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Coronary Artery Spasm: prevalent but not fully understood yet. –. Int J Cardiol 2022; 364:18-19. [DOI: 10.1016/j.ijcard.2022.05.050] [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: 05/12/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022]
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Role of acetylcholine spasm provocation test as a pathophysiological assessment in nonobstructive coronary artery disease. Cardiovasc Interv Ther 2020; 36:39-51. [PMID: 33108592 PMCID: PMC7829227 DOI: 10.1007/s12928-020-00720-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022]
Abstract
Coronary angiography (CAG) sometimes shows nonobstructive coronary arteries in patients with suspected angina or acute coronary syndrome (ACS). The high prevalence of nonobstructive coronary artery disease (CAD) in those patients has recently been reported not only in Japan but also in Western countries, and is clinically attracting attention. Coronary spasm is considered to be one of the leading causes of both suspected stable angina and ACS with nonobstructive coronary arteries. Coronary spasm could also be associated with left ventricular dysfunction leading to heart failure, which could be improved following the administration of calcium channel blockers. Because we rarely capture spontaneous attacks of coronary spasm with electrocardiograms or Holter recordings, an invasive diagnostic modality, acetylcholine (ACh) provocation test, can be useful in detecting coronary spasm during CAG. Furthermore, we can use the ACh-provocation test to identify high-risk patients with coronary spasm complicated with organic coronary stenosis, and then treat with intensive care. Nonobstructive CAD includes not only epicardial coronary spasm but also microvascular spasm or dysfunction that can be associated with recurrent anginal attacks and poor quality of life. ACh-provocation test could also be helpful for the assessment of microvascular spasm or dysfunction. We hope that cardiologists will increasingly perform ACh-provocation test to assess the pathophysiology of nonobstructive CAD.
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Verna E, Ghiringhelli S, Provasoli S, Scotti S, Salerno-Uriarte J. Epicardial and microvascular coronary vasomotor dysfunction and its relation to myocardial ischemic burden in patients with non-obstructive coronary artery disease. J Nucl Cardiol 2018; 25:1760-1769. [PMID: 28374328 DOI: 10.1007/s12350-017-0871-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/18/2017] [Indexed: 10/19/2022]
Abstract
AIM To assess the relative contribution of epicardial endothelium-dependent (EDD) and microvascular endothelium-independent (EIMVD) coronary vasomotor dysfunction to the extent of myocardial ischemia in patients with normal angiograms or non-obstructive coronary artery disease (NOCAD). METHODS Coronary vasomotion was evaluated by quantitative angiography and blood flow (CBF) measurements during intracoronary acetylcholine, nitroglycerine, and adenosine in 101 patients. Myocardial SPECT ischemic burden was evaluated by semi-quantitative scoring of summed stress (SSS) and summed ischemic (SDS) perfusion defect size. RESULTS Coronary vasomotor dysfunction was found in most patients (83; 77%) with a divergent behavior of EDD and EIMVD in one half of them (52.4%). There was no significant difference in SDS between patients with and without EIMVD, whereas SDS was significantly greater in subjects with EDD as compared to patients with normal response to acetylcholine (4.31 ± 2.44 vs 1.35 ± 1.45; P < .0001). Patients with EDD, either alone or in combination with EIMVD, had significantly higher SSS as compared to patients with lone EIMVD or normal vasomotor function (8.50 ± 5.32; 5.55 ± 3.21; 2.60 ± 2.14; and 1.74 ± 1.66, respectively; P < .0001). Acetylcholine CBF correlated inversely with both SDS (r = -0.545; P < .001) and SSS (r = 0.538; P < .001). CONCLUSIONS In NOCAD patients with symptoms and signs of myocardial ischemia, vasomotor dysfunction is common. EDD is associated with greater extent of ischemia as compared to isolated EIMVD. Thus, assessment of both EIMVD and EDD is needed to recognize mechanisms of ischemia and identify patients with greater ischemic burden.
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Affiliation(s)
- Edoardo Verna
- Department of Cardiology, Ospedale di Circolo & Fondazione Macchi, University Hospital-Varese, Università dell'Insubria, Viale Borri 57, 21100, Varese, Italy.
