contractile depression in patients post cardiac surgery. This drug exhibits an anti-apoptotic property; however, the underlying mechanism remains elusive. In this report, we characterized the myocardial protective of levosimendan in preventing cardiomyocyte apoptosis and post-operative stunning in an experimental ischemia–reperfusion model. Methods: Three groups of pigs (n = 8 per group) were subjected to 40 min of global, cardioplegic ischemia followed by 240 min of reperfusion. Levosimendan (65 μg/kg body weight) was given to pigs by intravenous infusion (L-IV) before ischemia or intracoronary administration during ischemia (L-IC). The Control group did not receive any levosimendan. Echocardiography was used to monitor cardiac function in all groups. Apoptosis levels were assessed from the left ventricle using the terminal transferase mediated dUTP nick end labeling (TUNEL) assay and immunocytochemical detection of Caspase-3. Results: Pigs after ischemia–reperfusion had a much higher TUNEL%, suggesting that our treatment protocol was effective. Levels of apoptosis were significantly increased in Control pigs that did not receive any levosimendan (0.062 ± 0.044%) relative to those received levosimendan either before (0.02 ± 0.017%, p = 0.03) or during (0.02 ± 0.017%, p = 0.03) the ischemia phase. Longitudinal left ventricular contraction in pigs that received levosimendan before ischemia (0.75 ± 0.12 mm) was significantly higher than those received levosimendan during ischemia (0.53 ± 0.11 mm, p = 0.003) or Control pigs (0.54 ± 0.11 mm, p = 0.01). Conclusion: Our results suggested that pigs received levosimendan displayed a markedly improved cell survival post I–R. The effect on cardiac contractility was only significant in our perfusion heart model when levosimendan was delivered intravenously before ischemia.
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Affiliation(s)
- Markus Malmberg
- Department of Surgery, Turku University Hospital Turku, Finland
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Hwang HJ, Youn HJ, Lee MY, Park CS, Choi YS, Chung WB, Lee JB, Shim B. Change of coronary flow velocity during the cold pressor test is related to endothelial markers in subjects with chest pain and a normal coronary angiogram. Clin Cardiol 2011; 35:119-24. [PMID: 22102482 DOI: 10.1002/clc.20980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 08/26/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Several studies demonstrated that endothelial or atherosclerotic biomarkers, including plasma free insulin-like growth factor-I(IGF-I), soluble CD40 ligand (sCD40L), adiponectin, and leptin have an influence on coronary endothelial function. HYPOTHESIS The aim of the present study was to investigate whether change of coronary flow velocity of the distal left anterior descending artery (LAD) during the cold pressor test (CPT) with transthoracic Doppler echocardiography (TTE) was associated with these biomarkers in subjects with chest pain and a normal coronary angiogram. METHODS In 190 subjects (mean age, 54±11 years; male:female, 113:77) with chest pain and a normal coronary angiogram, peak diastolic velocity (PDV) of the distal LAD during the CPT with TTE was assessed. Acetylcholine provocation test was performed in 58 subjects (mean age, 51±10 years) who were clinically suspected of vasospasm. CPT%PDV was defined as the percent change in PDV during the CPT. Associations between CPT%PDV and clinical parameters were analyzed. RESULTS According to multiple regression analysis, CPT%PDV was associated with plasma free IGF-I in the entire study population (β=0.295, P<0.001 in all subjects; β=0.341, P=0.001 in males; β=0.243, P=0.037 in females; β=0.303, P=0.002 in nonsmokers; and β=0.256, P=0.047 in smokers), and sCD40L in males (β=-0.269, P=0.008)and smokers (β=-0.261, P=0.046). Subjects with vasospasm to intracoronary acetylcholine had lower plasma free IGF-I(6.9±3.3 vs 8.9±3.4, P=0.026) and CPT%PDV (8.8±24.9 vs 52.7±26.0, P<0.001) than the others. Plasma adiponectin and leptin were not associated with CPT%PDV. CONCLUSIONS Change of coronary flow velocity assessed using the CPT with TTE may be related to endothelial markers, especially plasma free IGF-I.
