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Boivin-Proulx LA, Marquis-Gravel G, Rousseau-Saine N, Harel F, Jolicoeur EM, Pelletier-Galarneau M. Hyperventilation testing in the diagnosis of vasospastic angina: A clinical review and meta-analysis. Eur J Clin Invest 2024; 54:e14178. [PMID: 38348627 DOI: 10.1111/eci.14178] [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: 12/15/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 05/15/2024]
Abstract
BACKGROUND Given the limited access to invasive vasospastic reactivity testing in Western Countries, there is a need to further develop alternative non-invasive diagnostic methods for vasospastic angina (VSA). Hyperventilation testing (HVT) is defined as a class IIa recommendation to diagnose VSA by the Japanese Society of Cardiology. METHODS In this systematic review and meta-analysis reported according to the PRISMA statement, we review the mechanisms, methods, modalities and diagnostic accuracy of non-invasive HVT for the diagnostic of VSA. RESULTS A total of 106 articles published between 1980 and 2022 about VSA and HVT were included in the systematic review, among which 16 were included in the meta-analysis for diagnostic accuracy. Twelve electrocardiogram-HVT studies including 804 patients showed a pooled sensitivity of 54% (95% confidence intervals [CI]; 30%-76%) and a pooled specificity of 99% (95% CI; 88%-100%). Four transthoracic echocardiography-HVT studies including 197 patients revealed a pooled sensitivity of 90% (95% CI; 82%-94%) and a pooled specificity of 98% (95% CI; 86%-100%). Six myocardial perfusion imaging-HVT studies including 112 patients yielded a pooled sensitivity of 95% (95% CI; 63%-100%) and a pooled specificity of 78% (95% CI; 19%-98%). Non-invasive HVT resulted in a low rate of adverse events, ventricular arrhythmias being the most frequently reported, and were resolved with the administration of nitroglycerin. CONCLUSIONS Non-invasive HVT offers a safe alternative with high diagnostic accuracy to diagnose VSA in patients with otherwise undiagnosed causes of chest pain.
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Affiliation(s)
| | | | | | - François Harel
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - E Marc Jolicoeur
- CHUM Research Center and Cardiovascular Center, Montreal, Quebec, Canada
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Beltrame JF. Management of vasospastic angina. Heart 2022; 109:70-77. [PMID: 36371661 DOI: 10.1136/heartjnl-2022-321268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Vasospastic angina is a well-established cause of chest pain that is caused by coronary artery spasm. It can be clinically diagnosed during a spontaneous episode by documenting nitrate-responsive rest angina with associated transient ischaemic ECG changes but more often requires provocative coronary spasm testing with acetylcholine during coronary angiography. Vasospastic angina may result in recurrent episodes of angina (including nocturnal angina), which can progress on to major adverse cardiac events. Calcium channel blockers are first-line therapy for this condition, given their anti-anginal and cardioprotective benefits. Despite an established diagnostic and therapeutic management pathway for vasospastic angina, this diagnosis is often overlooked in patients presenting with chest pain. Thus, there is need for increased clinical awareness of vasospastic angina to improve outcomes in affected patients.
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Affiliation(s)
- John F Beltrame
- Discipline of Medicine, The University of Adelaide Adelaide Medical School, Adelaide, South Australia, Australia .,Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.,Basil Hetzel Institute, Adelaide, South Australia, Australia
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3
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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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Abstract
PURPOSE OF REVIEW To summarize gender- and sex-specific differences in the presentation, diagnosis, management, and pathophysiology of women presenting with acute coronary syndrome (ACS). RECENT FINDINGS Sex differences exist in many aspects of ACS that impact the identification, treatment, and outcomes in women. There are delays in the initiation of care, under recognized diagnostic differences based on sex, and inconsistencies in the management of ACS in women compared with men, that ultimately impact outcomes. Additionally, women with ACS are more likely than men to present with non-obstructive coronary artery disease (CAD), which appears to be due to diverse underlying pathophysiology. Women with ACS face diagnostic and treatment dilemmas from time of symptom onset to hospital discharge. Under-recognition, under-diagnosis, and under-treatment ultimately result in poorer outcomes in women. Underlying pathophysiologic differences in women require additional testing to elucidate underlying etiologies.