| | - Sergio Ghiringhelli
- Department of Cardiology, Ospedale di Circolo & Fondazione Macchi, University Hospital-Varese, Università dell'Insubria, Viale Borri 57, 21100, Varese, Italy
| | - Stefano Provasoli
- Department of Cardiology, Ospedale di Circolo & Fondazione Macchi, University Hospital-Varese, Università dell'Insubria, Viale Borri 57, 21100, Varese, Italy
| | - Simone Scotti
- Nuclear Medicine, Ospedale di Circolo & Fondazione Macchi, University Hospital, Università dell'Insubria, Varese, Italy
| | - Jorge Salerno-Uriarte
- Department of Cardiology, Ospedale di Circolo & Fondazione Macchi, University Hospital-Varese, Università dell'Insubria, Viale Borri 57, 21100, Varese, Italy
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Kaikita K, Ishii M, Sato K, Nakayama M, Arima Y, Tanaka T, Sugamura K, Sakamoto K, Izumiya Y, Yamamoto E, Tsujita K, Yamamuro M, Kojima S, Soejima H, Hokimoto S, Matsui K, Ogawa H. Determinants of Myocardial Lactate Production During Acetylcholine Provocation Test in Patients With Coronary Spasm. J Am Heart Assoc 2015; 4:e002387. [PMID: 26656861 PMCID: PMC4845259 DOI: 10.1161/jaha.115.002387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/23/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Myocardial lactate production in the coronary circulation during acetylcholine (ACh)-provocation test (abbreviated as lactate production) provides supporting evidence for coronary spasm-induced myocardial ischemia. The purpose of this study was to examine the clinical features, predictive factors, and prognosis of patients with coronary vasospastic angina (VSA) and lactate production. METHODS AND RESULTS We examined all 712 patients who underwent both myocardial lactate measurement during ACh-provocation test in the left coronary artery and genetic screening test of a -786T/C polymorphism in the 5'-flanking region of the endothelial nitric oxide synthase (eNOS) gene between January 1991 and December 2010. Lactate production was observed in 252 of the 712 patients and in 219 of 356 VSA patients diagnosed by ACh-provocation test. Compared with lactate production-negative VSA patients, the lactate production-positive counterparts were more likely to be nonsmoker female diabetics with -786T/C eNOS polymorphism (61% vs 31%, P<0.001, 62% vs 34%, P<0.001, 24% vs 14%, P=0.016, and 25% vs 15%, P=0.018, respectively). Multivariable logistic regression analysis identified female sex, diabetes mellitus, and -786T/C eNOS polymorphism to correlate with lactate production (odds ratio 3.51, 95% CI 2.16 to 5.70, P<0.001; odds ratio 2.53, 95% CI 1.38 to 4.65, P=0.003; and odds ratio 1.85, 95% CI 1.02 to 3.35, P=0.044, respectively). Kaplan-Meier survival curve showed no difference in 5-year survival rate free from major adverse cardiac events between lactate production-positive and -negative VSA patients (P=0.319). CONCLUSIONS The results indicated that female sex, diabetes, and mutation in -786T/C eNOS gene correlate with ACh-provoked myocardial ischemia in patients with coronary spasm.
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Affiliation(s)
- Koichi Kaikita
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Masanobu Ishii
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Koji Sato
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Masafumi Nakayama
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Yuichiro Arima
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Tomoko Tanaka
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Koichi Sugamura
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Kenji Sakamoto
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Yasuhiro Izumiya
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Eiichiro Yamamoto
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Kenichi Tsujita
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Megumi Yamamuro
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Sunao Kojima
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Hirofumi Soejima
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Seiji Hokimoto
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Kunihiko Matsui
- Department of Community MedicineKumamoto University HospitalKumamotoJapan
| | - Hisao Ogawa
- Department of Cardiovascular MedicineGraduate School of Medical SciencesKumamoto UniversityKumamotoJapan
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Titterington JS, Hung OY, Wenger NK. Microvascular angina: an update on diagnosis and treatment. Future Cardiol 2015; 11:229-42. [DOI: 10.2217/fca.14.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
ABSTRACT Many patients with chest pain who are relieved to learn that they have no obstructive stenoses at diagnostic angiography are misclassified as having noncardiac chest pain. Only recently have we developed the conceptual framework and diagnostic tools to understand that ischemic heart disease is not exclusively caused by obstructive coronary artery disease, but often has its origin in the microcirculation. This article will focus on the diagnosis and treatment of microvascular angina as a cause of myocardial ischemia in patients with abnormal but ‘normal appearing’ coronary arteries.
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Affiliation(s)
- Jane S Titterington
- Emory University School of Medicine, Department of Medicine, Division of Cardiology, Atlanta, GA, USA
| | - Olivia Y Hung
- Emory University School of Medicine, Department of Medicine, Division of Cardiology, Atlanta, GA, USA
| | - Nanette K Wenger
- Emory University School of Medicine, Department of Medicine, Division of Cardiology, Atlanta, GA, USA
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Arora P, Bhatia V, Arora M, Kaul U. Adenosine induced coronary spasm – A rare presentation. Indian Heart J 2014; 66:87-90. [PMID: 24581102 PMCID: PMC4054841 DOI: 10.1016/j.ihj.2013.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 12/12/2013] [Indexed: 11/22/2022] Open
Abstract
Adenosine is commonly used as a pharmacological agent in myocardial perfusion imaging, as an antiarrhythmic agent, and in Cath Lab. during PCI for treating no reflow phenomenon. Coronary spasm has been reported following adenosine injection during stress imaging. We report a rare complication with ST segment elevation, following adenosine injection, given for treatment of supraventricular tachycardia.
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Sato K, Kaikita K, Nakayama N, Horio E, Yoshimura H, Ono T, Ohba K, Tsujita K, Kojima S, Tayama S, Hokimoto S, Matsui K, Sugiyama S, Yamabe H, Ogawa H. Coronary vasomotor response to intracoronary acetylcholine injection, clinical features, and long-term prognosis in 873 consecutive patients with coronary spasm: analysis of a single-center study over 20 years. J Am Heart Assoc 2013; 2:e000227. [PMID: 23858100 PMCID: PMC3828805 DOI: 10.1161/jaha.113.000227] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/20/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long-term prognosis in patients with vasospastic angina (VSA). METHODS AND RESULTS This is a retrospective, observational, single-center study of 1877 consecutive patients who underwent ACh-provocation test between January 1991 and December 2010. ACh-provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh-positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh-negative patients. ACh-positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh-provoked diffuse spasm pattern in patients with VSA. Kaplan-Meier survival curve indicated better 5-year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA. CONCLUSIONS ACh-induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh-provoked coronary spasm subtypes in patients with VSA.
