1
|
Yan M, Shang H, Guo X, Hao L, Hou S, Zheng H. The diagnostic role of resting myocardial blood flow in STEMI patients after revascularization. Front Cardiovasc Med 2024; 11:1364772. [PMID: 38576422 PMCID: PMC10993732 DOI: 10.3389/fcvm.2024.1364772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/27/2024] [Indexed: 04/06/2024] Open
Abstract
Background The value of semiquantitative resting myocardial perfusion imaging (MPI) in coronary artery disease (CAD) is limited. At present, quantitative MPI can be performed by a new cadmium zinc tellurium single-photon emission computed tomography (CZT-SPECT) scan. The quantitative index of resting myocardial blood flow (MBF) has received little attention, and its manifestations and clinical value in the presence of unstable coronary blood flow have not been clarified. Purpose In patients with ST-segment elevation myocardial infarction (STEMI), whether resting MBF can provide additional value of blood flow than semi-quantitative resting MPI is not sure. We also explored the influencing factors of resting MBF. Methods This was a retrospective clinical study. We included 75 patients with STEMI in the subacute phase who underwent resting MPI and dynamic scans after reperfusion therapy. General patient information, STEMI-related data, MPI, gated MPI (G-MPI), and resting MBF data were collected and recorded. According to the clinically provided culprit vessels, the resting MBF was divided into ischemic MBF and non-ischemic MBF. The paired Wilcoxon signed-rank test was used for resting MBF. The receiver operating characteristic (ROC) curves were used to determine the optimal threshold for ischemia, and multiple linear regression analysis was used to analyze the influencing factors of resting MBF. Results There was a statistically significant difference between the ischemic MBF and non-ischemic MBF [0.59 (0.47-0.72) vs. 0.76 (0.64-0.93), p < 0.0001]. The ROC curve analysis revealed that resting MBF could identify ischemia to a certain extent, with a cutoff value of 0.5975, area under the curve (AUC) = 0.666, sensitivity = 55.8%, and specificity = 68.7%. Male sex and summed rest score (SRS) were influencing factors for resting MBF. Conclusion To a certain extent, resting MBF can suggest residual ischemia after reperfusion therapy in patients with STEMI. There was a negative correlation between male sex, SRS, and ischemic MBF. A lower resting MBF may be associated with more severe myocardial ischemia.
Collapse
Affiliation(s)
- Ming Yan
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hua Shang
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaorui Guo
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Luping Hao
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shuang Hou
- Department of Electronic Science and Technology, School of Electronic and Information Engineering, Beijing Jiaotong University, Beijing, China
| | - Hongming Zheng
- Department of Nuclear Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
2
|
Mannozzi J, Senador D, Kaur J, Gross M, McNitt M, Alvarez A, Lessanework B, O'Leary DS. Muscle metaboreflex stimulates the cardiac sympathetic afferent reflex causing positive feedback amplification of sympathetic activity: effect of heart failure. Am J Physiol Regul Integr Comp Physiol 2024; 326:R110-R120. [PMID: 38009212 DOI: 10.1152/ajpregu.00235.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 11/28/2023]
Abstract
Exercise intolerance is a hallmark symptom of heart failure and to a large extent stems from reductions in cardiac output that occur due to the inherent ventricular dysfunction coupled with enhanced muscle metaboreflex-induced functional coronary vasoconstriction, which limits increases in coronary blood flow. This creates a further mismatch between O2 delivery and O2 demand, which may activate the cardiac sympathetic afferent reflex (CSAR), causing amplification of the already increased sympathetic activity in a positive-feedback fashion. We used our chronically instrumented conscious canine model to evaluate if chronic ablation of afferents responsible for the CSAR would attenuate the gain of muscle metaboreflex before and after induction of heart failure. After afferent ablation, the gain of the muscle metaboreflex control of mean arterial pressure was significantly reduced before (-239.5 ± 16 to -95.2 ± 8 mmHg/L/min) and after the induction of heart failure (-185.6 ± 14 to -95.7 ± 12 mmHg/L/min). Similar results were observed for the strength (gain) of muscle metaboreflex control of heart rate, cardiac output, and ventricular contractility. Thus, we conclude that the CSAR contributes significantly to the strength of the muscle metaboreflex in normal animals with heart failure serving as an effective positive-feedback amplifier thereby further increasing sympathetic activity.NEW & NOTEWORTHY The powerful pressor responses from the CSAR arise via O2 delivery versus O2 demand imbalance. Muscle metaboreflex activation (MMA) simultaneously elicits coronary vasoconstriction (which is augmented in heart failure) and profound increases in cardiac work thereby upsetting oxygen balance. Whether MMA activates the CSAR thereby amplifying MMA responses is unknown. We observed that removal of the CSAR afferents attenuated the strength of the muscle metaboreflex in normal and subjects with heart failure.
Collapse
Affiliation(s)
- Joseph Mannozzi
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Danielle Senador
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Jasdeep Kaur
- Department of Kinesiology and Health Education, University of Texas at Austin, Austin, Texas, United States
| | - Matthew Gross
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Megan McNitt
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Alberto Alvarez
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Beruk Lessanework
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Donal S O'Leary
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, United States
| |
Collapse
|
3
|
RDW as A Predictor for No-Reflow Phenomenon in DM Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. J Clin Med 2023; 12:jcm12030807. [PMID: 36769459 PMCID: PMC9917933 DOI: 10.3390/jcm12030807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/07/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND No-reflow phenomenon (NRP) in ST-segment elevation myocardial infarction (STEMI) patients is not infrequent. The predictive value of red blood-cell distribution width (RDW) on NRP has not been explored. METHODS STEMI patients undergoing primary percutaneous coronary intervention (pPCI) were enrolled. Plasma samples were obtained at admission. Participants were divided into two groups according to RDW. Logistic regression and receiver operating characteristic (ROC) curve were performed to evaluate the relationship between RDW and NRP. Subgroup analysis was made between the diabetes mellitus (DM) group and the No-DM group. RESULTS The high RDW group had a higher NRP compared to the low group. In multivariate logistic regression analysis, DM (adjusted odds ratio [AOR]:1.847; 95% confidence interval [CI]: 1.209-2.822; p = 0.005) and hemoglobin (AOR: 0.986; 95% CI: 0.973-0.999; p < 0.05), other than RDW, were independent predictors of NRP. RDW (AOR: 2.679; 95% CI: 1.542-4.655; p < 0.001) was an independent predictor of NRP in the DM group, but not in the No-DM group. In the DM group, area under the ROC curve value for RDW predicting NRP was 0.707 (77.3% sensitivity, 56.3% specificity (p < 0.001)). CONCLUSIONS RDW is a predictor of NRP in DM patients with STEMI, which provides further assistance in clinicians' decision making.
