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Tsuda T, Patel G. Coronary microvascular dysfunction in childhood: An emerging pathological entity and its clinical implications. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100392. [PMID: 38680649 PMCID: PMC11046079 DOI: 10.1016/j.ahjo.2024.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
Coronary microvascular dysfunction (CMD) encompasses a spectrum of structural and functional alterations in coronary microvasculature resulting in impaired coronary blood flow and consequent myocardial ischemia without obstruction in epicardial coronary artery. The pathogenesis of CMD is complex involving both functional and structural alteration in the coronary microcirculation. In adults, CMD is predominantly discussed in context with anginal chest pain or existing ischemic heart disease and its risk factors. The presence of CMD suggests increased risk of adverse cardiovascular events independent of coronary atherosclerosis. Coronary microvascular dysfunction is also known in children but is rarely recognized due to paucity of concommitent coronary artery disease. Thus, its clinical presentation, underlying mechanism of impaired microcirculation, and prognostic significance are poorly understood. In this review article, we will overview variable CMD reported in children and delineate its emerging clinical significance.
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Affiliation(s)
- Takeshi Tsuda
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Gina Patel
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE 19803, USA
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Moody JB, Poitrasson-Rivière A, Renaud JM, Hagio T, Alahdab F, Al-Mallah MH, Vanderver MD, Ficaro EP, Murthy VL. Self-supervised deep representation learning of a foundation transformer model enabling efficient ECG-based assessment of cardiac and coronary function with limited labels. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.10.25.23297552. [PMID: 37961713 PMCID: PMC10635192 DOI: 10.1101/2023.10.25.23297552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background: Although deep learning methods have shown great promise for identification of structural and functional cardiac abnormalities using electrocardiographic data, these methods are data hungry, posing a challenge for critically important tasks where ground truth labels are relatively scarce. Impaired coronary microvascular and vasomotor function is difficult to identify with standard clinical methods of cardiovascular testing such as coronary angiography and noninvasive single photon emission tomography (SPECT) myocardial perfusion imaging (MPI). Gold standard data from positron emission tomography (PET) are gaining emphasis in clinical guidelines but are expensive and only available in relatively limited centers. We hypothesized that signals embedded within resting and stress electrocardiograms (ECGs) identify individuals with microvascular and vasomotor dysfunction. Methods: We developed and pretrained a self-supervised foundation vision transformer model using a large database of unlabeled ECG waveforms (N=800,035). We then fine-tuned the foundation model for two clinical tasks: the difficult problem of identifying patients with impaired myocardial flow reserve (AI-MFR), and the relatively easier problem of detecting impaired LVEF (AI-LVEF). A second ECG database was labeled with task-specific annotations derived from quantitative PET MPI (N=4167). Diagnostic accuracy of AI predictions was tested in a holdout set of patients undergoing PET MPI (N=1031). Prognostic evaluation was performed in the PET holdout cohort, as well as independent cohorts of patients undergoing pharmacologic or exercise stress SPECT MPI (N=6635). Results: The diagnostic accuracy of AI-MFR with SSL pretraining increased significantly compared to de novo supervised training (AUROC, sensitivity, specificity: 0.758, 70.1%, 69.4% vs. 0.632, 66.1%, 57.3%, p < 0.0001). SSL pretraining also produced a smaller increase in AI-LVEF accuracy (AUROC, sensitivity, specificity: 0.946, 89.4%, 85.9% vs. 0.918, 87.6%, 82.5%, p < 0.02). Abnormal AI-MFR was found to be significantly associated with mortality risk in all three test cohorts (Hazard Ratio (HR) 2.61 [95% CI 1.83, 3.71], p < 0.0001, PET cohort; HR 2.30 [2.03, 2.61], p < 0.0001, pharmacologic stress SPECT cohort; HR 3.76 [2.36, 5.99], p < 0.0001, exercise stress SPECT cohort). Conclusion: SSL pretraining of a vision transformer foundation model enabled identification of signals predictive of impaired MFR, a hallmark of microvascular and vasomotor dysfunction, and impaired LV function in resting and stress ECG waveforms. These signals are powerful predictors of prognosis in patients undergoing routine noninvasive stress testing and could enable more efficient diagnosis and management of these common conditions.
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Ong P, Rudolph TK, Wiebe J, Berger R, Woitek F, Landmesser U. [Angina and no obstruction on coronary angiography : New approaches to the diagnosis and treatment of vasomotor disorders]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:495-502. [PMID: 38517528 DOI: 10.1007/s00108-024-01690-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Clinical management of patients with angina and no obstructive coronary artery disease (ANOCA) is still challenging. This scenario affects up to 50% of patients undergoing diagnostic coronary angiography due to suspected coronary artery disease. Many patients report a long and debilitating history before adequate diagnostics and management are initiated. OBJECTIVES This article describes the current recommendations for diagnostic assessments and treatment in patients with ANOCA. Focus is placed on invasive diagnostics in the catheter laboratory, pharmacological/interventional treatment as well as the patient journey. RESULTS In patients with ANOCA, the current European Society of Cardiology (ESC) guidelines suggest that invasive assessments using acetylcholine and adenosine for the diagnosis of an underlying coronary vasomotor disorder should be considered. Acetylcholine is used to diagnose coronary spasm, whereas adenosine is used in conjunction with a wire-based assessment for the measurement of coronary flow reserve and microvascular resistance. The invasive assessments allow the determination of what are referred to as endotypes (coronary spasm, impaired coronary flow reserve, enhanced microvascular resistance or a combination thereof). Establishing a diagnosis is helpful to: (a) initiate targeted treatment to improve quality of life, (b) reassure the patient that a cardiac cause is found and (c) to assess individual prognosis. CONCLUSIONS Currently, patients with ANOCA are often not adequately managed. Referral to specialised centres is recommended to prevent long and debilitating patient histories until expertise in diagnosis and treatment becomes more widespread.