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Affiliation(s)
- Koji Sato
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Naoki Nakayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Eiji Horio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Hiromi Yoshimura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Takamichi Ono
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Keisuke Ohba
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Shinji Tayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Kunihiko Matsui
- Department of General Medicine, Yamaguchi University Hospital, Ube, Japan (K.M.)
| | - Seigo Sugiyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Hiroshige Yamabe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (K.S., K.K., N.N., E.H., H.Y., T.O., K.O., K.T., S.K., S.T., S.H., S.S., H.Y., H.O.)
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Ismail M, Asaad N, Al-Suwaidi J. Adenosine-induced coronary artery spasm: a case report. Med Princ Pract 2012; 21:82-5. [PMID: 22024961 DOI: 10.1159/000331809] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 04/14/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe an uncommon complication of intravenous adenosine administration. CLINICAL PRESENTATION AND INTERVENTION A 41-year-old female patient presented with palpitations due to supraventricular tachycardia. The patient was treated with intravenous adenosine with resolution of the tachycardia. Subsequently, the patient developed chest pain and ST segment elevation in the inferior leads that resolved with sublingual nitroglycerin. CONCLUSION This report showed a case of coronary spasm secondary to the administration of adenosine. We therefore recommend that discretion be exercised when giving adenosine, especially to patients with an underlying tendency for vasospastic reactions.
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Affiliation(s)
- Montaser Ismail
- Department of Cardiology and Cardiac Surgery, Hamad Medical Corporation, Doha, Qatar
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Hirata A, Kishida K, Hiuge-Shimizu A, Nakatsuji H, Funahashi T, Shimomura I. Qualitative score of systemic arteriosclerosis by vascular ultrasonography as a predictor of coronary artery disease in type 2 diabetes. Atherosclerosis 2011; 219:623-9. [PMID: 21930272 DOI: 10.1016/j.atherosclerosis.2011.08.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/22/2011] [Accepted: 08/25/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Patients with type 2 diabetes mellitus (T2DM) are at risk of polyvascular comorbidities and poor prognosis. Non-invasive techniques for early prediction of coronary artery disease (CAD) are desirable to prevent cardiovascular events in these patients. The aim of the present study was to investigate the association between CAD and systemic arteriosclerosis by qualitative vascular ultrasonography. METHODS The study subjects were 102 consecutive outpatients with T2DM [males/females = 60/42, age: mean ± SD 67 ± 9 (range, 40-85) years] evaluated by vascular ultrasonography for arteriosclerosis in the abdominal aorta, carotid, renal, and common iliac arteries. The total number of detected arteriosclerotic vascular lesions in the four arteries was determined. CAD was diagnosed by two cardiologists using either stress electrocardiography, myocardial scintigraphy, multi-detector row computed tomography or coronary angiography. RESULTS Multiple arteriosclerotic vascular lesions (>1) were detected in 64 (63%) patients. The total systemic vascular score was significantly higher in patients with CAD than those without (average score 2.7 versus 1.0, p < 0.0001). None of the CAD patients had a total score of 0. Age- and sex-adjusted multiple logistic regression analysis identified total score of ≥ 2 as the only predictor of CAD (p < 0.001). The sensitivity, specificity, positive and negative predictive values for total systemic vascular score in the prediction of CAD were 98%, 77%, 83%, and 97%, respectively, which were better than those for carotid mean and maximum intima-media thickness. CONCLUSION Non-invasive qualitative evaluation of systemic arteriosclerosis by the total systemic vascular score is potentially useful for the early prediction of CAD in T2DM patients.