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Saito Y, Shoji T, Tateishi K, Kitahara H, Fujimoto Y, Kobayashi Y. Mental Health Status in Patients Undergoing Intracoronary Acetylcholine Provocation Test. Adv Ther 2020; 37:3807-3815. [PMID: 32651740 DOI: 10.1007/s12325-020-01424-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Previous studies showed the relation of mental distress such as anxiety and depression to coronary vasoconstriction and myocardial ischemia. However, the mental health status of patients suspected to have vasospastic angina is unclear. METHODS A total of 99 patients underwent intracoronary acetylcholine (ACh) provocation tests for the diagnosis of vasospastic angina and mental health assessment using the 12-item General Health Questionnaire (GHQ-12) and State-Trait Anxiety Inventory Form Y (STAI Y-2). Patients with binary GHQ-12 ≥ 4 were defined as having poor mental health. RESULTS Median GHQ-12 and STAI Y-2 were 3 [1, 6] and 44 [36, 50]. Forty-one (41%) patients had binary GHQ-12 ≥ 4, and 48 (48%) had positive ACh provocation tests. The number of provoked vasospasms and rate of electrocardiographic change and chest pain during ACh tests were not significantly different between patients with and without GHQ-12 ≥ 4. The incidence of positive ACh provocation test was similar between the two groups (49% vs. 48%, p = 1.00). The multivariable analysis indicated that younger age, no history of percutaneous coronary intervention and no diabetes mellitus were factors associated with higher GHQ-12 and/or STAI Y-2 scores. CONCLUSIONS More than 40% of patients who underwent ACh provocation tests had poor mental condition. No impact of mental distress on positive ACh tests was found in this study.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Toshihiro Shoji
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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6
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Al Mheid I, Hayek S, Quyyumi AA. Provoking Coronary Vasospasm for Diagnosis of Variant Angina. JACC Cardiovasc Interv 2015; 8:924-6. [DOI: 10.1016/j.jcin.2015.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 03/11/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
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8
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Flammer J, Konieczka K, Flammer AJ. The primary vascular dysregulation syndrome: implications for eye diseases. EPMA J 2013; 4:14. [PMID: 23742177 PMCID: PMC3693953 DOI: 10.1186/1878-5085-4-14] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/26/2013] [Indexed: 01/08/2023]
Abstract
Vascular dysregulation refers to the regulation of blood flow that is not adapted to the needs of the respective tissue. We distinguish primary vascular dysregulation (PVD, formerly called vasospastic syndrome) and secondary vascular dysregulation (SVD). Subjects with PVD tend to have cold extremities, low blood pressure, reduced feeling of thirst, altered drug sensitivity, increased pain sensitivity, prolonged sleep onset time, altered gene expression in the lymphocytes, signs of oxidative stress, slightly increased endothelin-1 plasma level, low body mass index and often diffuse and fluctuating visual field defects. Coldness, emotional or mechanical stress and starving can provoke symptoms. Virtually all organs, particularly the eye, can be involved. In subjects with PVD, retinal vessels are stiffer and more irregular, and both neurovascular coupling and autoregulation capacity are reduced while retinal venous pressure is often increased. Subjects with PVD have increased risk for normal-tension glaucoma, optic nerve compartment syndrome, central serous choroidopathy, Susac syndrome, retinal artery and vein occlusions and anterior ischaemic neuropathy without atherosclerosis. Further characteristics are their weaker blood–brain and blood-retinal barriers and the higher prevalence of optic disc haemorrhages and activated astrocytes. Subjects with PVD tend to suffer more often from tinnitus, muscle cramps, migraine with aura and silent myocardial ischaemic and are at greater risk for altitude sickness. While the main cause of vascular dysregulation is vascular endotheliopathy, dysfunction of the autonomic nervous system is also involved. In contrast, SVD occurs in the context of other diseases such as multiple sclerosis, retrobulbar neuritis, rheumatoid arthritis, fibromyalgia and giant cell arteritis. Taking into consideration the high prevalence of PVD in the population and potentially linked pathologies, in the current article, the authors provide recommendations on how to effectively promote the field in order to create innovative diagnostic tools to predict the pathology and develop more efficient treatment approaches tailored to the person.