Collapse
|
4
|
Horie H, Hisatome I, Kurata Y, Yamamoto Y, Notsu T, Adachi M, Li P, Kuwabara M, Sakaguchi T, Kinugasa Y, Miake J, Koba S, Tsuneto M, Shirayoshi Y, Ninomiya H, Ito S, Kitakaze M, Yamamoto K, Yoshikawa Y, Nishimura M. α1-Adrenergic receptor mediates adipose-derived stem cell sheet-induced protection against chronic heart failure after myocardial infarction in rats. Hypertens Res 2021; 45:283-291. [PMID: 34853408 DOI: 10.1038/s41440-021-00802-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/08/2021] [Accepted: 10/15/2021] [Indexed: 11/09/2022]
Abstract
Cell-based therapy using adipose-derived stem cells (ADSCs) has emerged as a novel therapeutic approach to treat heart failure after myocardial infarction (MI). The purpose of this study was to determine whether inhibition of α1-adrenergic receptors (α1-ARs) in ADSCs attenuates ADSC sheet-induced improvements in cardiac functions and inhibition of remodeling after MI. ADSCs were isolated from fat tissues of Lewis rats. In in vitro studies using cultured ADSCs, we determined the mRNA levels of vascular endothelial growth factor (VEGF)-A and α1-AR under normoxia or hypoxia and the effects of norepinephrine and an α1-blocker, doxazosin, on the mRNA levels of angiogenic factors. Hypoxia increased α1-AR and VEGF mRNA levels in ADSCs. Norepinephrine further increased VEGF mRNA expression under hypoxia; this effect was abolished by doxazosin. Tube formation of human umbilical vein endothelial cells was promoted by conditioned media of ADSCs treated with the α1 stimulant phenylephrine under hypoxia but not by those of ADSCs pretreated with phenylephrine plus doxazosin. In in vivo studies using rats with MI, transplanted ADSC sheets improved cardiac functions, facilitated neovascularization, and suppressed fibrosis after MI. These effects were abolished by doxazosin treatment. Pathway analysis from RNA sequencing data predicted significant upregulation of α1-AR mRNA expression in transplanted ADSC sheets and the involvement of α1-ARs in angiogenesis through VEGF. In conclusion, doxazosin abolished the beneficial effects of ADSC sheets on rat MI hearts as well as the enhancing effect of norepinephrine on VEGF expression in ADSCs, indicating that ADSC sheets promote angiogenesis and prevent cardiac dysfunction and remodeling after MI via their α1-ARs.
Collapse
Affiliation(s)
- Hiromu Horie
- Division of Cardiovascular Surgery, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Ichiro Hisatome
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Yasutaka Kurata
- Department of Physiology II, Kanazawa Medical University, Uchinada, Japan.
| | - Yasutaka Yamamoto
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Tomomi Notsu
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Maaya Adachi
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Peili Li
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Masanari Kuwabara
- Intensive Care Unit and Department of Cardiology, Toranomon Hospital, Tokyo, Japan
| | - Takuki Sakaguchi
- Division of Medical Education, Department of Medical Education, Tottori University Faculty of Medicine, Yonago, Japan
| | - Yoshiharu Kinugasa
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine, Yonago, Japan
| | - Satoshi Koba
- Division of Integrative Physiology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Motokazu Tsuneto
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Yasuaki Shirayoshi
- Division of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Yonago, Japan
| | - Haruaki Ninomiya
- Department of Biological Regulation, Tottori University Faculty of Medicine, Yonago, Japan
| | - Shin Ito
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yasushi Yoshikawa
- Division of Cardiovascular Surgery, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Motonobu Nishimura
- Division of Cardiovascular Surgery, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| |
Collapse
|
5
|
Padro T, Manfrini O, Bugiardini R, Canty J, Cenko E, De Luca G, Duncker DJ, Eringa EC, Koller A, Tousoulis D, Trifunovic D, Vavlukis M, de Wit C, Badimon L. ESC Working Group on Coronary Pathophysiology and Microcirculation position paper on 'coronary microvascular dysfunction in cardiovascular disease'. Cardiovasc Res 2020; 116:741-755. [PMID: 32034397 DOI: 10.1093/cvr/cvaa003] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022] Open
Abstract
Although myocardial ischaemia usually manifests as a consequence of atherosclerosis-dependent obstructive epicardial coronary artery disease, a significant percentage of patients suffer ischaemic events in the absence of epicardial coronary artery obstruction. Experimental and clinical evidence highlight the abnormalities of the coronary microcirculation as a main cause of myocardial ischaemia in patients with 'normal or near normal' coronary arteries on angiography. Coronary microvascular disturbances have been associated with early stages of atherosclerosis even prior to any angiographic evidence of epicardial coronary stenosis, as well as to other cardiac pathologies such as myocardial hypertrophy and heart failure. The main objectives of the manuscript are (i) to provide updated evidence in our current understanding of the pathophysiological consequences of microvascular dysfunction in the heart; (ii) to report on the current knowledge on the relevance of cardiovascular risk factors and comorbid conditions for microcirculatory dysfunction; and (iii) to evidence the relevance of the clinical consequences of microvascular dysfunction. Highlighting the clinical importance of coronary microvascular dysfunction will open the field for research and the development of novel strategies for intervention will encourage early detection of subclinical disease and will help in the stratification of cardiovascular risk in agreement with the new concept of precision medicine.
Collapse
Affiliation(s)
- Teresa Padro
- Cardiovascular Program-ICCC, Research Institute Hospital Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain.,Cardiovascular Research Chair, Autonomous University Barcelona (UAB), Barcelona, Spain
| | - Olivia Manfrini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Raffaele Bugiardini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - John Canty
- Division of Cardiology, Department of Medicine, State University of New York at Buffalo, Buffalo, NY, USA
| | - Edina Cenko
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Maggiore della Carità Hospital, Eastern Piedmont University, Novara, Italy
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Science Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Akos Koller
- Department of Translational Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary.,Department of Physiology, New York Medical College, Valhalla, NY, USA
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, University of Athens Medical School, Athens, Greece
| | - Danijela Trifunovic
- Department of Cardiology, University Clinical Center of Serbia; and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Vavlukis
- University Clinic of Cardiology, Medical Faculty, Ss' Cyril and Methodius University, Skopje, Republic of Macedonia
| | - Cor de Wit
- Institut für Physiologie, Universität zu Lübeck, Lübeck, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Lina Badimon
- Cardiovascular Program-ICCC, Research Institute Hospital Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain.,Cardiovascular Research Chair, Autonomous University Barcelona (UAB), Barcelona, Spain
| |
Collapse
|
6
|
van den Born BJH, Lip GYH, Brguljan-Hitij J, Cremer A, Segura J, Morales E, Mahfoud F, Amraoui F, Persu A, Kahan T, Agabiti Rosei E, de Simone G, Gosse P, Williams B. ESC Council on hypertension position document on the management of hypertensive emergencies. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 5:37-46. [DOI: 10.1093/ehjcvp/pvy032] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 12/31/2022]
Abstract
Abstract
Hypertensive emergencies are those situations where very high blood pressure (BP) values are associated with acute organ damage, and therefore, require immediate, but careful, BP reduction. The type of acute organ damage is the principal determinant of: (i) the drug of choice, (ii) the target BP, and (iii) the timeframe in which BP should be lowered. Key target organs are the heart, retina, brain, kidneys, and large arteries. Patients who lack acute hypertension-mediated end organ damage do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation.