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Affiliation(s)
- Ayumu Hirata
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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Matsuzawa Y, Sugiyama S, Sugamura K, Nozaki T, Ohba K, Konishi M, Matsubara J, Sumida H, Kaikita K, Kojima S, Nagayoshi Y, Yamamuro M, Izumiya Y, Iwashita S, Matsui K, Jinnouchi H, Kimura K, Umemura S, Ogawa H. Digital Assessment of Endothelial Function and Ischemic Heart Disease in Women. J Am Coll Cardiol 2010; 55:1688-96. [DOI: 10.1016/j.jacc.2009.10.073] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 09/24/2009] [Accepted: 10/12/2009] [Indexed: 11/26/2022]
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Cassar A, Chareonthaitawee P, Rihal CS, Prasad A, Lennon RJ, Lerman LO, Lerman A. Lack of correlation between noninvasive stress tests and invasive coronary vasomotor dysfunction in patients with nonobstructive coronary artery disease. Circ Cardiovasc Interv 2009; 2:237-44. [PMID: 20031721 DOI: 10.1161/circinterventions.108.841056] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Despite a nonobstructive coronary angiogram, many patients may still have an abnormal coronary vasomotor response to provocation and to myocardial demand during stress. The ability of noninvasive stress tests to predict coronary vasomotor dysfunction in patients with nonobstructive coronary artery disease is unknown. METHODS AND RESULTS All patients with nonobstructive coronary artery disease who had invasive coronary vasomotor assessment and a noninvasive stress test (exercise ECG, stress echocardiography, or stress nuclear imaging) within 6 months of the cardiac catheterization with provocation at our institution were identified (n=376). Coronary vasomotor dysfunction was defined as a percentage increase in coronary blood flow of <or=50% to intracoronary acetylcholine (endothelium-dependent dysfunction) and/or a coronary flow reserve ratio of <or=2.5 to intracoronary adenosine (endothelium-independent dysfunction). We determined the sensitivity and specificity of various noninvasive stress tests to predict coronary vasomotor dysfunction in these patients. On invasive testing, 233 patients (63%) had coronary vasomotor dysfunction, of which 187 patients (51%) had endothelium-dependent dysfunction, 109 patients (29%) had endothelium-independent dysfunction, and 63 patients (17%) had both. On noninvasive stress testing, 157 (42%) had a positive imaging study and 56 (15%) a positive ECG stress test. The noninvasive stress tests had limited diagnostic accuracy for predicting coronary vasomotor dysfunction (41% sensitivity [95% CI, 34 to 47] and 57% specificity [95% CI, 49 to 66]), endothelium-dependent dysfunction (41% sensitivity [95% CI, 34 to 49] and 58% specificity [95% CI, 50 to 65]), or endothelium-independent dysfunction (46% sensitivity [95% CI, 37 to 56] and 61% specificity [95% CI, 54 to 67]). The exercise ECG test was more specific but less sensitive than the imaging tests. CONCLUSIONS This study suggests that a negative noninvasive stress test does not rule out coronary vasomotor dysfunction in symptomatic patients with nonobstructive coronary artery disease. This underscores the need for invasive assessment or novel more sensitive noninvasive imaging for these patients.
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Affiliation(s)
- Andrew Cassar
- Department of Internal Medicine, Mayo College of Medicine, Rochester, MN 55905, USA
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Cox ID, Clague JR, Bagger JP, Ward DE, Kaski JC. Endothelial dysfunction, subangiographic atheroma, and unstable symptoms in patients with chest pain and normal coronary arteriograms. Clin Cardiol 2009; 23:645-52. [PMID: 11016013 PMCID: PMC6654817 DOI: 10.1002/clc.4960230904] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow-up. Although repeat angiography usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information. HYPOTHESIS The study was undertaken to evaluate the relationship between endothelial dysfunction and subangiographic atheroma in patients with CPNA undergoing repeat angiography because of unstable symptoms. METHODS We investigated nine patients with CPNA (8 women, mean age 57 +/- 9 years) undergoing repeat angiography because of unstable anginal symptoms. After normal angiography, simultaneous coronary epicardial and microvascular vasomotor responses to intracoronary vasodilators [acetylcholine (10(-6) M), adenosine (18 micrograms) and nitroglycerin (300 micrograms)] were investigated in the left anterior descending artery using quantitative angiography and Doppler flow measurements. The presence of subangiographic atheroma was assessed by intravascular ultrasound. RESULTS Three patients demonstrated proximal and distal epicardial vasoconstriction and a reduction in coronary flow in response to acetylcholine, indicating concordant epicardial and microvascular endothelial dysfunction. These changes were associated with chest pain and ischemic electrocardiographic changes in two patients. None of the remaining patients suffered chest pain in response to intracoronary acetylcholine. Six patients had significant subangiographic disease (intimal thickness > 0.3 mm) on intravascular ultrasound imaging, and multivariate analysis indicated a significant relationship (R2 = 0.89, overall p = 0.001) between the extent of subangiographic disease and both plasma cholesterol concentration and hypertensive history. No significant relationship was demonstrated between endothelial dysfunction and the extent of subangiographic disease. CONCLUSION Concordant epicardial and microvascular endothelial dysfunction may be pathophysiologically and clinically significant in unstable patients with CPNA but does not appear to be directly related to the extent of subangiographic atheroma.
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Affiliation(s)
- I D Cox
- Cardiological Sciences Department, St. George's Hospital Medical School, London, U.K
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Ozçelik F, Altun A, Ozbay G. Antianginal and anti-ischemic effects of nisoldipine and ramipril in patients with syndrome X. Clin Cardiol 2009; 22:361-5. [PMID: 10326170 PMCID: PMC6656278 DOI: 10.1002/clc.4960220513] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Syndrome X is defined as typical angina pectoris, positive treadmill exercise test, negative intravenous ergonovine test, and angiographically normal coronary arteries. HYPOTHESIS In the present study, we investigated the anti-ischemic and antianginal effects of nisoldipine and ramipril in patients with syndrome X. METHODS After 2 weeks of the first wash-out period, 18 patients (7 men, 11 women, age 46 +/- 10 years) were given nisoldipine (NIS) 5 mg twice daily for 4 weeks, and after 2 weeks of the second wash-out period, the same patients were given ramipril (RAM) 2.5 mg once daily for 4 weeks. A treadmill exercise test with modified Bruce protocol was performed at the end of each period. RESULTS The time to angina in exercise (607 +/- 115 s-650 +/- 117 s, p = 0.006, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), total exercise time (612 +/- 110 s-656 +/- 114 s, p = 0.0008, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), and maximum MET value (11.09 +/- 2.08-11.86 +/- 2.04, p = 0.0016, vs. 11.42 +/- 2.09-12.2 +/- 2.26, p = 0.01) were increased significantly with both therapy modalities. The time to 1 mm ST-segment depression (123 +/- 93 s-220 +/- 172 s, p = 0.002) was increased significantly with NIS therapy. The time to ST-segment recovery (434 +/- 268 s-330 +/- 233 s, p = 0.016 vs. 443 +/- 289 s-370 +/- 278 s, p = 0.012), the frequency of anginal attacks per week (1.27 +/- 1.4-0 +/- 0.38, p = 0.005, vs. 1 +/- 1.32-0.33 +/- 0.59, p = 0.028), and the need for sublingual nitroglycerin (1.16 +/- 1.29-0.11 +/- 0.32, p = 0.005, vs. 0.94 +/- 1.16-0.27 +/- 0.57, p = 0.012) were decreased significantly with both drugs. CONCLUSION We observed that 10 mg daily NIS and 2.5 mg daily RAM have similar anti-ischemic and antianginal effects in patients with syndrome X.