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Affiliation(s)
- Peter Ong
- Abteilung für Kardiologie und Angiologie, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland.
| | - Tanja K Rudolph
- Klinik für Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Jens Wiebe
- Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland
| | - Rudolf Berger
- Abteilung für Kardiologie und Nephrologie, Innere Medizin I, Krankenhaus der Barmherzigen Brüder, Johannes von Gott Platz 1, 7000, Eisenstadt, Österreich
| | - Felix Woitek
- Herzzentrum Dresden GmbH, Universitätsklinik, Fetscherstraße 76, 01307, Dresden, Deutschland
| | - Ulf Landmesser
- Klinik für Kardiologie, Angiologie und Intensivmedizin, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
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Tremmel R, Martínez Pereyra V, Broders I, Schaeffeler E, Hoffmann P, Nöthen MM, Bekeredjian R, Sechtem U, Schwab M, Ong P. Genetic associations of cardiovascular risk genes in European patients with coronary artery spasm. Clin Res Cardiol 2024:10.1007/s00392-024-02446-x. [PMID: 38635033 DOI: 10.1007/s00392-024-02446-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Coronary artery spasm (CAS) is a frequent finding in patients presenting with angina pectoris. Although the pathogenesis of CAS is incompletely understood, previous studies suggested a genetic contribution. Our study aimed to elucidate genetic variants in a cohort of European patients with angina and unobstructed coronary arteries who underwent acetylcholine (ACh) provocation testing. METHODS A candidate association analysis of 208 genes previously associated with cardiovascular conditions was performed using genotyped and imputed variants in patients grouped in epicardial (focal, diffuse) CAS (n = 119) and microvascular CAS (n = 87). Patients with a negative ACh test result (n = 45) served as controls. RESULTS We found no association below the genome-wide significance threshold of p < 5 × 10-8, thus not confirming variants in ALDH2, NOS3, and ROCK2 previously reported in CAS patients of Asian ancestry. However, the analysis identified suggestive associations (p < 10-05) for the groups of focal epicardial CAS (CDH13) and diffuse epicardial CAS (HDAC9, EDN1). Downstream analysis of the potential EDN1 risk locus showed that CAS patients have significantly increased plasma endothelin-1 levels (ET-1) compared to controls. An EDN1 haplotype comprising rs9349379 and rs2070698 was significantly associated to ET-1 levels (p = 0.01). CONCLUSIONS In summary, we suggest EDN1 as potential genetic risk loci for patients with diffuse epicardial CAS, and European ancestry. Plasma ET-1 levels may serve as a potential cardiac marker.
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Affiliation(s)
- Roman Tremmel
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
| | - Valeria Martínez Pereyra
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Incifer Broders
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
| | - Per Hoffmann
- Institute of Human Genetics, University of Bonn, Bonn, Germany
- Division of Medical Genetics, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Markus M Nöthen
- Institute of Human Genetics, University of Bonn, Bonn, Germany
- Department of Genomics, Life & Brain Center, University of Bonn, Bonn, Germany
| | - Raffi Bekeredjian
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Departments of Clinical Pharmacology, and Pharmacy and Biochemistry, University of Tübingen, Tübingen, Germany
- University of Tübingen, Tübingen, Germany
| | - Peter Ong
- Department of Cardiology and Angiology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany.
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Sato T, Hanna P, Mori S. Innervation of the coronary arteries and its role in controlling microvascular resistance. J Cardiol 2024:S0914-5087(24)00010-8. [PMID: 38346669 DOI: 10.1016/j.jjcc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 04/08/2024]
Abstract
The coronary circulation plays a crucial role in balancing myocardial perfusion and oxygen demand to prevent myocardial ischemia. Extravascular compressive forces, coronary perfusion pressure, and microvascular resistance are involved to regulate coronary blood flow throughout the cardiac cycle. Autoregulation of the coronary blood flow through dynamic adjustment of microvascular resistance is maintained by complex interactions among mechanical, endothelial, metabolic, neural, and hormonal mechanisms. This review focuses on the neural mechanism. Anatomy and physiology of the coronary arterial innervation have been extensively investigated using animal models. However, findings in the animal heart have limited applicability to the human heart as cardiac innervation is generally highly variable among species. So far, limited data are available on the human coronary artery innervation, rendering multiple questions unresolved. Recently, the clinical entity of ischemia with non-obstructive coronary arteries has been proposed, characterized by microvascular dysfunction involving abnormal vasoconstriction and impaired vasodilation. Thus, measurement of microvascular resistance has become a standard diagnostic for patients without significant stenosis in the epicardial coronary arteries. Neural mechanism is likely to play a pivotal role, supported by the efficacy of cardiac sympathetic denervation to control symptoms in patients with angina. Therefore, understanding the coronary artery innervation and control of microvascular resistance of the human heart is increasingly important for cardiologists for diagnosis and to select appropriate therapeutic options. Advancement in this field can lead to innovations in diagnostic and therapeutic approaches for coronary artery diseases.