Collapse
Affiliation(s)
- Bert-Jan H van den Born
- Department of Internal Medicine, Division of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jana Brguljan-Hitij
- Hypertension Division, University Medical Centre Ljubljana, Department of Internal Medicine, Dr. Peter Držaj Hospital, Ljubljana, Slovenia
| | - Antoine Cremer
- Hypertension Unit, Department of Cardiology, Hopital Saint André and University Hospital of Bordeaux, Bordeaux, France
| | - Julian Segura
- Hypertension Unit, Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Hypertension Unit, Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Felix Mahfoud
- Department for Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Fouad Amraoui
- Department of Internal Medicine, Division of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Thomas Kahan
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Enrico Agabiti Rosei
- Clinica Medica Generale, Department of Clinical and Experimental Sciences, University of Brescia, and Department of Medicine, Azienda Spedali Civili di Brescia, Brescia, Italy
| | - Giovanni de Simone
- Hypertension Research Center, Department of Translational Medical Sciences, Federico II University Hospital, Naples, Italy
| | - Philippe Gosse
- Hypertension Unit, Department of Cardiology, Hopital Saint André and University Hospital of Bordeaux, Bordeaux, France
| | - Bryan Williams
- University College London (UCL) and UCL Hospitals, London, UK
| |
Collapse
|
7
|
Ryngach ЕА, Treshkur TV, Tatarinova AA, Shlyakhto EV. [Algorithm for the management of patients with stable coronary artery disease and high-grade ventricular arrhythmias]. TERAPEVT ARKH 2017. [PMID: 28635905 DOI: 10.17116/terarkh201789194-102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper gives an original algorithm for the management of patients with stable coronary artery disease, preserved/moderately reduced left ventricular systolic function, and high-grade ventricular arrhythmias from the first registration of the latter to the choice of treatment policy. Great attention is paid to the assessment of a private clinical case, by determining the nature of arrhythmias, and to the involvement of autonomic regulation in the genesis of ventricular arrhythmias. The importance of topical diagnosis of ventricular arrhythmias and identification of psychological disorders is emphasized. Diagnostic problems are solved in a step-by-step fashion using up-to-date techniques. The key point of the algorithm proposed is to prevent sudden cardiac death.
Collapse
Affiliation(s)
- Е А Ryngach
- North-West Federal Medical Research Center, Ministry of Health of Russia, Saint Petersburg, Russia
| | - T V Treshkur
- North-West Federal Medical Research Center, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A A Tatarinova
- North-West Federal Medical Research Center, Ministry of Health of Russia, Saint Petersburg, Russia
| | - E V Shlyakhto
- North-West Federal Medical Research Center, Ministry of Health of Russia, Saint Petersburg, Russia
| |
Collapse
|
8
|
Abstract
The heart is uniquely responsible for providing its own blood supply through the coronary circulation. Regulation of coronary blood flow is quite complex and, after over 100 years of dedicated research, is understood to be dictated through multiple mechanisms that include extravascular compressive forces (tissue pressure), coronary perfusion pressure, myogenic, local metabolic, endothelial as well as neural and hormonal influences. While each of these determinants can have profound influence over myocardial perfusion, largely through effects on end-effector ion channels, these mechanisms collectively modulate coronary vascular resistance and act to ensure that the myocardial requirements for oxygen and substrates are adequately provided by the coronary circulation. The purpose of this series of Comprehensive Physiology is to highlight current knowledge regarding the physiologic regulation of coronary blood flow, with emphasis on functional anatomy and the interplay between the physical and biological determinants of myocardial oxygen delivery. © 2017 American Physiological Society. Compr Physiol 7:321-382, 2017.
Collapse
Affiliation(s)
- Adam G Goodwill
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Dick
- California Medical Innovations Institute, 872 Towne Center Drive, Pomona, CA
| | - Alexander M Kiel
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN
- Weldon School of Biomedical Engineering, Purdue University, 206 S Martin Jischke Drive, Lafayette, IN
| | - Johnathan D Tune
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
9
|
Shome JS, Perera D, Plein S, Chiribiri A. Current perspectives in coronary microvascular dysfunction. Microcirculation 2017; 24. [DOI: 10.1111/micc.12340] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/06/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Joy S. Shome
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Divaka Perera
- Cardiovascular Division; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| | - Sven Plein
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
- Division of Biomedical Imaging; Multidisciplinary Cardiovascular Research Centre; Leeds Institute of Cardiovascular and Metabolic Medicine; University of Leeds; Leeds UK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering; The Rayne Institute; King's College London; St. Thomas’ Hospital; London UK
| |
Collapse
|
10
|
Celik T, Balta S, Mikhailidis DP, Ozturk C, Aydin I, Tok D, Yildirim AO, Demir M, Iyisoy A. The Relation Between No-Reflow Phenomenon and Complete Blood Count Parameters. Angiology 2016; 68:381-388. [PMID: 27418628 DOI: 10.1177/0003319716659193] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The no-reflow (NR) phenomenon represents an acute reduction in coronary blood flow without coronary vessel obstruction, coronary vessel dissection, spasm, or thrombosis. No reflow is an important complication among patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The complete blood count (CBC) is one of the most frequently ordered laboratory tests in clinical practice. Various studies have evaluated the performance of CBC parameters to predict disease severity and mortality risk. Automated cell counters are routinely available in many clinical laboratories and can be used to determine red blood cell distrubiton width (RDW), platetecrit, platelet count, and and some ratios like the neutrophil-lymphocyte ratio and RDW-platelet ratio. These hematological markers have been reported to be independent predictors of impaired angiographic reperfusion and long-term mortality among patients with STEMI undergoing pPCI. In this context, we reviewed the role of admission CBC parameters for the prediction of NR in patients with STEMI undergoing pPCI.
Collapse
Affiliation(s)
- Turgay Celik
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Sevket Balta
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Dimitri P Mikhailidis
- 2 Department of Clinical Biochemistry, University College London Medical School, University College London, London, England
| | - Cengiz Ozturk
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ibrahim Aydin
- 3 Department of Clinical Biochemistry, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Duran Tok
- 4 Department of Infectious Diseases, Gulhane Military Medical Academy, School of Medicine, Ankara, Turkey
| | - Ali Osman Yildirim
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Mustafa Demir
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Atila Iyisoy
- 1 Department of Cardiology, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| |
Collapse
|
11
|
|
12
|
Abstract
No-reflow is responsible for 40% of the primary percutaneous coronary intervention without complete myocardial reperfusion despite successful reopening of the infarct-related artery. This review describes the main pathophysiological mechanisms of no-reflow, its clinical manifestation, including the strong association with increased in-hospital mortality, malignant arrhythmias, and cardiac failure as well as the diagnostic methods. The latter ranges from simple angiographic thrombolysis in myocardial infarction grade score to more complex angiographic indexes, imaging techniques such as myocardial contrast echo or cardiac magnetic resonance, and surrogate clinical end points such as ST-segment resolution. This review also summarizes the strategies of prevention and treatment of no-reflow, considering the most recent studies results regarding medical therapy and devices.