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Affiliation(s)
- F Ozçelik
- Trakya University, Faculty of Medicine, Cardiology Department, Edirne, Turkey
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Evaluation of post-stress left ventricular dysfunction and its relationship with perfusion abnormalities using gated SPECT in patients with cardiac syndrome X. Nucl Med Commun 2008; 29:208-14. [PMID: 18349790 DOI: 10.1097/mnm.0b013e3282f52c49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cardiac syndrome X defines patients with typical angina, a positive exercise ECG stress test and angiographically documented normal coronary arteries. In previous studies, post-stress prolonged left ventricular dysfunction (PLVD) using gated SPECT (G-SPECT) had been well correlated with myocardial perfusion abnormalities and degree of stenotic vessels in CAG in patients with coronary artery disease. However, evaluation of left ventricular myocardial perfusion, wall motion and left ventricular ejection fraction (LVEF) in patients with cardiac syndrome X, using G-SPECT had not been studied yet. Thus, the aim of this study was to analyse PLVD using (99m)Tc-MIBI GSPECT in patients with cardiac syndrome X. METHODS Of the patients in whom G-SPECT was performed in our institution between 2004 and 2006, 17 patients with anginal chest pain, positive exercise ECG stress test and normal coronary angiograms were retrospectively included to the study (group I). Fifteen patients with normal myocardial perfusion and another 15 patients with ischaemia on G-SPECT were selected as control groups (groups II and III). (99m)Tc-MIBI G-SPECT was performed for all patients according to 2 day (stress-rest) protocol. Stress and rest LVEF were derived automatically (SLVEF and RLVEF). Difference LVEF (DLVEF) (stress-rest) was calculated. Semiquantitative analyses were made both for myocardial perfusion and wall motion (WM), using a 20-segment model and a 5-point scoring system. DLVEF, perfusion and WM scores of all groups were compared among three groups and relationship between DLVEF, perfusion and WM scores were evaluated. RESULTS Abnormal perfusion were detected in eight (47.1%) of patients, while the remaining nine (52.9%) had normal myocardial perfusion, in group I. Six of 17 (35.3%) patients in group I had post-stress WM abnormalities. Mean of DLVEF values were -3.1+/-3.0%, 4.4+/-2.0% and -6.0+/-5.1% in groups I, II and III, respectively (P<0.05 for group II vs. group I and group III; P>0.05 for group I vs. group III). LVEF response impairment (< or =5% increase from rest to post-stress images) was found in 17 (100%), seven (46.6%), 14 (93.3%) of patients in groups I, II and III, respectively. CONCLUSION Abnormal myocardial perfusion, concordant transient segmental WM abnormalities and LVEF response impairment are not uncommon in patients with cardiac syndrome X of this cohort of the study population. Therefore, post-stress prolonged stunning may be attributed to these findings in some of cardiac syndrome X patients as in true ischaemic patients. However, further studies with larger number of subjects and long-term follow-up are necessary to support these findings.
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15
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Mende A, Takano H, Kodama Y, Nakamura T, Umetani K, Fujioka D, Saito Y, Kobayashi T, Kawabata KI, Obata JE, Kitta Y, Kugiyama K. Relation between transcardiac gradient of VEGF and coronary flow response in humans. Int J Cardiol 2006; 119:156-62. [PMID: 17067705 DOI: 10.1016/j.ijcard.2006.07.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Revised: 07/15/2006] [Accepted: 07/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Angiogenic growth factors, produced in the myocardium and coronary vascular bed, increase myocardial blood flow. This study examined whether plasma levels of vascular endothelial growth factor (VEGF) in coronary circulation may be related to coronary blood flow responses. METHODS Blood flow responses in the left anterior descending coronary artery to an intracoronary infusion of acetylcholine (ACh) were measured by an intracoronary flow wire technique in 46 consecutive control subjects with normal coronary angiograms and left ventriculograms. Circulating VEGF levels were measured by ELISA in plasma obtained from the aortic root (AO) and anterior interventricular vein (AIV). RESULTS The transcardiac gradient of VEGF, calculated by the difference in VEGF concentrations between the AIV and AO, showed a positive correlation with the coronary blood flow increase in response to ACh independently of traditional coronary risk factors. In patients with cardiac syndrome X (n=17), defined as a positive exercise stress test with a normal coronary angiograms and left ventriculogram, the transcardiac VEGF gradient was significantly lower than in the risk factors-matched control subjects (n=21). CONCLUSIONS The transcardiac gradient of plasma VEGF was independently and positively correlated with the coronary blood flow increase in response to ACh. A reduced transcardiac VEGF gradient was present in cardiac syndrome X, a condition with a blunted coronary blood flow response.