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Affiliation(s)
- Takanori Sato
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shumpei Mori
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Wang H, Wu Q, Yang L, Chen L, Liu W, Guo J, Xu J. Application of AMR in evaluating microvascular dysfunction after ST-elevation myocardial infarction. Clin Cardiol 2024; 47:e24196. [PMID: 37997762 PMCID: PMC10823552 DOI: 10.1002/clc.24196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/04/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND A guidewire-free angiography-derived microcirculatory resistance (AMR) derived from Quantitative flow ratio (QFR) exhibits good diagnostic accuracy for assessing coronary microvascular dysfunction (CMD), but there are no relevant studies supporting the specific application of AMR in patients with ST-elevation myocardial infarction (STEMI). The study aims to evaluate CMD in patients with STEMI using the AMR index. METHODS This study included patients with STEMI who underwent percutaneous coronary intervention (PCI) from June 1, 2020 to September 28, 2021. All patients were divided into two groups: the CMD (n = 215) and non-CMD (n = 291) groups. After matching, there were 382 patients in both groups.1-year follow-up major adverse cardiac events (MACEs) were evaluated. RESULTS After matching, the primary endpoint was achieved in 41 patients (10.7%), with 27 and 14 patients in the CMD and non-CMD groups, respectively (HR 1.954 [95% CI 1.025-3.726]; 14.1% versus 7.3%, p = .042). Subgroup analysis revealed that 18 patients (4.7%) were readmitted for heart failure, with 15 and 3 in the CMD and non-CMD groups, respectively (HR 5.082 [95% CI 1.471-17.554]; 7.9% versus 1.6%, p = .010). Post-PCI AMR ≥ 250 was significantly associated with a higher risk of the primary endpoint and was its independent predictor (HR 2.265 [95% CI 1.136-4.515], p = .020). CONCLUSION The retrospective use of AMR with a cutoff value of ≥250 after PCI in patients with STEMI can predict a significant difference in the 1-year MACE rates when compared with a propensity score-matched group with normal AMR.
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Affiliation(s)
- Hao Wang
- Department of CardiologyThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Qi Wu
- The First Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Lang Yang
- Department of CardiologyThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Long Chen
- Shanghai Pulse Medical Technology Inc.ShanghaiChina
| | - Wen‐Zhong Liu
- Department of CardiologyThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Jun Guo
- Department of CardiologyThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Jing‐Song Xu
- Department of CardiologyThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
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Jiang C, Xu H, Wu Y. Effect of chemotherapy in tumor on coronary arteries: Mechanisms and management. Life Sci 2024; 338:122377. [PMID: 38135114 DOI: 10.1016/j.lfs.2023.122377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 12/24/2023]
Abstract
Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. The development of coronary ischemia events, myocardial infarction, and heart failure has been associated with many conventional chemotherapeutic agents, new targeted therapies, and immunotherapy. The most frequent pathological manifestations of chemotherapy-mediated coronary damage include acute vasospasm, acute thrombosis, accelerated atherosclerosis development, and microvascular dysfunction. Potential screening techniques for CAD patients include baseline risk factor evaluation, polygenic risk factors, and coronary artery calcium scores. Determining the risk requires consideration of both the type of chemotherapy and the type of cancer being treated. Cardiology-oncology guidelines offer some suggestions for the care of coronary artery disease, which might involve medication, lifestyle changes, and coronary revascularization.
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Affiliation(s)
- Chengqing Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Ullrich-Daub H, Daub S, Olschewski M, Münzel T, Gori T. Diseases of the Coronary Microcirculation: Diagnosis and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:739-746. [PMID: 37721132 PMCID: PMC10722490 DOI: 10.3238/arztebl.m2023.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) comprises a variety of pathogenic mechanisms that impair the microcirculation of the heart. Clinical studies have shown that 30-50% of patients suffering from myocardial ischemia without significant coronary artery stenosis have CMD. The disease is associated with ele - vated mortality and poor quality of life. Whenever a patient presents with symptoms of angina pectoris and no underlying disease is detected by the usual methods, CMD should be considered a possible cause. METHODS This review is based on publications retrieved by a selective search in PubMed and on current international guidelines and recommendations of specialty societies. RESULTS The diagnosis of CMD is based on objective evidence of a microvascular origin of symptoms. The guidelines contain a class IIa recommendation for invasive coronary flow reserve and microvascular resistance measurements. Noninvasive tests such as positron emission tomography and cardiac magnetic resonance imaging are less accurate and are given a class IIb recommendation. No highquality therapeutic trials are available to date, and the treatment of CMD is thus based on that of chronic coronary syndrome. Lifestyle modification is performed to reduce risk factors. Patients with an abnormal coronary flow reserve or elevated microvascular resistance can be treated with an ACE inhibitor or angiotensin receptor blocker. Beta-blockers and calcium channel antagonists can relieve angina pectoris. Statins lower the LDL level and have positive pleiotropic effects. First-line treatment can be supplemented with further medications. CONCLUSION Approximately 25% of patients with CMD have symptoms that do not respond to intensive treatment with the currently available modalities. New treatments, including interventional therapies, are being studied. Their long-term benefit remains to be assessed and compared to that of the existing methods.
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Affiliation(s)
- Helen Ullrich-Daub
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Steffen Daub
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Maximilian Olschewski
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Thomas Münzel
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
| | - Tommaso Gori
- University Medical Center Mainz, Center for Cardiology, Cardiology I, German Center for Cardiovascular Research (DZHK), RheinMain site, Mainz, Germany
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Tong J, Bei GG, Zhang LB, Sun Y, Qi M, Yang BQ. Relationship between quantitative epicardial adipose tissue based on coronary computed tomography angiography and coronary slow flow. BMC Cardiovasc Disord 2023; 23:500. [PMID: 37817079 PMCID: PMC10566056 DOI: 10.1186/s12872-023-03541-z] [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: 04/22/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND The purpose of this study was to explore the relationship between quantitative epicardial adipose tissue (EAT) based on coronary computed tomography angiography (CCTA) and coronary slow flow (CSF). METHODS A total of 85 patients with < 40% coronary stenosis on diagnostic coronary angiography were included in this retrospective study between January 2020 and December 2021. A semi-automatic method was developed for EAT quantification on CCTA images. According to the thrombolysis in myocardial infarction flow grade, the patients were divided into CSF group (n = 39) and normal coronary flow group (n = 46). Multivariate logistic regression was used to explore the relationship between EAT and CSF. Receiver operating characteristic (ROC) curve was plotted to evaluate the diagnostic value of EAT in CSF. RESULTS EAT volume in the CSF group was significantly higher than that of the normal coronary flow group (128.83± 21.59 mL vs. 101.87± 18.56 mL, P < 0.001). There was no significant difference in epicardial fat attenuation index between the two groups (P > 0.05). Multivariate logistic regression analysis showed that EAT volume was independently related to CSF [odds ratio (OR) = 4.82, 95% confidence interval (CI): 3.06-7.27, P < 0.001]. The area under ROC curve for EAT volume in identifying CSF was 0.86 (95% CI: 0.77-0.95). The optimal cutoff value of 118.46 mL yielded a sensitivity of 0.80 and a specificity of 0.94. CONCLUSIONS Increased EAT volume based on CCTA is strongly associated with CSF. This preliminary finding paves the way for future and larger studies aimed to definitively recognize the diagnostic value of EAT in CSF.