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Affiliation(s)
- Hui-Jeong Hwang
- Division of Cardiology, Department of Internal Medicine College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Abstract
BACKGROUND Increased microvascular resistance and small artery remodelling are key abnormalities in the pathophysiology of essential hypertension. We investigated the relation between the impairment of coronary and forearm minimum vascular resistances (C-Rmin and F-Rmin) and the degree of hypertension. METHOD Seventy-five never-treated essential hypertension patients with 24-h systolic blood pressure (BP) at least 130 mmHg or diastolic BP at least 80 mmHg were assigned into grade 1 (office BP 140/90-159/99 mmHg) and grade 2 (office BP 160/100-179/109 mmHg) hypertension and compared to normotensive controls (n = 25). The patients were (48 years, 60% men) without cardiovascular disease. C-Rmin and coronary flow reserve (CFR) were derived from flow measurements in the left anterior descending artery using transthoracic echocardiography. F-Rmin was measured using venous occlusion plethysmography. Resting systemic vascular resistance index (SVRI) was measured with a gas rebreathing technique. RESULTS Compared to normotensive controls: 24-h mean BP was raised 14% in grade 1 essential hypertension and 28% in grade 2 essential hypertension, whereas F-Rmin and C-Rmin were elevated by 58 and 87% in grade 1 essential hypertension and 72 and 125% in grade 2 essential hypertension. C-Rmin and F-Rmin were thus both increased more than expected from the BP level. SVRI and left-ventricular mass were increased proportionally to the BP. CFR was decreased by approximately 30% in both essential hypertension groups. CONCLUSION The results demonstrate excessive microvascular structural abnormalities in hypertension suggesting microvascular alterations occur early and not just as an adaptation to the BP level. Thus the level of BP elevation does not give an accurate indication of the microvascular involvement and impairment in essential hypertension.
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Impaired coronary flow reserve in obstructive sleep apnea and its improvement after continuous positive airway pressure therapy: a transthoracic Doppler echocardiographic study. J Echocardiogr 2011; 9:59-63. [PMID: 27276881 DOI: 10.1007/s12574-010-0074-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2010] [Revised: 10/07/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND It is reported that patients with obstructive sleep apnea syndrome (OSAS) show endothelial dysfunction and that treatment of OSAS by continuous positive airway pressure (CPAP) therapy improves it. OBJECTIVE In this study we evaluated coronary flow reserve (CFR), which is considered to be affected by coronary microvascular dysfunction, and the change in CFR during treatment of OSAS by CPAP. METHODS Eleven patients who were diagnosed as having OSAS by polysomnography (PSG) were studied. Phasic coronary flow velocity was obtained in the left anterior descending coronary artery at baseline and during hyperemic conditions with transthoracic 2D echocardiography. CFR was defined as the ratio of hyperemic to basal mean diastolic velocity. CFR was obtained before and after the initiation of CPAP therapy. RESULTS Coronary flow reserve was decreased (<2.5) in 8 of 11 (73%) patients at baseline. After CPAP therapy, CFR of these 8 patients increased significantly. CONCLUSION Coronary flow reserve was decreased in 73% of the patients with OSAS and was significantly improved after CPAP therapy.