Collapse
|
13
|
Reprint of: the paradox of α-adrenergic coronary vasoconstriction revisited. J Mol Cell Cardiol 2012; 52:832-9. [PMID: 22420694 DOI: 10.1016/j.yjmcc.2011.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 03/10/2011] [Accepted: 03/13/2011] [Indexed: 11/20/2022]
Abstract
Activation of coronary vascular α-adrenoceptors results in vasoconstriction which competes with metabolic vasodilation during sympathetic activation. Epicardial conduit vessel constriction is largely mediated by α(1)-adrenoceptors; the constriction of the resistive microcirculation largely by α(2)-adrenoceptors, but also by α(1)-adrenoceptors. There is no firm evidence that α-adrenergic coronary vasoconstriction exerts a beneficial effect on transmural blood flow distribution. In fact, α-blockade in anesthetized and conscious dogs improves blood flow to all transmural layers, during normoperfusion and hypoperfusion. Also, in patients with coronary artery disease, blockade of α(1)- and α(2)-adrenoceptors improves coronary blood flow, myocardial function and metabolism. This article is part of a Special Issue entitled "Coronary Blood Flow".
Collapse
|
14
|
Berwick ZC, Dick GM, Tune JD. Heart of the matter: coronary dysfunction in metabolic syndrome. J Mol Cell Cardiol 2012; 52:848-56. [PMID: 21767548 PMCID: PMC3206994 DOI: 10.1016/j.yjmcc.2011.06.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 06/16/2011] [Accepted: 06/30/2011] [Indexed: 12/14/2022]
Abstract
Metabolic syndrome (MetS) is a collection of risk factors including obesity, dyslipidemia, insulin resistance/impaired glucose tolerance, and/or hypertension. The incidence of obesity has reached pandemic levels, as ~20-30% of adults in most developed countries can be classified as having MetS. This increased prevalence of MetS is critical as it is associated with a two-fold elevated risk for cardiovascular disease. Although the pathophysiology underlying this increase in disease has not been clearly defined, recent evidence indicates that alterations in the control of coronary blood flow could play an important role. The purpose of this review is to highlight current understanding of the effects of MetS on regulation of coronary blood flow and to outline the potential mechanisms involved. In particular, the role of neurohumoral modulation via sympathetic α-adrenoceptors and the renin-angiotensin-aldosterone system (RAAS) are explored. Alterations in the contribution of end-effector K(+), Ca(2+), and transient receptor potential (TRP) channels are also addressed. Finally, future perspectives and potential therapeutic targeting of the microcirculation in MetS are discussed. This article is part of a Special Issue entitled "Coronary Blood Flow".
Collapse
Affiliation(s)
- Zachary C. Berwick
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Gregory M. Dick
- Department of Exercise Physiology Center for Cardiovascular and Respiratory Sciences West Virginia University School of Medicine
| | - Johnathan D. Tune
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202
| |
Collapse
|
15
|
Gregorini L, Marco J, Heusch G. Peri-interventional coronary vasomotion. J Mol Cell Cardiol 2011; 52:883-9. [PMID: 21971073 DOI: 10.1016/j.yjmcc.2011.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 09/05/2011] [Accepted: 09/14/2011] [Indexed: 12/21/2022]
Abstract
A percutaneous coronary intervention (PCI) is a unique condition to study the effects of ischemia and reperfusion in patients with severe coronary atherosclerosis when coronary vasomotor function is compromised by loss of endothelial and autoregulatory vasodilation. We studied the effects of intracoronary non-selective α-, as well as selective α(1)- and α(2)-blockade in counteracting the observed vasoconstriction in patients with stable and unstable angina and in patients with acute myocardial infarction. Coronary vasoconstriction in our studies was a diffuse phenomenon and involved not only the culprit lesion but also vessels with angiographically not visible plaques. Post-PCI vasoconstriction was reflected by increased coronary vascular resistance and associated with decreased LV-function. α (1)-Blockade with urapidil dilated epicardial coronary arteries, improved coronary flow reserve and counteracted LV dysfunction. Non-selective α-blockade with phentolamine induced epicardial and microvascular dilation, while selective α(2)-blockade with yohimbine had only minor vasodilator and functional effects. Intracoronary α-blockade also attenuated the no-reflow phenomenon following primary PCI. This article is part of a Special Issue entitled "Coronary Blood Flow".
Collapse
Affiliation(s)
- Luisa Gregorini
- Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Via Parea 4, Milan, Italy.
| | | | | |
Collapse
|
16
|
Heusch G. The paradox of α-adrenergic coronary vasoconstriction revisited. J Mol Cell Cardiol 2011; 51:16-23. [DOI: 10.1016/j.yjmcc.2011.03.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 03/10/2011] [Accepted: 03/13/2011] [Indexed: 10/18/2022]
|
17
|
Butler MJ, Chan W, Taylor AJ, Dart AM, Duffy SJ. Management of the no-reflow phenomenon. Pharmacol Ther 2011; 132:72-85. [PMID: 21664376 DOI: 10.1016/j.pharmthera.2011.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 01/03/2023]
Abstract
The lack of reperfusion of myocardium after prolonged ischaemia that may occur despite opening of the infarct-related artery is termed "no reflow". No reflow or slow flow occurs in 3-4% of all percutaneous coronary interventions, and is most common after emergency revascularization for acute myocardial infarction. In this setting no reflow is reported to occur in 30% to 40% of interventions when defined by myocardial perfusion techniques such as myocardial contrast echocardiography. No reflow is clinically important as it is independently associated with increased occurrence of malignant arrhythmias, cardiac failure, as well as in-hospital and long-term mortality. Previously the no-reflow phenomenon has been difficult to treat effectively, but recent advances in the understanding of the pathophysiology of no reflow have led to several novel treatment strategies. These include prophylactic use of vasodilator therapies, mechanical devices, ischaemic postconditioning and potent platelet inhibitors. As no reflow is a multifactorial process, a combination of these treatments is more likely to be effective than any of these alone. In this review we discuss the pathophysiology of no reflow and present the numerous recent advances in therapy for this important clinical problem.
Collapse
Affiliation(s)
- Michelle J Butler
- Department of Cardiovascular Medicine, the Alfred Hospital, Melbourne, Australia
| | | | | | | | | |
Collapse
|
18
|
Babu GG, Walker JM, Yellon DM, Hausenloy DJ. Peri-procedural myocardial injury during percutaneous coronary intervention: an important target for cardioprotection. Eur Heart J 2010; 32:23-31. [PMID: 21037252 DOI: 10.1093/eurheartj/ehq393] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Percutaneous coronary intervention (PCI) has become the predominant procedure for coronary revascularization in patients with both stable and unstable coronary artery disease (CAD). Over the past two decades, technical advances in PCI have resulted in a better and safer therapeutic procedure with minimal procedural complications. However, about 30% of patients undergoing elective PCI sustain myocardial injury arising from the procedure itself, the extent of which is significant enough to carry prognostic importance. The peri-procedural injury which accompanies PCI might therefore reduce some of the beneficial effects of coronary revascularization. The availability of more sensitive serum biomarkers of myocardial injury such as creatine phosphokinase MB isoenzyme (CK-MB), Troponin T, and Troponin I has enabled the quantification of previously undetectable myocardial injury. Peri-procedural myocardial injury (PMI) can also be visualized by cardiac magnetic resonance imaging, a technique which allows the detection and quantification of myocardial necrosis following PCI. The identification of CAD patients at greatest risk of sustaining PMI during PCI would allow targeted treatment with novel therapies capable of limiting the extent of PMI or reducing the number of patients experiencing PMI.