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Affiliation(s)
- Jing Tong
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China
| | - Gui-Guang Bei
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China
| | - Li-Bo Zhang
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China
| | - Yu Sun
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China
| | - Miao Qi
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China
| | - Ben-Qiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang, 110016, Liaoning Province, China.
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Kopeva KV, Mochula AV, Maltseva AN, Soldenko MV, Grakova EV, Zavadovsky KV. Prognostic Role of Dynamic CZT Imaging in Heart Failure With Preserved Ejection Fraction. Clin Nucl Med 2023; Publish Ahead of Print:00003072-990000000-00602. [PMID: 37290425 DOI: 10.1097/rlu.0000000000004738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the prognostic role of myocardial flow reserve (MFR) and myocardial blood flow (MBF) estimates obtained with dynamic cadmium-zinc-telluride (CZT) imaging in the development and progression of heart failure with preserved ejection fraction (HFpEF) in patients with nonobstructive coronary artery disease (CAD) during a 12-month follow-up period. PATIENTS AND METHODS A total of 112 patients (70 men; median age of 62.5 [57.0; 69.0] years) with nonobstructive coronary artery disease were enrolled in the study. Dynamic CZT-SPECT, echocardiography, and coronary CT angiography studies were performed baseline. RESULTS Distribution of patients was performed by adverse events: group 1 comprised patients with adverse outcomes (n = 25), and group 2 comprised those without it (n = 87). Based on receiver operating characteristic analysis, the levels of MFR ≤1.62 (area under the curve [AUС], 0.884; Р < 0.001), stress-MBF ≤1.35 mL/min per gram (AUС, 0.750; Р < 0.001), and NT-proBNP ≥760.5 pg/mL (AUС, 0.764; Р = 0.001) were identified as cutoff values to predict adverse outcomes. Univariate analysis revealed that type 2 diabetes mellitus (P = 0.044), the levels of MFR ≤1.62 (P = 0.014), stress-MBF ≤1.35 mL/min per gram (P = 0.012), NT-proBNP ≥760.5 pg/mL (P = 0.018), and diastolic dysfunction (P = 0.009) were potential risk factors for the development and progression of HFpEF. Multivariate analysis demonstrated that the values of NT-proBNP ≥760.5 pg/mL (odds ratio, 1.87; 95% confidence interval, 1.17-3.62; P = 0.027) and MFR ≤1.62 (odds ratio, 2.801; 95% confidence interval, 1.19-6.55; P = 0.018) were independent predictors of adverse outcomes. CONCLUSIONS Our data suggest that reduced MFR ≤1.62 obtained with dynamic CZT imaging and overexpression of NT-proBNP ≥760.5 pg/mL can individuate patients at high risk of development and progression of HFpEF during a 12-month follow-up period, independently of baseline clinical parameters and imaging variables.
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Affiliation(s)
- Kristina V Kopeva
- From the Departments of Myocardial Pathology and Nuclear, Cardiology Research Institute, Branch of the Federal State Budgetary Scientific Institution, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russia
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12
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Zhang H, Caobelli F, Che W, Huang Y, Zhang Y, Fan X, Hu X, Xu C, Fei M, Zhang J, Lv Z, Shi K, Yu F. The prognostic value of CZT SPECT myocardial blood flow (MBF) quantification in patients with ischemia and no obstructive coronary artery disease (INOCA): a pilot study. Eur J Nucl Med Mol Imaging 2023; 50:1940-1953. [PMID: 36786817 PMCID: PMC10199834 DOI: 10.1007/s00259-023-06125-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Despite the demonstrated adverse outcome, it is difficult to early identify the risks for patients with ischemia and no obstructive coronary artery disease (INOCA). We aimed to explore the prognostic potential of CZT SPECT in INOCA patients. METHODS The study population consisted of a retrospective cohort of 118 INOCA patients, all of whom underwent CZT SPECT imaging and invasive coronary angiography (ICA). Dynamic data were reconstructed, and MBF was quantified using net retention model. Major adverse cardiovascular events (MACEs) were defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, heart failure, late coronary revascularization, or hospitalization for unstable angina. RESULTS During a median follow-up of 15 months (interquartile range (IQR) 11-20), 19 (16.1%) MACEs occurred; both stress myocardial blood flow (sMBF) ([Formula: see text]) and coronary flow reserve (CFR) ([Formula: see text]) were significantly lower in the MACE group. Optimal thresholds of sMBF<3.16 and CFR<2.52 were extracted from the ROC curves, and both impaired sMBF (HR: 15.08; 95% CI 2.95-77.07; [Formula: see text]) and CFR (HR: 6.51; 95% CI 1.43-29.65; [Formula: see text]) were identified as prognostic factors for MACEs. Only sMBF<3.16 (HR: 11.20; 95% CI 2.04-61.41; [Formula: see text]) remained a robust predictor when sMBF and CFR were integrated considered. Compared with CFR, sMBF provides better prognostic model discrimination and reclassification ability (C-index improvement = 0.06, [Formula: see text]; net reclassification improvement (NRI) = 0.19; integrated discrimination improvement (IDI) = 0.10). CONCLUSION The preliminary results demonstrated that quantitative analysis on CZT SPECT provides prognostic value for INOCA patients, which may allow the stratification for early prevention and intervention.