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Affiliation(s)
- Josef Flammer
- Department of Ophthalmology, University of Basel, Mittlere Strasse 91, Basel CH-4031, Switzerland.
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De Giorgi F, Sarnelli G, Cirillo C, Savino IG, Turco F, Nardone G, Rocco A, Cuomo R. Increased severity of dyspeptic symptoms related to mental stress is associated with sympathetic hyperactivity and enhanced endocrine response in patients with postprandial distress syndrome. Neurogastroenterol Motil 2013; 25:31-8.e2-3. [PMID: 22908903 DOI: 10.1111/nmo.12004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mental stress (MS) may alter gastric sensory-motor function. The aim of the study was to assess postprandial autonomic nervous system activity and stress hormones in response to acute mental stress in dyspeptic patients. METHODS A total of 25 patients with postprandial distress syndrome (PDS; 11 mol L(-1), age 35.9 ± 9.3 years) and 12 healthy controls (5 mol L(-1), age 25.8 ± 4.6 years) underwent electrogastrography and (13) C-octanoate gastric emptying study using a 480 kcal solid meal. Heart rate variability (LF/HF ratio) and corticotrophin-releasing factor, adrenocorticotropic hormone (ACTH), and cortisol serum levels were also evaluated. Dyspeptic symptoms were scored by analogue visual scale and expressed as symptoms total score (TS). The protocol was repeated twice in each subject, with and without a mental stress test before the meal. KEY RESULTS Mental stress significantly increased postprandial symptoms severity in patients (TS: stress 111 ± 18 vs basal 50 ± 10; P < 0.05). Low-/high-frequency component ratio was significantly higher in patients after MS at 120 min (stress 5.46 ± 0.41 vs basal 3.41 ± 0.64; P < 0.01) and 180 min (stress 5.29 ± 0.2 vs basal 3.58 ± 0.19; P < 0.05). During stress session, in patients we found a significantly higher ACTH level than baseline at 30, 60, 90, 150, 210, 240, and 270 min and a significantly higher cortisol level at 30, 60, 90, 120, 210, and 270 min. Gastric emptying rate and electrical activity were not influenced by MS. CONCLUSIONS & INFERENCES In PDS patients, administration of MS before meal increases symptoms severity by inducing sympathetic hyperactivity and increased stress hormones levels. As the gastric emptying looks not altered, we conclude that these neurohormonal responses mainly affect sensitive function.
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Affiliation(s)
- F De Giorgi
- Department of Clinical and Experimental Medicine, University of Naples Federico II, Naples, Italy
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Abstract
OBJECTIVES The aim of this study was to examine the associations between depressive symptoms and mental stress-induced myocardial ischemia (MSIMI) in patients with coronary heart disease (CHD). METHODS Adult patients with documented CHD were recruited for baseline mental stress and exercise stress screening testing as a part of the enrollment process of the Responses of Myocardial Ischemia to Escitalopram Treatment trial. Patients were administered the Beck Depression Inventory II and the Center for Epidemiologic Studies Depression Scale. After a 24-48-hour β-blocker withdrawal, participants completed three mental stress tests followed by a treadmill exercise test. Ischemia was defined as a) any development or worsening of any wall motion abnormality and b) reduction of left ventricular ejection fraction at least 8% by transthoracic echocardiography and/or ischemic ST-segment change by electrocardiography during stress testing. MSIMI was considered present when ischemia occurred in at least one mental test. Data were analyzed using logistic regression adjusting for age, sex, and resting left ventricular ejection fraction. RESULTS One hundred twenty-five (44.2%) of 283 patients were found to have MSIMI, and 93 (32.9%) had ESIMI. Unadjusted analysis showed that Beck Depression Inventory II scores were positively associated with the probability of MSIMI (odds ratio = 0.1.30: 95% confidence interval = 1.06-1.60, p = .013) and number of MSIMI-positive tasks (all p < .005). These associations were still significant after adjustment for covariates (p values <.05). CONCLUSIONS In patients with CHD, depressive symptoms were associated with a higher probability of MSIMI. These observations may enhance our understanding of the mechanisms contributing to the association of depressive symptoms to future cardiovascular events. Trial Registration Clinicaltrials.gov identifier: NCT00574847.