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Affiliation(s)
- Akira Mende
- Department of Internal Medicine II, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, 1110 Shimokato, Nakakoma-gun, Yamanashi, 409-3898, Japan
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16
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Takano H, Kodama Y, Kitta Y, Nakamura T, Obata JE, Mende A, Kawabata KI, Saitoh Y, Fujioka D, Kobayashi T, Hasebe H, Kugiyama K. Transcardiac adiponectin gradient is independently related to endothelial vasomotor function in large and resistance coronary arteries in humans. Am J Physiol Heart Circ Physiol 2006; 291:H2641-6. [PMID: 16877558 DOI: 10.1152/ajpheart.00702.2006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adiponectin, an adipocyte-derived protein, has been shown to have vasculoprotective effects. This study examined the possible relationship between coronary vasomotor function and the transcardiac gradient of adiponectin, reflecting adiponectin utilization and/or accumulation in the coronary vascular bed. The epicardial diameter and blood flow response of the left anterior descending coronary artery to intracoronary infusions of ACh was analyzed in 108 consecutive subjects who had a normal coronary angiogram and left ventriculogram. Adiponectin levels were measured by ELISA in plasma obtained from the aortic root (Ao) and the anterior interventricular vein (AIV). Adiponectin levels in the AIV were lower than levels in the Ao. In multivariate linear regression analysis, the transcardiac gradient of adiponectin (Ao - AIV levels) showed a positive correlation with increases in epicardial coronary diameter and coronary blood flow in response to ACh that was independent of traditional coronary risk factors. The transcardiac gradient of adiponectin was not significantly associated with the coronary dilator response to isosorbide dinitrate and the coronary flow response to sodium nitroprusside. In other groups of patients with coronary spastic angina (n = 41) or microvascular angina (n = 32) who had impaired coronary vasomotor responses, there was no significant gradient of adiponectin between the Ao and AIV. The transcardiac gradient of adiponectin may modulate endothelial vasomotor function in large and resistance coronary arteries and may play a role in the pathogenesis of diseases presenting with coronary vasomotor dysfunction.
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Affiliation(s)
- Hajime Takano
- Dept. of Internal Medicine II, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo City, 409-3898 Japan
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17
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Vinereanu D, Fraser AG, Robinson M, Lee A, Tweddel A. Adenosine provokes diastolic dysfunction in microvascular angina. Postgrad Med J 2002; 78:40-2. [PMID: 11796872 PMCID: PMC1742231 DOI: 10.1136/pmj.78.915.40] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Adenosine stress echocardiography was performed in nine patients (58 (+/-3) years, eight women) with documented microvascular angina. Global ventricular function was assessed by Tc(99m) blood pool imaging and Doppler, whereas longitudinal ventricular function was assessed by simultaneous tissue Doppler echocardiography of the lateral mitral annulus. Adenosine was infused incrementally to onset of chest pain in all patients. There was no significant change in global or longitudinal systolic function. Adenosine induced global diastolic dysfunction, demonstrated by blood pool imaging and by Doppler of the transmitral flow. All patients had long axis diastolic dysfunction at peak adenosine, revealed by a ratio of early to late diastolic velocity of lateral mitral annulus <1, which was absent at rest. Adenosine, as a stress agent, provokes regional and global diastolic dysfunction in microvascular angina, which may be a consequence of subendocardial ischaemia. Long axis diastolic dysfunction can be easily revealed by tissue Doppler of the lateral annular motion.
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Affiliation(s)
- D Vinereanu
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
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18
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Sun SS, Huang JL, Tsai SC, Ho YJ, Kao CH. The higher likelihood of developing cardiomegaly during follow-up in patients with syndrome X and abnormal thallium-201 myocardial perfusion SPECT. Int J Cardiovasc Imaging 2001; 17:271-8. [PMID: 11599866 DOI: 10.1023/a:1011661300903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
'Syndrome X' describes patients with exertional chest pain and a normal coronary arteriogram. In some patients, acute myocardial ischemia can be demonstrated by regional myocardial perfusion defects on thallium-201 exercise test. However, some patients with typical angina have normal perfusion on thallium-201 heart scintigraphy. It is not clear whether there are different prognoses for patients with normal and abnormal thallium studies. In this study, the clinical features, long term follow-up and clinical results of syndrome X patients with normal and abnormal thallium studies were evaluated to determine the differences between these two groups. Fifty-nine patients (52 males, seven females, mean age 62+/-6 years) with syndrome X were enrolled and divided into two groups on the basis of results of thallium-201 heart scintigraphy. Group I was comprised of 22 patients with normal thallium-201 perfusion scan and group II was comprised of 37 patients with abnormal thallium-201 heart scan. All subjects received coronary arteriography, exercise test, thallium-201 myocardial SPECT, ejection fraction of left ventricle, echocardiography, blood analysis and long term follow-up with questionnaire for 10 years. Lower maximal rate-pressure product and higher angina scores were found in group II. More patients developed cardiomegaly (nine of 33 patients) in group II than in group I (one of 21 patients). Both groups, however, were at low risk for cardiac events (cardiac death or myocardial infarction).