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Affiliation(s)
- Han Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Federico Caobelli
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yan Huang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yu Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xin Fan
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xueping Hu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Chong Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Mengyu Fei
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Jiajia Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Zhongwei Lv
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Computer Aided Medical Procedures and Augmented Reality, Institute of Informatics I16, Technical University of Munich, Munich, Germany.
| | - Fei Yu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China.
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13
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Berkowicz P, Totoń-Żurańska J, Kwiatkowski G, Jasztal A, Csípő T, Kus K, Tyrankiewicz U, Orzyłowska A, Wołkow P, Tóth A, Chlopicki S. Accelerated ageing and coronary microvascular dysfunction in chronic heart failure in Tgαq*44 mice. GeroScience 2023; 45:1619-1648. [PMID: 36692592 PMCID: PMC10400753 DOI: 10.1007/s11357-022-00716-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/12/2022] [Indexed: 01/25/2023] Open
Abstract
Age represents a major risk factor in heart failure (HF). However, the mechanisms linking ageing and HF are not clear. We aimed to identify the functional, morphological and transcriptomic changes that could be attributed to cardiac ageing in a model of slowly progressing HF in Tgαq*44 mice in reference to the cardiac ageing process in FVB mice. In FVB mice, ageing resulted in the impairment of diastolic cardiac function and in basal coronary flow (CF), perivascular and interstitial fibrosis without changes in the cardiac activity of angiotensin-converting enzyme (ACE) or aldosterone plasma concentration. In Tgαq*44 mice, HF progression was featured by the impairment of systolic and diastolic cardiac function and in basal CF that was associated with a distinct rearrangement of the capillary architecture, pronounced perivascular and interstitial fibrosis, progressive activation of cardiac ACE and systemic angiotensin-aldosterone-dependent pathways. Interestingly, cardiac ageing genes and processes were represented in Tgαq*44 mice not only in late but also in early phases of HF, as evidenced by cardiac transcriptome analysis. Thirty-four genes and 8 biological processes, identified as being ageing related, occurred early and persisted along HF progression in Tgαq*44 mice and were mostly associated with extracellular matrix remodelling and fibrosis compatible with perivascular fibrosis resulting in coronary microvascular dysfunction (CMD) in Tgαq*44 mice. In conclusion, accelerated and persistent cardiac ageing contributes to the pathophysiology of chronic HF in Tgαq*44 mice. In particular, prominent perivascular fibrosis of microcirculation resulting in CMD represents an accelerated cardiac ageing phenotype that requires targeted treatment in chronic HF.
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Affiliation(s)
- Piotr Berkowicz
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Justyna Totoń-Żurańska
- Centre for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Kwiatkowski
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Agnieszka Jasztal
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Tamás Csípő
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Kamil Kus
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Urszula Tyrankiewicz
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Anna Orzyłowska
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Paweł Wołkow
- Centre for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Attila Tóth
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stefan Chlopicki
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland.
- Faculty of Medicine, Chair of Pharmacology, Jagiellonian University Medical College, Krakow, Poland.
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14
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Li Y, Ye Z, Guo Z, Xie E, Wang M, Zhao X, Liu M, Li P, Yu C, Gao Y, Zheng J. Ticagrelor vs. clopidogrel for coronary microvascular dysfunction in patients with STEMI: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1102717. [PMID: 37273883 PMCID: PMC10233131 DOI: 10.3389/fcvm.2023.1102717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/17/2023] [Indexed: 06/06/2023] Open
Abstract
Purpose Approximately half of ST-segment elevation myocardial infarction (STEMI) patients who undergo revascularization present with coronary microvascular dysfunction. Dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor), is recommended to reduce rates of cardiovascular events after STEMI. The present study performed a pooled analysis of randomized controlled trials (RCTs) to compare effects of ticagrelor and clopidogrel on coronary microcirculation dysfunction in STEMI patients who underwent the primary percutaneous coronary intervention. Methods The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for eligible RCTs up to September 2022, with no language restriction. Coronary microcirculation indicators included the corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), myocardial blush grade (MBG), TIMI myocardial perfusion grade (TMPG), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). Results Seven RCTs that included a total of 957 patients (476 who were treated with ticagrelor and 481 who were treated with clopidogrel) were included. Compared with clopidogrel, ticagrelor better accelerated microcirculation blood flow [cTFC = -2.40, 95% confidence interval (CI): -3.38 to -1.41, p < 0.001] and improved myocardial perfusion [MBG = 3, odds ratio (OR) = 1.99, 95% CI: 1.35 to 2.93, p < 0.001; MBG ≥ 2, OR = 2.57, 95% CI: 1.61 to 4.12, p < 0.001]. Conclusions Ticagrelor has more benefits for coronary microcirculation than clopidogrel in STEMI patients who undergo the primary percutaneous coronary intervention. However, recommendations for which P2Y12 receptor inhibitor should be used in STEMI patients should be provided according to results of studies that investigate clinical outcomes.