Collapse
Affiliation(s)
- Girish Ganesha Babu
- Division of Medicine, The Hatter Cardiovascular Institute, University College Medical School, 67 Chenies Mews, London, UK
| | | | | | | |
Collapse
|
19
|
Comparing the Effects of Carvedilol Enantiomers on Regression of Established Cardiac Hypertrophy Induced by Pressure Overload. Lab Anim Res 2010. [DOI: 10.5625/lar.2010.26.1.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
20
|
|
21
|
Knaapen P, Camici PG, Marques KM, Nijveldt R, Bax JJ, Westerhof N, Götte MJW, Jerosch-Herold M, Schelbert HR, Lammertsma AA, van Rossum AC. Coronary microvascular resistance: methods for its quantification in humans. Basic Res Cardiol 2009; 104:485-98. [PMID: 19468781 PMCID: PMC2722717 DOI: 10.1007/s00395-009-0037-z] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 05/11/2009] [Accepted: 05/13/2009] [Indexed: 12/20/2022]
Abstract
Coronary microvascular dysfunction is a topic that has recently gained considerable interest in the medical community owing to the growing awareness that microvascular dysfunction occurs in a number of myocardial disease states and has important prognostic implications. With this growing awareness, comes the desire to accurately assess the functional capacity of the coronary microcirculation for diagnostic purposes as well as to monitor the effects of therapeutic interventions that are targeted at reversing the extent of coronary microvascular dysfunction. Measurements of coronary microvascular resistance play a pivotal role in achieving that goal and several invasive and noninvasive methods have been developed for its quantification. This review is intended to provide an update pertaining to the methodology of these different imaging techniques, including the discussion of their strengths and weaknesses.
Collapse
Affiliation(s)
- Paul Knaapen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Yao DK, Jia SQ, Wang L, Li HW, Zhang YC, Wang YL, Wang LX. Therapeutic effect of urapidil on myocardial perfusion in patients with ST-elevation acute coronary syndrome. Eur J Intern Med 2009; 20:152-7. [PMID: 19327603 DOI: 10.1016/j.ejim.2008.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 05/05/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the effect of urapidil on myocardial perfusion, and ventricular function in patients with ST-elevation acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PCI). METHODS Fifty-four patients were randomized into urapidil (12.5 mg, ic, n=27) or control group. Infarct related artery (IRA) was targeted with PCI following urapidil administration. TIMI blood flow, corrected TIMI frame count (cTFC), myocardial blush grade (MBG), ST resolution (STR) on ECG, creatine kinase MB (CK-MB) and cardiac troponin T (cTnT) were measured before, and after PCI. RESULTS cTFC (18.38+/-3.30 vs 21.44+/-4.26, P=0.005), in the treatment group was lower than the placebo group, whereas MBG was higher (P=0.04). More patients in the urapidil group achieved significant STR following PCI (93% vs 70%, P=0.04). Left ventricular ejection fraction (LVEF), measured with echocardiography, in the urapidil group was higher than the control group 30 days after PCI (0.58+/-0.06 vs 0.54+/-0.06, P=0.04). Peak CK-MB and peak cTnT in the urapidil group was lower than the control group (P<0.01). Myocardial nitric oxide concentration in the urapidil group was higher than that of the control group (P<0.01). Following PCI, the endothelin-1 level did not change in the urapidil group (P>0.05) but it was increased in the control group (P<0.05). CONCLUSIONS Urapidil treatment improves coronary flow, myocardial perfusion and left ventricular function following PCI in patients with ST-elevation ACS. These beneficial effects are associated with an enhanced biosynthesis of nitric oxide.
Collapse
Affiliation(s)
- Dao-kuo Yao
- Heart & Blood Vessel Center of Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
Considerable focus has been directed towards coronary arterial disease in the management of coronary heart disease, however the coronary microcirculation plays a major role in the regulation of coronary blood flow. Thus while we have multiple medical and revascularisation therapies to treat large vessel coronary artery disease, therapies directed towards the microcirculation are very limited. This review paper summarises important aspects of coronary microvascular dysfunction including (a) methods of assessment, (b) clinical classification of associated disorders, (c) possible pathophysiological mechanisms, and (d) potential therapies. Hence this will provide important background to advancing our understanding and management of coronary heart disease by targeting the coronary microcirculation.
Collapse
Affiliation(s)
- John F Beltrame
- Cardiology Unit, The Queen Elizabeth Hospital, Lyell McEwin Health Service, University of Adelaide, Adelaide, Australia.
| | | | | |
Collapse
|
24
|
Kolyva C, Verhoeff BJ, Spaan JAE, Piek JJ, Siebes M. Increased diastolic time fraction as beneficial adjunct of α1-adrenergic receptor blockade after percutaneous coronary intervention. Am J Physiol Heart Circ Physiol 2008; 295:H2054-60. [DOI: 10.1152/ajpheart.91400.2007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effect of α1-receptor blockade with urapidil on coronary blood flow and left ventricular function has been attributed to relief of diffuse coronary vasoconstriction following percutaneous coronary intervention (PCI). We hypothesized that an increase in diastolic time fraction (DTF) contributes to the beneficial action of urapidil. In eleven patients with a 63% (SD 13) diameter stenosis, ECG, aortic pressure (Pa) and distal intracoronary pressure (Pd), and blood flow velocity were recorded at baseline and throughout adenosine-induced hyperemia. Measurements were obtained before and after PCI and after subsequent α1-receptor blockade with urapidil (10 mg ic). DTF was determined from the ECG and the Pa waveform. Functional parameters such as coronary flow velocity reserve, fractional flow reserve, and an index of hyperemic microvascular resistance (HMR) were assessed. Urapidil administration after PCI induced an upward shift in the DTF-heart rate relationship, resulting in a 3.1% (SD 2.7) increase in hyperemic DTF at a constant heart rate ( P < 0.005) due to a shorter duration of systole. Hyperemic Pa and Pd decreased, respectively, by 6.1% (SD 6.6; P < 0.05) and 5.7% (SD 5.8; P < 0.01) after α1-blockade. Although epicardially measured functional parameters were on average not altered by α1-blockade due to concurrent changes in pressure and heart rate, HMR decreased by urapidil in those patients where coronary pressure remained constant. In conclusion, α1-receptor blockade after PCI produced a modest but significant prolongation of DTF at a given heart rate, thereby providing an adjunctive beneficial mechanism for improving subendocardial perfusion, which critically depends on DTF.