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Affiliation(s)
- S S Sun
- Department of Nuclear Medicine, China Medical College Hospital, Taichung, Taiwan
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19
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Ortega A, Moreno R, Alonso JC, Domínguez P, Almoguera I, Bittini A, Lampreave JL, Suárez M, Gómez A, Martínez L, Sosa V, Sarnago F, García-Fernández MA, Pérez-Vázquez JM. [Results of myocardial scintigraphy with 99mTc-tetrofosmin and dipyridamole administration in patients diagnosed of microvascular angina]. REVISTA ESPANOLA DE MEDICINA NUCLEAR 2000; 19:337-73. [PMID: 11062109 DOI: 10.1016/s0212-6982(00)71887-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The objective of the study was to evaluate the results of the myocardial scintigraphy with 99mTc-tetrofosmin (Tc-Tf) and pharmacological stimulation with dipyridamole in patients diagnosed of microvascular angina. The study population is made up of 50 patients discharged with the diagnosis of microvascular angina who had undergone Tc-Tf-dipyridamole. Clinical and electrical positivity appeared in 40% and 12% of the patients, respectively. Myocardial perfusion defects were found in 35 patients (70%), and were reversible in 21 (60%), fixed in 11 (21%), and combined in 3 (9%). Abnormalities were inferior, anteroseptal and lateral in 21, 18, and 2 patients, respectively. Patients with a positive exercise treadmill test, compared with those with a negative one, had more frequent perfusion abnormalities (91% vs 50%, p = 0.0327) and myocardial ischemia (64% vs 20%, p = 0.392). Women, in comparison with men, had angina (56% vs 22%, p = 0.013), and anteroseptal perfusion abnormalities (26% vs 4%, p = 0.028) more frequently. On the contrary, men had inferior perfusion abnormalities more frequently (57% vs 30%, p = 0.057). Thus, Tc-Tf-dipyridamole shows perfusion abnormalities in 70% of patients with microvascular angina (91% in patients with a positive exercise treadmill test). Scintigraphic pattern may be partially conditioned by gender in these patients.
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Affiliation(s)
- A Ortega
- Servicios de Medicina Nuclear. Hospital General Universitario Gregorio Marañón. Madrid
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20
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Rosen SD, Camici PG. Endothelium-dependent and -independent perfusion reserve and the effect of L-arginine on myocardial perfusion in patients with syndrome X. Circulation 2000; 101:E205-6. [PMID: 10831535 DOI: 10.1161/01.cir.101.21.e205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S D Rosen
- MRC Cyclotron Unit, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0NN,
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21
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Abstract
Myocardial perfusion abnormalities occur in the absence of epicardial coronary artery disease in patients with a wide spectrum of cardiovascular disorders including microvascular angina, hypertension and left ventricular hypertrophy, coronary atherosclerosis, hypercholesterolemia, and non-ischemic left ventricular dysfunction. These patients have limited coronary microvascular dilator reserve which occasionally is associated with evidence of myocardial ischemia. Primary microvascular hyperconstriction (spasm) is also proposed to cause myocardial ischemia in a subset of patients with rest angina. There is ample evidence suggesting that endothelial dysfunction contributes to microvascular dysfunction, but the precise mechanism of endothelial dysfunction is not known. Nitric oxide is one of the key molecules which control microvascular tone and therefore coronary blood flow, and its decreased availability appears to be involved under certain conditions. This hypothesis has attracted considerable interest as a new therapeutic strategy for these patients having coronary microvascular derangements caused by divergent cardiovascular diseases.
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Affiliation(s)
- M Mohri
- Research Institute of Angiocardiology and Cardiovascular Clinic, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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22
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Insights into the Pathophysiology of Syndrome X Obtained Using Positron Emission Tomography (PET). DEVELOPMENTS IN CARDIOVASCULAR MEDICINE 1999. [DOI: 10.1007/978-1-4615-5181-2_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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23
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Cannon RO. Can measures of coronary dynamics explain chest pain without coronary artery disease? Mayo Clin Proc 1998; 73:1226-8. [PMID: 9868424 DOI: 10.4065/73.12.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Cannon RO, Curiel RV, Prasad A, Quyyumi AA, Panza JA. Comparison of coronary endothelial dynamics with electrocardiographic and left ventricular contractile responses to stress in the absence of coronary artery disease. Am J Cardiol 1998; 82:710-4. [PMID: 9761078 DOI: 10.1016/s0002-9149(98)00456-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Coronary artery endothelial dysfunction has been proposed as a cause of myocardial ischemia and symptoms in patients with angina-like chest pain despite normal coronary angiograms, especially those with ischemic-appearing ST-segment depression during exercise (syndrome X). We measured coronary vasomotor responses to acetylcholine (3 to 300 microg/min) in 42 patients (27 women and 15 men) with effort chest pain and normal coronary angiograms who also had normal electrocardiograms and echocardiograms at rest. All patients underwent treadmill exercise testing and measurement of systolic wall thickening responses to dobutamine (40 microg/kg/min) during transesophageal echocardiography. There were no differences in the acetylcholine-stimulated epicardial coronary diameter (+5+/-13% vs +1+/-13%, p=0.386) and flow (+179+/-90% vs +169+/-96%, p=0.756), or in the systolic wall thickening responses (+134+/-65% vs +118+/-57%, p=0.445) from baseline values in the 12 syndrome X patients compared with the 30 patients with negative exercise test results. In patients in the lowest quartile of coronary flow responses to acetylcholine, dobutamine increased systolic wall thickening by 121+/-73%; 3 had ischemic-appearing ST-segment depression during this stress. This contractile response to dobutamine was no different than the increase in systolic wall thickening (129+/-48%, p=0.777) in patients in the highest quartile of coronary flow responses, 3 of whom also had ischemic-appearing ST-segment depression during this stress. Thus, coronary endothelial dysfunction in the absence of coronary artery disease does not account for ischemic-appearing ST-segment depression in patients with chest pain despite normal coronary angiograms. Further, coronary endothelial dysfunction is not associated with myocardial contractile responses to stress consistent with myocardial ischemia.