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Affiliation(s)
- Yike Li
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zixiang Ye
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Ziyu Guo
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Enmin Xie
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Wang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Xuecheng Zhao
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Mei Liu
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peizhao Li
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Changan Yu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yanxiang Gao
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jingang Zheng
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
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15
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Montisci R, Marchetti MF, Ruscazio M, Biddau M, Secchi S, Zedda N, Casula R, Tuveri F, Kerkhof PLM, Meloni L, Tona F. Non-invasive coronary flow velocity reserve assessment predicts adverse outcome in women with unstable angina without obstructive coronary artery stenosis. J Public Health Res 2023; 12:22799036231181716. [PMID: 37333028 PMCID: PMC10264896 DOI: 10.1177/22799036231181716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Background Evaluation of coronary flow velocity reserve (CFVR) is the physiological approach to assess the severity of coronary stenosis and microvascular dysfunction. Impaired CFVR occurs frequently in women with suspected or known coronary artery disease. The aim of this study was to assess the role of CFVR to predict long-term cardiovascular event rate in women with unstable angina (UA) without obstructive coronary artery stenosis. Methods CFVR in left anterior descending coronary artery was assessed by adenosine transthoracic echocardiograhy in 161 women admitted at our Department with UA and without obstructive coronary artery disease. Results During a mean FU of 32.5 ± 19.6 months, 53 cardiac events occurred: 6 nonfatal acute myocardial infarction, 22 UA, 7 coronary revascularization by percutaneous transluminal coronary angioplasty, 1 coronary bypass surgery, 3 ischemic stroke, and 8 episodes of congestive heart failure with preserved ejection fraction and 6 cardiac deaths. Using a ROC curve analysis, CFVR 2.14 was the best predictor of cardiac events and was considered as abnormal CFVR. Abnormal CFVR was associated with lower cardiac event-free survival (30 vs 80%, p < 0.0001). During FU, 70% of women with reduced CFVR had cardiac events whereas only 20% with normal CFVR (p = 0.0001). At multivariate Cox analysis, smoke habitus (p = 0.003), metabolic syndrome (p = 0.01), and CFVR (p < 0.0001) were significantly associated with cardiac events at FU. Conclusion Noninvasive CFVR provides an independent predictor of cardiovascular prognosis information in women with UA without obstructive coronary artery disease whereas, impaired CFVR seems to be associated with higher CV events at FU.
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Affiliation(s)
- Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Maria Francesca Marchetti
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Massimo Ruscazio
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Mattia Biddau
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Sara Secchi
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Norma Zedda
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Roberto Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Francesca Tuveri
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Peter LM Kerkhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Luigi Meloni
- Clinical Cardiology, AOU Cagliari, Department of Clinical Sciences and Public Health, University of Cagliari, Italy
| | - Francesco Tona
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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16
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Mochula AV, Kopeva KV, Maltseva AN, Grakova EV, Gulya M, Smorgon AV, Gusakova A, Zavadovsky KV. The myocardial flow reserve in patients with heart failure with preserved ejection fraction. Heart Vessels 2023; 38:348-360. [PMID: 36045268 DOI: 10.1007/s00380-022-02161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023]
Abstract
To evaluate the myocardial flow reserve (MFR) and myocardial blood flow (MBF) parameters in patients with heart failure with preserved ejection fraction (HFpEF) and to assess their relationship with the severity of HF and the levels of soluble ST2 (sST2). A total of 59 consecutive patients (median age of 65.0 (58.0; 69.0) years) with non-obstructive coronary artery disease (CAD) and preserved EF were enrolled. Serum levels biomarkers were measured by enzyme immunoassay. MBF and MFR parameters were evaluated by dynamic CZT-SPECT. All patients were divided into two groups: group 1 comprised patients (n = 41) with HFpEF, and group 2 comprised those (n = 18) without HFpEF. In group 1 global MFR (gMFR) values were lower by 27.8% (p = 0.003) than in group 2. The values of gMFR correlated with NT-proBNP (r = - 0.290) and sST2 (r = -0.331) levels. Based on ROC-analysis, gMFR ≤ 2.27 (AUC = 0.746; p < 0.001) were associated with the presence of HFpEF. In patients with HFpEF (n = 41) the values of gMFR were related to NYHA classes (p < 0.001) and the parameters of diastolic dysfunction (p < 0.001). The values of gMFR ≤ 2.27 may be used for the evaluation of microvascular changes in patients with HFpEF and non-obstructive CAD.
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Affiliation(s)
- Andrew V Mochula
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation.
| | - Kristina V Kopeva
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Alina N Maltseva
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Elena V Grakova
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Marina Gulya
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Andrey V Smorgon
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Anna Gusakova
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
| | - Konstantin V Zavadovsky
- Cardiology Research Institute, Tomsk National Research Medical Center (TNRMC), Russian Academy of Sciences (RAS), 111a, Kievskaya Str., Tomsk, 634012, Russian Federation
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Zhang J, Ma M, Li H, Pu Z, Liu H, Huang T, Cheng H, Gong Y, Chu Y, Wang Z, Jiang J, Xia L. Early diagnosis of coronary microvascular dysfunction by myocardial contrast stress echocardiography. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:7845-7858. [PMID: 37161175 DOI: 10.3934/mbe.2023339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Coronary microvascular dysfunction (CMD) is one of the basic mechanisms of myocardial ischemia. Myocardial contrast echocardiography (MCE) is a bedside technique that utilises microbubbles which remain entirely within the intravascular space and denotes the status of microvascular perfusion within that region. Some pilot studies suggested that MCE may be used to diagnose CMD, but without further validation. This study is aimed to investigate the diagnostic performance of MCE for the evaluation of CMD. MCE was performed at rest and during adenosine triphosphate stress. ECG triggered real-time frames were acquired in the apical 4-chamber, 3-chamber, 2-chamber, and long-axis imaging planes. These images were imported into Narnar for further processing. Eighty-two participants with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. Thermodilution was used as the gold standard to diagnose CMD. CMD was present in 23 (28%) patients. Myocardial blood flow reserve (MBF) was assessed using MCE. CMD was defined as MBF reserve < 2. The MCE method had a high sensitivity (88.1%) and specificity (95.7%) in the diagnosis of CMD. There was strong agreement with thermodilution (Kappa coefficient was 0.727; 95% CI: 0.57-0.88, p < 0.001). However, the correlation coefficient (r = 0.376; p < 0.001) was not high.