Collapse
|
25
|
Affiliation(s)
- Paolo G Camici
- Medical Research Council Clinical Sciences Centre Hammersmith Hospital, and National Heart and Lung Institute, Imperial College, London, United Kingdom.
| | | |
Collapse
|
26
|
Shannon R, Chaudhry M. Effect of alpha1-adrenergic receptors in cardiac pathophysiology. Am Heart J 2006; 152:842-50. [PMID: 17070143 DOI: 10.1016/j.ahj.2006.05.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 05/22/2006] [Indexed: 11/20/2022]
Abstract
Compelling evidence now exists that proves adrenergic blockade is at the center of neurohormonal antagonism in heart failure (HF). Catecholamines are well known to act through both beta- and alpha-adrenergic receptors (ARs), which mediate their effects through distinct receptor pathways. Beta-AR blockers are commonly used in the treatment of HF and have distinct receptor affinity profiles. The recent COMET trial comparing 2 important beta-blocking drugs showed a distinct advantage for carvedilol in decreasing the risk of mortality from HF. The mechanism of action for carvedilol differs from metoprolol tartrate in its ability to block both alpha- and beta-ARs, leading to renewed interest in the potential role of alpha-ARs in the progression of HF. In contrast, however, the ALLHAT study discontinued use of doxazosin, an alpha1-receptor blocker because of an increase in cardiovascular events among patients using this drug. The results of these studies appear to be in contrast with respect to the role of alpha-ARs in regards to cardiovascular pathophysiology. Further study of the alpha-receptor and understanding the role of alpha-ARs in HF is necessary to understand the therapeutic effect of alpha-blockade. This article reviews our understanding of the alpha-AR in HF.
Collapse
Affiliation(s)
- Richard Shannon
- Allegheny General Hospital, University School of Medicine, Pittsburgh, PA 15212, USA
| | | |
Collapse
|
27
|
Abstract
During the past three decades, percutaneous coronary intervention has become one of the cardinal treatment strategies for stenotic coronary artery disease. Technical advances, including the introduction of new devices such as stents, have expanded the interventional capabilities of balloon angioplasty. At the same time, there has been a decline in the rate of major adverse cardiac events, including Q-wave acute myocardial infarction, emergency coronary artery bypass grafting, and cardiac death. Despite these advances, the incidence of post-procedural cardiac marker elevation has not substantially decreased since the first serial assessment 20 years ago. As of now, these post-procedural cardiac marker elevations are considered to represent peri-procedural myocardial injury (PMI) with worse long-term outcome potential. Recent progress has been made for the identification of two main PMI patterns, one near the intervention site (proximal type, PMI type I) and one in the distal perfusion territory of the treated coronary artery (distal type, PMI type II) as well as for preventive strategies. Integrating these new developments into the wealth of clinical information on this topic, this review aims at giving a current perspective on the entity of PMI.
Collapse
Affiliation(s)
- Joerg Herrmann
- Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street S.W., Rochester, MN 55905, USA.
| |
Collapse
|
28
|
Kozàkovà M, Marco J, Heusch G, Bernies M, Bossi IM, Palombo C, Anguissola GB, Donatelli F, Laurent JP, Gregorini L. The alpha1-adrenergic blocker urapidil improves contractile function in patients 3 months after coronary stenting: a randomized, double-blinded study. Am Heart J 2004; 147:E6. [PMID: 14760340 DOI: 10.1016/j.ahj.2003.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The recovery of left ventricular function (LVF) after revascularization takes time. alpha-Adrenergic blockade acutely improves coronary blood flow and LVF, whereas the effects of more prolonged alpha-adrenergic blockade on LVF recovery after stenting are unknown. METHODS In 32 patients (age 58 +/- 12 y) with an 82% +/- 6% stenosis, ejection fraction (EF) and systolic thickening (%Th) were measured by transthoracic echocardiography before and 30 minutes to 2 hours after revascularization. In a double-blinded protocol, either 200 microg/kg urapidil or placebo was given intravenously, and LVF was measured 10 minutes later. Two hours later, oral treatment with 30 mg/d drug or placebo was started, and LVF measured again after 24 hours and 3 months. RESULTS Before revascularization, EF was 49.4% +/- 8.5% (+/-SD) and 51.3% +/- 8.8% in the urapidil-treated and the placebo groups, respectively. Thirty minutes to 2 hours after coronary stenting, EF was unchanged. After intravenous drug administration, EF increased to 56.5% +/- 9.7%). At 24 hours and 3 months after revascularization, EF became 59.5% +/- 7.9% and 59.6% +/- 8.2% in the urapidil-treated group, respectively, whereas EF in the placebo group did not change (50.4% +/- 5.7% and 49.7% +/- 4.9%, respectively). Revascularization did not acutely improve %Th. Intravenous urapidil improved %Th from 31.4% +/- 17.6% to 44.2% +/- 11.6%, whereas there was no change in the placebo group. At 3 months, %Th was 49.5% +/- 12.9% in the urapidil-treated group and 39.7% +/- 8.9% in the placebo group. CONCLUSIONS These data suggest that long-term alpha-adrenergic blockade might improve LVF at midterm after coronary revascularization.
Collapse
Affiliation(s)
- Michaela Kozàkovà
- Clinique Pasteur, Centre de Cardiologie Interventionelle, Toulouse, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Frimerman A, Keren G, Rosenschein U, Basan S, Miller H. Clinical parameters and functional tests are not predictive for in-stent restenosis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2003; 5:151-5. [PMID: 12959732 DOI: 10.1080/14628840310017816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To study the correlation between clinical parameters and the occurrence of in-stent restenosis in a cohort of patients from the Tel Aviv Medical Center who underwent repeat angiograms for clinical indications following stenting. BACKGROUND After stenting, recurrences of symptoms or ischemia on functional tests are considered to be clinical signs of restenosis. METHODS The authors' study group consisted of 149 out of 1469 patients (10%) who underwent stent implantation between 1996 and 1998 and were under clinical follow-up. This group had a repeat angiogram for clinical indications: chest pain or a positive functional test (thallium study or ergometry). RESULTS Sixty-eight patients (45%) had in-stent restenosis (ISR), 32 (21%) had a patent stent site with a significant coronary atherosclerosis elsewhere requiring revascularization (NTLR), and 51 (34%) had a patent stent site and did not require additional revascularization (PS). Baseline characteristics were similar in all the groups. There was a 63% rate of objective evidence of ischemia in the PS group, similar to the ISR (63%) and NTLR (74%) groups. In the ISR versus the NTLR and PS groups the stents were longer (22 +/- 10 versus 17 +/- 7 and 16 +/- 6 mm, p < 0.001) with a smaller diameter (3 +/- 0.4 versus 3.3 +/- 0.5 and 3.2 +/- 0.4 mm, p < 0.05) and a higher rate of multiple stents in the target lesion (34% versus 19% and 14%, p < 0.05) CONCLUSIONS In the cohort of patients who underwent angiography following stenting for chest pain or a positive functional test, 55% were found to have a patent stent site. The 5% total in-stent restenosis is significantly lower than the rate in angiography-based reports. On the other hand, the group with a patent stent had a higher than expected rate of objective evidence of ischemia. Therefore clinical parameters and functional tests are not predictive for in-stent restenosis.