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Nardi F, Verna E, Secco GG, Rognoni A, Sante Bongo A, Iraghi G, Bertuol S, Lupi A. Variant angina associated with coronary artery endothelial dysfunction and myocardial bridge: a case report and review of the literature. Intern Med 2011; 50:2601-6. [PMID: 22041365 DOI: 10.2169/internalmedicine.50.6086] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The association of variant angina (VA) and myocardial bridges is a rare finding. We describe a case of VA with recurrent coronary spasm triggered by different stimuli at the site of a myocardial bridge. The interplay of endothelial dysfunction, coronary vasoconstriction and myocardial bridging was detected by intracoronary acetylcholine test and IVUS. We speculate that mechanical stimulation at the bridge site caused endothelial dysfunction and enhanced local susceptibility to vasoconstrictor stimuli. Variant angina should always be suspected in cases of ST-elevation acute coronary syndrome without any significant angiographic coronary stenosis.
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12
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Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version. Circ J 2010; 74:1745-62. [PMID: 20671373 DOI: 10.1253/circj.cj-10-74-0802] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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13
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Kaushik M, Alla VM, Mooss A. A false alarm. Am J Med 2009; 122:833-5. [PMID: 19699378 DOI: 10.1016/j.amjmed.2009.05.005] [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: 12/04/2008] [Revised: 05/26/2009] [Accepted: 05/27/2009] [Indexed: 11/16/2022]
Affiliation(s)
- Manu Kaushik
- Department of Internal Medicine, Creighton University Medical Center, Omaha, NE 68131, USA.
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Yoshida K, Inoue T, Hirakawa N, Node K. Endoscopic thoracic sympathectomy as a novel strategy for vasospastic angina refractory to medical treatments. J Cardiol 2008; 52:49-52. [DOI: 10.1016/j.jjcc.2008.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 04/15/2008] [Accepted: 04/21/2008] [Indexed: 10/21/2022]
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Kim PJ, Seung KB, Kim DB, Her SH, Shin DI, Jang SW, Park CS, Park HJ, Jung HO, Baek SH, Kim JH, Choi KB. Clinical and angiographic characteristics of acute myocardial infarction caused by vasospastic angina without organic coronary heart disease. Circ J 2007; 71:1383-6. [PMID: 17721015 DOI: 10.1253/circj.71.1383] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Vasospastic angina (VA) can occasionally cause acute myocardial infarction (AMI). METHODS AND RESULTS From January 2003 to June 2005, coronary spastic angina was diagnosed in 292 patients by performing spasm provocation tests. Among the 292 patients, 21 (7.2% of all the VA patients) had an AMI. There were 20 patients who initially visited the emergency room for AMI without suffering prior VA. One patient with a history of VA had an AMI when he discontinued his medication. Among the 21 VA patients with AMI, 14 had experienced severe emotional stress before they visited the emergency room. The spasm provocation test showed that the VA patients with AMI had more multivessel and diffuse spasm than the VA patients without AMI (p<0.001). CONCLUSION Clinically, the VA patients with AMI usually had their first symptom of VA as the severe chest pain of AMI. Two-thirds of the VA patients with AMI had experienced emotional stress before their AMI. Angiographically, the spasm provocation test for VA patients with AMI showed more multivessel and diffuse spasm than in VA patients without AMI.