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Affiliation(s)
- Jucheng Zhang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
- Key Laboratory of Medical Molecular Imaging of Zhejiang Province, Hangzhou 310009, China
| | - Minwen Ma
- Department of Clinical Engineering, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Huajun Li
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Zhaoxia Pu
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, United Kingdom
| | - Tianhai Huang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Huan Cheng
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
| | - Yinglan Gong
- Institute of Wenzhou, Zhejiang University, Wenzhou 325036, China
| | - Yonghua Chu
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Zhikang Wang
- Department of Clinical Engineering, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Jun Jiang
- Department of Cardiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou 310009, China
| | - Ling Xia
- Key Laboratory for Biomedical Engineering of Ministry of Education, Institute of Biomedical Engineering, Zhejiang University, Hangzhou 310027, China
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18
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Sueda S, Sakaue T. Sex-related differences in coronary vasomotor disorders: Comparisons between Western and Japanese populations. J Cardiol 2023; 81:161-167. [PMID: 35534347 DOI: 10.1016/j.jjcc.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Sex-related differences in the prevalence of cardiac disorders have been elucidated beyond races. Angina/ischemia with nonobstructive coronary artery disease (AINOCA) is often observed in females. Coronary microvascular dysfunction (CMD) and coronary epicardial spasm (CES) are the principal cause of AINOCA. The clinical outcomes of Western patients with CMD were less satisfactory than expected, while the prognosis of Japanese patients with CES treated with medications including calcium channel blockers was favorable. However, the incidence and clinical features of coronary spasm endotypes were different between Western and Japanese populations. Furthermore, sex-related differences in the clinical manifestations and outcomes of patients with different spasm endotypes remain uncertain beyond race. In this article, we will review the sex differences in Japanese AINOCA patients with coronary vasomotor disorders, including CMD and CES, and compare them with those of Western patients.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama City, Ehime Prefecture, Japan.
| | - Tomoki Sakaue
- Department of Cardiology, Yawatahama City General Hospital, Yawatahama City, Ehime Prefecture, Japan
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19
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Zhao L, Wang Q, Xu P, Su X, Luo Q, Ding Y. Evaluation of left ventricular function in ischemia with non-obstructive coronary arteries: a research based on adenosine stress myocardial contrast echocardiography. Int J Cardiovasc Imaging 2023; 39:349-357. [PMID: 36308671 DOI: 10.1007/s10554-022-02740-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/01/2022] [Indexed: 01/26/2023]
Abstract
Patients with ischemia with non-obstructive coronary arteries (INOCA) have an increased risk of adverse cardiovascular events in the future, which is widespread but underdiagnosed. The purpose of this study is to explore the application value of adenosine stress myocardial contrast echocardiography (ASMCE) in INOCA disease, so that clinicians can early identify and intervene patients with left ventricular function subclinical impairment in INOCA. We enrolled 118 patients with INOCA by ASMCE and invasive coronary angiography (ICA), 97 of whom had complete data. The study population was divided into two subgroups depending on coronary flow velocity reserve (CFVR): impaired CFVR group (n = 34) and normal CFVR group (n = 63). Global longitudinal strain endocardial myocardial (GLSendo), mid-myocardial (GLSmid) and epicardial myocardial (GLSepi) increased after stress in both groups; transmural strain, wall motion scored index (WMSI) and myocardial perfusion scored index (MPSI) increased and FORCE decreased in impaired CFVR group after stress, but there was no difference in normal group before and after stress. There was no significant difference in left ventricular myocardial mechanical parameters, including ΔGLSendo, ΔGLSmid, ΔGLSepi, GLSendo-epi Reserve, Δpeak strain dispersion (PSD), PSD Reserve between the two groups, but ΔEF, strain reserve and left ventricular contractile reserve (LVCR) in the impaired CFVR group were lower than those in the normal CFVR group, while ΔWMSI and ΔMPSI were increased. CFVR can be a clinically valuable indicator in the ASMCE diagnosis of patients with microvascular angina pectoris in INOCA. In the evaluation of left ventricular function in INOCA patients, attention should be paid not only to myocardial deformation, but also to the dynamic changes of LVCR and myocardial perfusion during peak hyperemia.
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Affiliation(s)
- Li Zhao
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China
| | - Qinghui Wang
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China.
| | - Pengli Xu
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China
| | - Xuan Su
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China
| | - Qingyi Luo
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China
| | - Yunchuan Ding
- Department of Ultrasound, Yanan Hospital of Kunming City, Kunming, 650051, Yunnan, China
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Vahdatpour C, Epstein S, Jones K, Smoot M, Parker A, Ryan J, Bryant A. A review of cardio-pulmonary microvascular dysfunction in pulmonary hypertension. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100255. [PMID: 38510189 PMCID: PMC10946046 DOI: 10.1016/j.ahjo.2023.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 03/22/2024]
Abstract
Microvascular dysfunction progressing to pulmonary hypertension can be a primary cause of right ventricular failure or a secondary cause because of an underlying systemic illness. Little is known regarding the etiology and epidemiology of coronary microvascular dysfunction in pulmonary hypertension. Despite this limitation, its presence has been described in patients with pulmonary hypertension. This review focuses on the pathogenesis of cardiac and pulmonary microvascular dysfunction in pulmonary hypertension. Additionally, this review provides a contemporary assessment on the diagnosis and treatment of microvascular dysfunction in patients in pulmonary hypertension. This topic is important to raise awareness of microvascular dysfunction in the coronary and pulmonary circulation, so that future studies will investigate its impact on the pulmonary hypertension patient cohort.