Collapse
|
30
|
Murphy SA, Chen C, Gourlay SG, Gibbons RJ, Barron HV, Gibson CM. Impairment of myocardial perfusion in both culprit and nonculprit arteries in acute myocardial infarction: a LIMIT AMI substudy. Am J Cardiol 2003; 91:325-8. [PMID: 12565089 DOI: 10.1016/s0002-9149(02)03160-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
31
|
Heusch G. Emerging importance of alpha-adrenergic coronary vasoconstriction in acute coronary syndromes and its genetic background. J Am Coll Cardiol 2003; 41:195-6. [PMID: 12535807 DOI: 10.1016/s0735-1097(02)02703-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
32
|
Hellstrom HR. Can the premises of the spasm of resistance vessel concept permit improvement in the treatment and prevention of ischemic heart disease? Med Hypotheses 2003; 60:36-51. [PMID: 12450766 DOI: 10.1016/s0306-9877(02)00330-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this communication, the spasm of resistance vessel (S-RV) concept of ischemic heart disease (IHD) and other ischemic will be reviewed and updated, and evidence will be presented that principles of the hypothesis might improve the treatment and prevention of IHD. The S-RV concept provides a different basic pathogenetic framework for IHD, and suggestions for treatment and prevention stem from its different basic conceptualization of this disorder. The concept asserts that S-RV directly induces symptoms in IHD, and this position challenges the accepted pathogenetic mechanism for this disorder, i.e., that symptoms in IHD are due directly to obstructive occlusions of epicardial arteries secondary to coronary artery disease. The S-RV concept avers that ischemia-induced S-RV is a major factor in IHD, and evidence supporting this position is provided. Another major position of the hypothesis is that no-reflow (reduced flow after infarction and severe myocardial ischemia in the absence of infarction) is due to ischemic injury-induced S-RV, and a variety of evidences to support this position are offered.Proposed improvement in the treatment of IHD is based mainly on treating ischemia-induced S-RV. alpha-Adrenergic sympathetic blockade reverses ischemia-induced S-RV, and alpha-adrenergic blockade is suggested as therapy for acute coronary syndromes and to prevent complications of percutaneous coronary interventions. Also, angiotensin-converting enzyme inhibition, which has actions similar to alpha-adrenergic blockade, is also suggested. Proposals for the prevention of IHD are based the prevention of S-RV, and special emphasis is given to preventing exercise- and stress-related IHD.
Collapse
Affiliation(s)
- H R Hellstrom
- Department of Pathology, College of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA.
| |
Collapse
|
33
|
Abstract
The endothelium plays a key role in vascular homeostasis through the release of a variety of autocrine and paracrine substances, the best characterized being nitric oxide. A healthy endothelium acts to prevent atherosclerosis development and its complications through a complex and favorable effect on vasomotion, platelet and leukocyte adhesion and plaque stabilization. The assessment of endothelial function in humans has generally involved the description of vasomotor responses, but more widely includes physiological, biochemical and genetic markers that characterize the interaction of the endothelium with platelets, leukocytes and the coagulation system. Stable markers of inflammation such as high sensitivity C-reactive protein are indirect and potentially useful measures of endothelial function for example. Attenuation of the effect of nitric oxide accounts for the majority of what is described as endothelial dysfunction. This occurs in response to atherosclerosis or its risk factors. Much remains to be learned about the molecular and genetic pathophysiological mechanisms of endothelial cell abnormalities. However, pharmacological intervention with a growing list of medications can favorably modify endothelial function, paralleling beneficial effects on cardiovascular morbidity and mortality. In addition, several small studies have provided tantalizing evidence that measures of endothelial health might provide prognostic information about an individual patient's risk of subsequent events. As such, the sum of this evidence makes the clinical assessment of endothelial function an attractive surrogate marker of atherosclerosis disease activity. The review will focus on the role of nitric oxide in atherosclerosis and the clinical relevance of these findings.
Collapse
Affiliation(s)
- Todd J Anderson
- Department of Medicine, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
34
|
Gregorini L, Marco J, Farah B, Bernies M, Palombo C, Kozàkovà M, Bossi IM, Cassagneau B, Fajadet J, Di Mario C, Albiero R, Cugno M, Grossi A, Heusch G. Effects of selective alpha1- and alpha2-adrenergic blockade on coronary flow reserve after coronary stenting. Circulation 2002; 106:2901-7. [PMID: 12460869 DOI: 10.1161/01.cir.0000040998.88272.a7] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary flow reserve (CFR) is not normalized shortly after coronary stenting. We hypothesized that alpha-adrenergic coronary vasoconstriction acts to limit CFR. METHODS AND RESULTS We assessed flow velocity by Doppler wires and cross-sectional area by angiography in 46 patients undergoing coronary culprit lesion stenting (81+/-4% stenosis). Hyperemia was induced by adenosine (24 micro g IC or 140 micro g/kg per minute IV) before and after stenting. Finally, either the alpha(1)-antagonist urapidil (10 mg IC) or the alpha(2)-antagonist yohimbine (3 mg IC) was randomly combined with adenosine. In 8 subjects with angiographically normal coronary arteries, CFR was increased from 3.21+/-0.30 to 3.74+/-0.43 by yohimbine and to 4.58+/-0.65 by urapidil, respectively (P=0.0001). Patients were divided according to the cutoff of CFR > or =3.0 (n=18) or <2.5 (n=28). Revascularization per se did not change CFR. However, 15 minutes after stenting, CFR decreased to 2.05+/-0.55 from CFR 3.64+/-0.58, whereas in patients with CFR 2.39+/-0.51, it remained unchanged. Yohimbine improved CFR to 3.26+/-0.42 and to 3.41+/-0.58 in patients with >3.0 and <2.05+/-0.55 baseline CFR, respectively. Urapidil improved CFR to 3.52+/-0.30 and 3.98+/-1.07, respectively. CONCLUSIONS Urapidil and yohimbine attenuated the CFR impairment occurring after revascularization by increasing both the epicardial vasodilator effect of adenosine and the blood flow velocity, thus suggesting that the adrenergic system plays an important role in limiting the capacity of the coronary circulation to dilate.
Collapse
Affiliation(s)
- Luisa Gregorini
- Experimental Surgery and Transplantation Institute, Ospedale Maggiore IRCCS, University of Milano, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Gibson CM, Frisch D, Murphy SA, Gourlay SG, Gibbons R, Baran KW, Nguyen M, Palmeri S, Barron HV. The relationship of intracoronary stent placement following thrombolytic therapy to tissue level perfusion. J Thromb Thrombolysis 2002; 13:63-8. [PMID: 12101381 DOI: 10.1023/a:1016253028348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Stenting has been shown to improve lumen diameters and thereby improve epicardial blood flow, but the impact of stent placement on tissue level perfusion has not been well characterized. METHODS Data were drawn from the LIMIT trial of rhuMAb CD18 (anti WBC antibody) in acute myocardial infarction (AMI). Adjunctive/rescue stenting was performed at the discretion of the investigator. The TIMI Myocardial Perfusion Grade (TMPG) was assessed and digital subtraction angiography (DSA) was used to quantify brightness of the myocardial blush. RESULTS TIMI 3 flow was 54.2% (64/118) before stent placement, and improved to 87.2% (102/117, p < 0.001) following stent placement. Likewise, Corrected TIMI Frame Counts (CTFCs) improved from medians of 37.6 to 21 (p < 0.001). By DSA, the rate of growth in brightness also tended to be greater after stenting (2.3 +/- 0.4 Gray/sec, n = 54 vs 3.1 +/- 0.3, n = 54, p = 0.07). The incidence of TMPG 0 decreased following stent placement (25.2% (29/118) vs 14.3% (16/118), p = 0.03) and the incidence of a stain in the myocardium (TMPG 1) increased (13.5% (16/118) vs 28.6% (34/118), p = 0.004). CONCLUSION Adjunctive stenting following thrombolytic administration in AMI improves epicardial TIMI 3 flow and TIMI frame counts as well as dye inflow into the myocardium: TMPG 0 is reduced and myocardial blush measured quantitatively by DSA tends to be brighter. However, more TMPG 1 or dye staining was present on next injection, suggesting dye outflow may be impaired.