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Affiliation(s)
- Pum Joon Kim
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Shiina Y, Funabashi N, Lee K, Toyoda T, Sekine T, Honjo S, Hasegawa R, Kawata T, Wakatsuki Y, Hayashi S, Murakami S, Koike K, Daimon M, Komuro I. Relaxation effects of lavender aromatherapy improve coronary flow velocity reserve in healthy men evaluated by transthoracic Doppler echocardiography. Int J Cardiol 2007; 129:193-7. [PMID: 17689755 DOI: 10.1016/j.ijcard.2007.06.064] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 06/30/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE It has been reported that mental stress is an independent risk factor for cardiovascular events and impairs coronary circulation. Lavender aromatherapy, one of the most popular complementary treatments, is recognized as a beneficial mental relaxation therapy. However, no study has examined the effect of this therapy on coronary circulation. We aimed to assess the effect of lavender aromatherapy on coronary circulation by measuring coronary flow velocity reserve (CFVR) with noninvasive transthoracic Doppler echocardiography (TTDE). MATERIAL AND METHODS We enrolled 30 young healthy men (mean age 34+/-4.7 years, range 24-40 years). Coronary flow velocities in the left anterior descending coronary artery were recorded by TTDE at rest and during hyperemia induced with an intravenous infusion of adenosine triphosphate (ATP). CFVR was calculated as the ratio of hyperemic to basal mean diastolic flow velocity. CFVR was assessed at baseline and immediately after lavender aromatherapy (four drops of essential oil diluted with 20 ml of hot water and inhaled for 30 min). Simultaneously, serum cortisol was measured as a marker of stress hormones. To exclude the relaxation effects of rest, the same measurements were repeated in the same volunteers without aromatherapy as a control study. RESULTS CFVR measurements were obtained in all volunteers (100%). Blood pressure and heart rate responses to ATP infusion were not affected by lavender aromatherapy. Serum cortisol significantly decreased after lavender aromatherapy (8.4+/-3.6 to 6.3+/-3.3, p<0.05), but remained unchanged in controls (9.1+/-3.5 to 8.1+/-3.9, p=ns). In addition, CFVR significantly increased after lavender aromatherapy (3.8+/-0.87 to 4.7+/-0.90, p<0.001), but not in controls (3.9+/-0.8 to 3.9+/-0.8, p=ns). CONCLUSIONS Lavender aromatherapy reduced serum cortisol and improved CFVR in healthy men. These findings suggest that lavender aromatherapy has relaxation effects and may have beneficial acute effects on coronary circulation.
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Affiliation(s)
- Yumi Shiina
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8670, Japan
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Goldhaber-Fiebert S, Grecu L. Postoperative ST-segment elevation: was vasospasm caused by anaphylaxis or by its treatment with epinephrine? Ann Allergy Asthma Immunol 2006; 97:449-53. [PMID: 17069097 DOI: 10.1016/s1081-1206(10)60933-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anaphylaxis must be recognized and treated promptly to avoid significant morbidity and mortality. In this clinical setting, electrocardiographic changes can be multifactorial. OBJECTIVE To discuss vasospasm as a cause of myocardial ischemia and its possible triggering by anaphylaxis itself or by the administration of epinephrine. METHODS We describe a patient with multiple previous allergies who received intravenous epinephrine to treat suspected anaphylaxis. She immediately developed crushing chest pain with ST-segment elevations in the inferior leads. Throughout the discussion, we address differential diagnoses, physiologic features, and treatment. RESULTS Her symptoms and electrocardiographic changes were consistent with vasospasm, which resolved after treatment with sublingual nitroglycerin. However, the reaction was sufficient to cause an elevation in the troponin T level and, therefore, myocardial damage on the cellular level. CONCLUSIONS Cardiovascular complications, including electrocardiographic changes, may be induced by anaphylactic mediators or by medications used for its treatment.
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Affiliation(s)
- Sara Goldhaber-Fiebert
- Department of Anesthesia and Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Hizume T, Morikawa K, Takaki A, Abe K, Sunagawa K, Amano M, Kaibuchi K, Kubo C, Shimokawa H. Sustained Elevation of Serum Cortisol Level Causes Sensitization of Coronary Vasoconstricting Responses in Pigs In Vivo. Circ Res 2006; 99:767-75. [PMID: 16960099 DOI: 10.1161/01.res.0000244093.69985.2f] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vasospastic angina is induced by stress, for which cortisol secreted by activated hypothalamic/pituitary/adrenal axis may play an important role. However, direct evidence for this notion is still lacking. In this study, we examined whether sustained elevation of serum cortisol level sensitizes coronary vasoconstricting responses in pigs in vivo and, if so, whether Rho-kinase, which we found is a key molecule of coronary vasospasm, is involved. Oral administration of cortisol (20 mg/kg per day) increased its serum level to that seen in restraint stress in pigs. Thus, we examined coronary vasomotor responses in the following 4 groups: (1) control (without cortisol); (2) cortisol (20 mg/kg per day, p.o.) for 9 days; (3) cortisol plus RU38486 (a glucocorticoids receptor antagonist, 10 mg/kg per day, p.o.) for 9 days; and (4) cortisol for 9 days followed by 6-week withdrawal. Coronary angiography showed that intracoronary serotonin caused coronary hyperconstriction and reduction in coronary blood flow associated with ischemic ECG changes (coronary vasospasm) in only the cortisol group. All of these responses were abolished by hydroxyfasudil, a specific Rho-kinase inhibitor, in vivo. Organ chamber experiments demonstrated that serotonin concentration-dependently caused hypercontractions of coronary vascular smooth muscle associated with Rho-kinase activation (as evidenced by the enhanced phosphorylation of myosin binding subunit, a substrate of Rho-kinase) in only the cortisol group. All of these responses were again inhibited by hydroxyfasudil in vitro. These results indicate that sustained elevation of serum cortisol level sensitizes coronary vasoconstricting responses through Rho-kinase activation, suggesting the link between stress and coronary vasospasm.