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Nguyen PK, Terashima M, Fair JM, Varady A, Taylor-Piliae RE, Iribarren C, Go AS, Haskell WL, Hlatky MA, Fortmann SP, McConnell MV. Physical Activity in Older Subjects Is Associated With Increased Coronary Vasodilation. JACC Cardiovasc Imaging 2011; 4:622-9. [DOI: 10.1016/j.jcmg.2011.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 04/14/2011] [Accepted: 04/21/2011] [Indexed: 12/15/2022]
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Kiviniemi TO, Schindler T, Tulppo M, Knuuti J, Raitakari O, Koskenvuo JW. Cold pressor test safety-the incidence of vasovagal reactions. Am J Cardiol 2011; 107:492-3. [PMID: 21257022 DOI: 10.1016/j.amjcard.2010.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 10/26/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
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Coronary microvascular endothelial function deteriorates late (12 months) after sirolimus-eluting stent implantation. J Cardiol 2010; 56:229-35. [PMID: 20599356 DOI: 10.1016/j.jjcc.2010.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 05/06/2010] [Accepted: 05/21/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Coronary flow velocity reserve (CFVR) may reflect coronary microvascular endothelial function in the absence of significant epicardial coronary artery stenosis. The purpose of this study was to evaluate coronary microvascular endothelial function late (6 and 12 months) after sirolimus-eluting stent (SES) implantation using transthoracic Doppler echocardiography. METHODS AND RESULTS A total of 21 lesions from 21 patients with significant left anterior descending artery stenosis who underwent percutaneous coronary intervention (PCI) with SES were enrolled and studied. As a control group, 10 patients who were treated with bare metal stent (BMS) were also studied. CFVR was measured at 6 and 12 months after PCI. Coronary angiography was also performed at 6 and 12 months (SES only) after stenting. Between 6 and 12 months after SES implantation, there was no significant difference in angiographical diameter stenosis. On the other hand, CFVR significantly decreased between 6 and 12 months in the SES group (2.5±0.5 vs. 2.2±0.5, p<0.01), but not in the BMS group (2.3±0.4 vs. 2.5±0.3, p=0.1). CONCLUSIONS Coronary microvascular endothelial function may deteriorate between 6 and 12 months after SES implantation.
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Kiviniemi TO, Saraste A, Lehtimäki T, Toikka JO, Saraste M, Raitakari OT, Hartiala JJ, Viikari J, Koskenvuo JW. Decreased endothelin-1 levels after acute consumption of red wine and de-alcoholized red wine. Atherosclerosis 2010; 211:283-6. [DOI: 10.1016/j.atherosclerosis.2010.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 01/12/2010] [Accepted: 01/13/2010] [Indexed: 10/19/2022]
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Hwang HJ, Chung WB, Park JH, Oh SS, Chung JW, Choi YS, Youn HJ. Estimation of Coronary Flow Velocity Reserve Using Transthoracic Doppler Echocardiography and Cold Pressor Test Might Be Useful for Detecting of Patients with Variant Angina. Echocardiography 2010; 27:435-41. [DOI: 10.1111/j.1540-8175.2009.01038.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kiviniemi TO, Saraste A, Toikka JO, Saraste M, Raitakari OT, Pärkkä JP, Lehtimäki T, Hartiala JJ, Viikari J, Koskenvuo JW. Effects of cognac on coronary flow reserve and plasma antioxidant status in healthy young men. Cardiovasc Ultrasound 2008; 6:25. [PMID: 18522727 PMCID: PMC2427009 DOI: 10.1186/1476-7120-6-25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 06/03/2008] [Indexed: 11/29/2022] Open
Abstract
Background The cardioprotective effects of certain alcoholic beverages are partly related to their polyphenol content, which may improve the vasodilatory reactivity of arteries. Effect of cognac on coronary circulation, however, remains unknown. The purpose of this randomized controlled cross-over study was to determine whether moderate doses of cognac improve coronary reactivity as assessed with cold pressor testing (CPT) and coronary flow reserve (CFR) measument. Methods Study group consisted of 23 subjects. Coronary flow velocity and epicardial diameter was assessed using transthoracic echocardiography at rest, during CPT and adenosine infusion-derived CFR measurements before drinking, after a moderate (1.2 ± 0.1 dl) and an escalating high dose (total amount 2.4 ± 0.3 dl) of cognac. To explore the bioavailability of antioxidants, the antioxidant contents of cognac was measured and the absorption from the digestive tract was verified by plasma antioxidant capacity determination. Results Serum alcohol levels increased to 1.2 ± 0.2‰ and plasma antioxidant capacity from 301 ± 43.9 μmol/l to 320 ± 25.0 μmol/l by 7.6 ± 11.8%, (p = 0.01) after high doses of cognac. There was no significant change in flow velocity during CPT after cognac ingestion compared to control day. CFR was 4.4 ± 0.8, 4.1 ± 0.9 (p = NS), and 4.5 ± 1.2 (p = NS) before drinking and after moderate and high doses on cognac day, and 4.5 ± 1.4, and 4.0 ± 1.2 (p = NS) on control day. Conclusion Cognac increased plasma antioxidant capacity, but it had no effect on coronary circulation in healthy young men. Trial Registration NCT00330213
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Affiliation(s)
- Tuomas O Kiviniemi
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland.