Collapse
|
36
|
Rimoldi O, Spyrou N, Foale R, Hackett DR, Gregorini L, Camici PG. Limitation of coronary reserve after successful angioplasty is prevented by oral pretreatment with an alpha1-adrenergic antagonist. J Cardiovasc Pharmacol 2000; 36:310-5. [PMID: 10975587 DOI: 10.1097/00005344-200009000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Coronary vasoconstriction that occurs after percutaneous transluminal coronary angioplasty (PTCA) is abolished by intracoronary phentolamine. An impairment of coronary vasodilator reserve (CVR) has been observed < or = 7 days after successful PTCA. To ascertain whether pretreatment with the alpha1-adrenergic receptor blocker doxazosin could prevent the limitation of CVR after PTCA, we carried out a randomised, double-blind, controlled study on 26 patients with significant (> 75%) single vessel disease undergoing PTCA. Twelve patients received doxazosin 4 mg daily in addition to their standard treatment, while 14 patients received matching placebo, starting 11 days before PTCA. Myocardial blood flow (MBF) at baseline and after i.v. dipyridamole (0.56 mg/kg) was measured within 5 days after PTCA using positron emission tomography (PET) with oxygen-15-labelled water. Angioplasty was successful in all patients with a residual stenosis < or = 35%. At PET scanning, hemodynamic parameters were comparable in the two groups. In the territory subtended by the dilated artery, CVR was significantly higher in patients treated with doxazosin compared with those receiving placebo (2.78 +/- 0.1.21 vs. 1.95 +/- 0.68; p < 0.01). Conversely, CVR in the remote territories subtended by angiographically normal arteries was similar in the two groups (2.53 +/- 0.92 and 2.48 +/- 0.80, respectively; p = NS). Treatment with oral doxazosin in addition to standard antianginal therapy can prevent the impairment of CVR frequently observed despite successful PTCA.
Collapse
Affiliation(s)
- O Rimoldi
- MRC Clinical Sciences Centre, Hammersmith Hospital, London, England, UK.
| | | | | | | | | | | |
Collapse
|
37
|
Heusch G, Baumgart D, Camici P, Chilian W, Gregorini L, Hess O, Indolfi C, Rimoldi O. alpha-adrenergic coronary vasoconstriction and myocardial ischemia in humans. Circulation 2000; 101:689-94. [PMID: 10673263 DOI: 10.1161/01.cir.101.6.689] [Citation(s) in RCA: 181] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of quantitative coronary angiography, combined with Doppler and PET, has recently been directed at the study of alpha-adrenergic coronary vasomotion in humans. Confirming prior animal experiments, there is no evidence of alpha-adrenergic coronary constrictor tone at rest. Again confirming prior experiments, responses to alpha-adrenoceptor activation are augmented in the presence of coronary endothelial dysfunction and atherosclerosis, involving both alpha(1)- and alpha(2)-adrenoceptors in epicardial conduit arteries and microvessels. Such augmented alpha-adrenergic coronary constriction is observed during exercise and coronary interventions, and it is powerful enough to induce myocardial ischemia and limit myocardial function. Recent studies indicate a genetic determination of alpha(2)-adrenergic coronary constriction.
Collapse
Affiliation(s)
- G Heusch
- Abteilung für Pathophysiologie and Abteilung für Kardiologie, Universitätsklinikum Essen, Essen, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
38
|
|
39
|
Gregorini L, Marco J, Kozàkovà M, Palombo C, Anguissola GB, Marco I, Bernies M, Cassagneau B, Distante A, Bossi IM, Fajadet J, Heusch G. Alpha-adrenergic blockade improves recovery of myocardial perfusion and function after coronary stenting in patients with acute myocardial infarction. Circulation 1999; 99:482-90. [PMID: 9927393 DOI: 10.1161/01.cir.99.4.482] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AMI reperfusion by thrombolysis does not improve TIMI flow and LV function. The role of infarct-related artery (IRA) stenosis and superimposed changes in coronary vasomotor tone in maintaining LV dysfunction must be elucidated. METHODS AND RESULTS Forty patients underwent diagnostic angiography 24 hours after thrombolysis. Seventy-two hours after thrombolysis, the culprit lesion was dilated with coronary stenting. During angioplasty, LV function was monitored by transesophageal echocardiography. Percent regional systolic thickening was quantitatively assessed before PTCA, soon after stenting, 15 minutes after stenting, and after phentolamine 12 microg/kg IC (n=10), the alpha1-blocker urapidil 600 microg/kg IV (n=10), or saline (n=10). Ten patients pretreated with beta-blockers received urapidil 10 mg IC. Coronary stenting significantly improved thickening in IRA-dependent and in non-IRA-dependent myocardium (from 27+/-15% to 38+/-16% and from 40+/-15% to 45+/-15%, respectively). Simultaneously, TIMI frame count decreased from 39+/-11 and 40+/-11 in the IRA and non-IRA, respectively, to 23+/-10 and 25+/-7 (P<0.05). Fifteen minutes after stenting, thickening worsened in both IRA- and non-IRA-dependent myocardium (to 19+/-14% and 28+/-14%, P<0.05), and TIMI frame count returned, in both the IRA and non-IRA, to the values obtained before stenting. Phentolamine and urapidil increased thickening to 36+/-17% and 41+/-14% in IRA and to 48+/-11% and 49+/-17% in non-IRA myocardium respectively, and TIMI frame count decreased to 16+/-6 and to 17+/-5, respectively. Changes were attenuated with beta-blocker pretreatment. CONCLUSIONS Our finding that alpha-adrenergic blockade attenuates vasoconstriction and postischemic LV dysfunction supports the hypothesis of an important role of neural mechanisms in this phenomenon.
Collapse
Affiliation(s)
- L Gregorini
- Clinique Pasteur, Centre de Cardiologie Interventionelle, Toulouse, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
The alpha-adrenergic blockers have played an important role in the treatment of vascular diseases. Nonselective alpha blockers have been used as treatments for patients with severe hypertension, including pheochromocytoma. Selective alpha 1 blockers have been used in the treatment of hypertension and prostatic obstruction, and these drugs have also been considered in the treatment of other vascular and nonvascular conditions. They have unique metabolic actions, specifically on plasma lipids and lipoproteins, which could be of clinical benefit.
Collapse
Affiliation(s)
- W H Frishman
- Department of Medicine, New York Medical College, Valhalla, USA
| | | |
Collapse
|