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Affiliation(s)
- Takatoshi Hizume
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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19
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Hong SJ, Seo HS, Rha SW, Oh DJ, Kwon JA, Lee KN, Jang YS, Ro YM, Park CG. Decrease in plasma adiponectin concentrations in patients with variant angina pectoris. Circ J 2006; 70:414-8. [PMID: 16565557 DOI: 10.1253/circj.70.414] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Plasma adiponectin is decreased in patients with coronary artery diseases, especially in patients with acute coronary syndrome (ACS). However, the correlation between plasma adiponectin and variant angina pectoris (VAP) has not been verified. Plasma adiponectin concentrations between VAP and other coronary artery diseases was compared in the present study. The association between plasma adiponectin concentration and VAP was also investigated. METHODS AND RESULTS Plasma adiponectin concentrations in the VAP group (n=101) were compared with those of the ACS group (n=117), the stable angina pectoris group (n=108), and the normal coronary group (n=81). Plasma adiponectin concentrations in VAP and ACS were significantly lower than that of the normal coronary group (6.6+/-5.4 vs 5.2+/-4.0 vs 9.0 +/-6.2 microg/ml, p<0.001, respectively). Multivariate analysis indicated that plasma adiponectin (odds ratio (OR) 0.735, 95% confidence interval (CI) 0.621-0.855, p=0.011), smoking (OR 2.012, 95% CI 1.210-3.880, p=0.020), and age (OR 0.976, 95% CI 0.957-0.997, p=0.022) correlated independently with the development of VAP. CONCLUSIONS Our results suggest that a decrease in plasma adiponectin concentration might be associated with the development of VAP.
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Affiliation(s)
- Soon Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul
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Kotlyar M, Brauer LH, al'absi M, Adson DE, Robiner W, Thuras P, Harris J, Finocchi ME, Bronars CA, Candell S, Hatsukami DK. Effect of bupropion on physiological measures of stress in smokers during nicotine withdrawal. Pharmacol Biochem Behav 2006; 83:370-9. [PMID: 16581115 DOI: 10.1016/j.pbb.2006.02.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Revised: 01/11/2006] [Accepted: 02/18/2006] [Indexed: 10/24/2022]
Abstract
Studies suggest that among cigarette smokers trying to quit, stress undermines abstinence. Little research has assessed if therapies that increase smoking cessation rates impact physiological measures of stress response. Forty-three subjects completed this repeated-measures study in which a laboratory assessment was completed at baseline and after 17 days of treatment with either placebo (n=15), bupropion sustained release (150 mg twice daily) (n=14) or bupropion with stress reduction counseling (n=14). All subjects quit smoking 3 days prior to the second laboratory assessment. At each laboratory assessment physiological measures of stress (i.e. blood pressure, heart rate, plasma epinephrine, norepinephrine and cortisol concentrations) were measured during rest periods and in response to a speech, a math and a cold pressor task. Among subjects taking placebo, physiological measures of stress were generally lower at rest and during the stressors after smoking cessation. In those taking bupropion these measures were equivalent at the two assessments. Additionally, compared to placebo, those on bupropion had a greater diastolic blood pressure response to the speech stressor and greater systolic blood pressure response to the math stressor during the second laboratory session. This study suggests that bupropion may be maintaining physiological measures of stress during the nicotine withdrawal period.
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Affiliation(s)
- Michael Kotlyar
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA.
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