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Nguyen PK, Meyer C, Engvall J, Yang P, McConnell MV. Noninvasive assessment of coronary vasodilation using cardiovascular magnetic resonance in patients at high risk for coronary artery disease. J Cardiovasc Magn Reson 2008; 10:28. [PMID: 18513419 PMCID: PMC2467421 DOI: 10.1186/1532-429x-10-28] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 05/30/2008] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Impaired coronary vasodilation to both endothelial-dependent and endothelial-independent stimuli have been associated with atherosclerosis. Direct measurement of coronary vasodilation using x-ray angiography or intravascular ultrasound is invasive and, thus, not appropriate for asymptomatic patients or for serial follow-up. In this study, high-resolution coronary cardiovascular magnetic resonance (CMR) was used to investigate the vasodilatory response to nitroglycerine (NTG) of asymptomatic patients at high risk for CAD. METHODS A total of 46 asymptomatic subjects were studied: 13 high-risk patients [8 with diabetes mellitus (DM), 5 with end stage renal disease (ESRD)] and 33 age-matched controls. Long-axis and cross-sectional coronary artery images were acquired pre- and 5 minutes post-sublingual NTG using a sub-mm-resolution multi-slice spiral coronary CMR sequence. Coronary cross sectional area (CSA) was measured on pre- and post-NTG images and % coronary vasodilation was calculated. RESULTS Patients with DM and ESRD had impaired coronary vasodilation to NTG compared to age-matched controls (17.8 +/- 7.3% vs. 25.6 +/- 7.1%, p = 0.002). This remained significant for ESRD patients alone (14.8 +/- 7.7% vs. 25.6 +/- 7.1%; p = 0.003) and for DM patients alone (19.8 +/- 6.3% vs. 25.6 +/- 7.1%; p = 0.049), with a non-significant trend toward greater impairment in the ESRD vs. DM patients (14.8 +/- 7.7% vs. 19.8 +/- 6.3%; p = 0.23). CONCLUSION Noninvasive coronary CMR demonstrates impairment of coronary vasodilation to NTG in high-risk patients with DM and ESRD. This may provide a functional indicator of subclinical atherosclerosis and warrants clinical follow up to determine prognostic significance.