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Affiliation(s)
- R O Cannon
- Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892-1650, USA
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25
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Kugiyama K, Inobe Y, Ohgushi M, Morita E, Motoyama T, Ogawa H, Yasue H. Comparison of coronary hemodynamics during infusions of dobutamine and adenosine in patients with angina pectoris. JAPANESE CIRCULATION JOURNAL 1998; 62:1-6. [PMID: 9559411 DOI: 10.1253/jcj.62.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pharmacologic stress tests are used to evaluate the significance of coronary arterial stenosis, and adenosine and dobutamine are often used for this purpose. The aim of this study was to examine coronary hemodynamics in 16 patients with stable exertional angina who had organic stenosis (> 90%) in the left anterior descending coronary arteries and in 13 control subjects at baseline and during separate intravenous infusions of dobutamine (20 micrograms/kg per min [corrected]) and adenosine (140 micrograms/kg per min [corrected]). Measurements of great cardiac vein blood flow and lactate and oxygen contents in the blood from the aortic root and great cardiac vein were analyzed in patients with ischemic signs of myocardial ischemia (ST-segment depression in the precordial ECG leads and/or myocardial lactate production) during the infusions (in 11 patients during adenosine infusion and in 12 patients during dobutamine infusion) and in control subjects. Myocardial oxygen consumption during adenosine infusion did not change compared with the baseline in both groups, whereas it increased during dobutamine infusion in both groups (p < 0.01 compared with the baseline in each case). However, great cardiac vein blood flow was significantly increased compared with the baseline during both infusions in both groups (p < 0.01 compared with baseline in each case), and the oxygen contents of great cardiac vein blood, which contains effluent from the ischemic region, showed no decrease but increased significantly during both infusions in the patients in comparison with control subjects. Although the global oxygen supply was excessive, myocardial ischemia occurred during dobutamine and adenosine infusions in the patients. As myocardial oxygen consumption remained unchanged during adenosine infusion, regional myocardial flow reduction, possibly as a result of flow maldistribution, may contribute, at least partly, to adenosine-induced myocardial ischemia. An increase in myocardial oxygen consumption may be the principal cause of myocardial ischemia during dobutamine infusion, but an inappropriate flow increase in normal myocardium may occur during dobutamine-induced ischemia.
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Affiliation(s)
- K Kugiyama
- Division of Cardiology, Kumamoto University School of Medicine, Japan
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Elliott PM, Krzyzowska-Dickinson K, Calvino R, Hann C, Kaski JC. Effect of oral aminophylline in patients with angina and normal coronary arteriograms (cardiac syndrome X). Heart 1997; 77:523-6. [PMID: 9227295 PMCID: PMC484794 DOI: 10.1136/hrt.77.6.523] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with syndrome X (exertional angina, positive exercise test, normal coronary arteriogram) have an altered perception of cardiac pain. This symptom may arise from increased sensitivity to adenosine. Previous studies suggest that intravenous aminophylline (an adenosine receptor blocker) improves exercise tolerance in patients with this disorder. OBJECTIVE To examine the efficacy of oral aminophylline in syndrome X. METHODS 13 patients (11 women and two men, mean (SD) 54 (6) years) with syndrome X were studied. Patients were randomised in a double blind crossover study to receive either oral aminophylline or placebo for three weeks. All patients underwent symptom limited exercise testing and ambulatory electrocardiography at the end of each three week period. RESULTS 10 patients completed the study. The time to angina during exercise testing in patients who were given aminophylline was longer than for the placebo group (mean (SD) 632 (202) seconds v 522 (264) seconds, P = 0.004). Peak exercise ST depression did not differ significantly between patients who received aminophylline and those administered placebo (mean (SD) -1.9 (0.7) mm v -1.5 (0.8) mm). Six patients taking aminophylline reported a reduction in the total number of episodes of chest pain during the three weeks, but the frequency and duration of ST segment depression during Holter monitoring was unchanged. CONCLUSION Oral aminophylline has a favourable effect on exercise induced chest pain threshold in patients with syndrome X. The disparate effects on symptoms and ST segment changes are intriguing and further study is warranted.
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Affiliation(s)
- P M Elliott
- St George's Hospital Medical School, London, United Kingdom
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