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Affiliation(s)
- Patricia K Nguyen
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
| | - Craig Meyer
- Department of Biomedical Engineering, University of Virginia, Virginia, USA
| | - Jan Engvall
- Department of Clinical Physiology, Linköping Heart Center, Linköping, Sweden
| | - Phillip Yang
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
| | - Michael V McConnell
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
- Department of Electrical Engineering, Stanford University, Stanford, USA
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Kiviniemi T. Assessment of coronary blood flow and the reactivity of the microcirculation non-invasively with transthoracic echocardiography. Clin Physiol Funct Imaging 2008; 28:145-55. [DOI: 10.1111/j.1475-097x.2008.00794.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Maret E, Engvall J, Nylander E, Ohlsson J. Feasibility and diagnostic power of transthoracic coronary Doppler for coronary flow velocity reserve in patients referred for myocardial perfusion imaging. Cardiovasc Ultrasound 2008; 6:12. [PMID: 18373873 PMCID: PMC2292686 DOI: 10.1186/1476-7120-6-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2008] [Accepted: 03/29/2008] [Indexed: 11/12/2022] Open
Abstract
Background Myocardial perfusion imaging (MPI), using single photon emission computed tomography (SPECT) is a validated method for detecting coronary artery disease. Transthoracic Doppler echocardiography (TTDE) of flow at rest and during adenosine provocation has previously been evaluated in selected patient groups. We therefore wanted to compare the diagnostic ability of TTDE in the left anterior descending coronary artery (LAD) to that of MPI in an unselected population of patients with chest pain referred for MPI. Our hypothesis was that TTDE with high accuracy would identify healthy individuals and exclude them from the need for further studies, enabling invasive investigations to be reserved for patients with a high probability of disease. Methods Sixty-nine patients, 44 men and 25 women, age 61 ± 10 years (range 35–82), with a clinical suspicion of stress induced myocardial ischemia, were investigated. TTDE was performed at rest and during adenosine stress for myocardial scintigraphy. Results We found that coronary flow velocity reserve (CFVR) determined from diastolic measurements separated normal from abnormal MPI findings with statistical significance. TTDE identified coronary artery disease, defined from MPI, as reversible ischemia and/or permanent defect, with a sensitivity of 60% and a specificity of 79%. The positive predictive value was 43% and the negative predictive value was 88%. There was an overlap between groups which could be due to abnormal endothelial function in patients with normal myocardial perfusion having either hypertension or diabetes. Conclusion TTDE is an attractive non-invasive method to evaluate chest pain without the use of isotopes, but the diagnostic power is strongly dependent on the population investigated. Even in our heterogeneous clinical cardiac population, we found that CFVR>2 in the LAD excluded significant coronary artery disease detected by MPI.
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Affiliation(s)
- Eva Maret
- Department of Clinical Physiology, Ryhov County Hospital, SE-551 85 Jonkoping, Sweden.
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Kiviniemi TO, Saraste A, Toikka JO, Saraste M, Raitakari OT, Pärkkä JP, Lehtimäki T, Hartiala JJ, Viikari J, Koskenvuo JW. A moderate dose of red wine, but not de-alcoholized red wine increases coronary flow reserve. Atherosclerosis 2007; 195:e176-81. [PMID: 17662293 DOI: 10.1016/j.atherosclerosis.2007.06.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Revised: 06/11/2007] [Accepted: 06/19/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Red wine consumption is associated with reduced cardiovascular disease mortality. Its cardioprotective properties may be partly related to its ability to improve endothelial function. The purpose of this randomized controlled cross-over study was to determine whether moderate doses of red wine and de-alcoholized red wine improve coronary flow velocity reserve (CFR). METHODS Using transthoracic Doppler echocardiography, 176 CFR measurements were made in 22 healthy men before and after ingestion of a moderate (4.0+/-0.4 dl) and an escalating high dose (total amount 8.1+/-0.9 dl) of alcohol-containing red wine and de-alcoholized red wine, which contained similar amounts of phenolic substances. The difference in plasma antioxidant capacity was determined by colorimetric assay kit. RESULTS Red wine increased CFR from 3.8+/-1.4 to 4.5+/-1.4 (p<0.01) and 4.0+/-1.2 (p=NS) after moderate and high doses, respectively; whereas de-alcoholized red wine had no significant effects on CFR (4.0+/-0.7, 4.3+/-1.3 and 4.5+/-1.4, respectively). Plasma antioxidant capacity increased significantly after high dose of red wine (27.5+/-14.7%, p<0.001), but not after de-alcoholized red wine (0.5+/-10.5%, p=NS) despite similar amounts of phenolic substances. Differences between CFR and plasma antioxidant capacities before and after drinking had no significant association. CONCLUSIONS A moderate dose of red wine, but not de-alcoholized red wine increases CFR. The increase of CFR is probably mediated by other than direct antioxidant properties of polyphenols, because the simultaneous increase of CFR and plasma antioxidant capacity were not associated.
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Affiliation(s)
- Tuomas O Kiviniemi
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Kiinamyllynkatu 4-8, FIN-20520 Turku, Finland.
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