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Affiliation(s)
- Cyrus Vahdatpour
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Samuel Epstein
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Kirk Jones
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Madeline Smoot
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Alex Parker
- Department of Cardiology, University of Florida, Gainesville, FL, USA
| | - John Ryan
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andrew Bryant
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Rehan R, Yong A, Ng M, Weaver J, Puranik R. Coronary microvascular dysfunction: A review of recent progress and clinical implications. Front Cardiovasc Med 2023; 10:1111721. [PMID: 36776251 PMCID: PMC9908997 DOI: 10.3389/fcvm.2023.1111721] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
The coronary microcirculation plays a cardinal role in regulating coronary blood flow to meet the changing metabolic demands of the myocardium. Coronary microvascular dysfunction (CMD) refers to structural and functional remodeling of the coronary microcirculation. CMD plays a role in the pathogenesis of obstructive and non-obstructive coronary syndromes as well as myocardial diseases, including heart failure with preserved ejection fraction (HFpEF). Despite recent diagnostic advancements, CMD is often under-appreciated in clinical practice, and may allow for the development of novel therapeutic targets. This review explores the diagnosis and pathogenic role of CMD across a range of cardiovascular diseases, its prognostic significance, and the current therapeutic landscape.
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Affiliation(s)
- Rajan Rehan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Andy Yong
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - Martin Ng
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia
| | - James Weaver
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Sydney Medical School, University of Sydney, Darlington, NSW, Australia,*Correspondence: Rajesh Puranik,
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Epicardial atherosclerosis and coronary tortuosity in patients with acetylcholine-induced coronary spasm. Coron Artery Dis 2023; 34:34-41. [PMID: 36484218 DOI: 10.1097/mca.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Angina pectoris in the absence of relevant epicardial stenoses is frequently caused by coronary spasm. This mechanism of angina is common yet underdiagnosed in daily clinical practice. The pathophysiology of coronary spasm is complex, multifactorial, and not completely understood. The purpose of this study was to analyze the relationship between macroscopic coronary morphologies and coronary spasm. METHODS Epicardial atherosclerosis, coronary vessel tortuosity, coronary aneurysms, and myocardial bridges were analyzed angiographically in 610 patients and a potential association with the result of an intracoronary acetylcholine (ACh) provocation test was investigated. RESULTS The comparison showed that angiographic morphologic variations in the coronary arteries are related to the occurrence of coronary spasm. We observed a strong association between the presence of epicardial atherosclerosis and epicardial spasm [87 patients of 179 with epicardial spasm had epicardial atherosclerosis (49%) vs. 45 patients of 172 with microvascular spasm (26%) vs. 89 patients of 259 with negative/inconclusive ACh test (36%); P < 0.005]. Moreover, we found a higher frequency of coronary tortuosity in patients with microvascular spasm [99 patients of 172 with microvascular spasm had at least moderate coronary tortuosity (58%) vs. 76 patients of 179 with epicardial spasm (43%) vs. 126 patients of 259 with negative/inconclusive ACh test (49%); P = 0.017]. Multivariable analysis revealed epicardial atherosclerosis (<50% stenosis) on coronary angiography as a predictor for epicardial spasm (OR, 2.096; 95% CI, 1.467-2.995; P < 0.0005). Female sex (OR, 5.469; 95% CI, 3.433-8.713; P < 0.0005), and exertional angina (OR, 2.411; 95% CI, 1.597-3.639; P < 0.0005) were predictors of microvascular spasm in multivariable analysis. CONCLUSION In angina patients with no obstructive coronary artery disease, epicardial atherosclerosis is associated with ACh-induced epicardial coronary spasm. Moreover, coronary microvascular spasm is more prevalent in female patients and those with exertional angina. Our results provide insights into the relationship between coronary morphology and coronary vasomotor function.
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23
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Zhu H, Wang H, Zhu X, Chen Q, Fang X, Xu X, Ping Y, Gao B, Tong G, Ding Y, Chen T, Huang J. The Importance of Integrated Regulation Mechanism of Coronary Microvascular Function for Maintaining the Stability of Coronary Microcirculation: An Easily Overlooked Perspective. Adv Ther 2023; 40:76-101. [PMID: 36279093 DOI: 10.1007/s12325-022-02343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 01/25/2023]
Abstract
Coronary microvascular dysfunction (CMD) refers to a group of disorders affecting the structure and function of coronary microcirculation and is associated with an increased risk of major adverse cardiovascular events. At present, great progress has been made in the diagnosis of CMD, but there is no specific treatment for it because of the complexity of CMD pathogenesis. Vascular dysfunction is one of the important causes of CMD, but previous reviews mostly considered microvascular dysfunction as a whole abnormality so the obtained conclusions are skewed. The coronary microvascular function is co-regulated by multiple mechanisms, and the mechanisms by which microvessels of different luminal diameters are regulated vary. The main purpose of this review is to revisit the mechanisms by which coronary microvessels at different diameters regulate coronary microcirculation through integrated sequential activation and briefly discuss the pathogenesis, diagnosis, and treatment progress of CMD from this perspective.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xinyu Zhu
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Qilan Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaojiang Fang
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Yan Ping
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Beibei Gao
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Guoxin Tong
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Yu Ding
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, No. 453 Stadium Road, Hangzhou, 310007, Zhejiang, China.
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, No. 261 Huansha Road, Hangzhou, 310006, Zhejiang, China.
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Computing intracoronary blood flow rate under incomplete boundary conditions: Combing coronary anatomy and fractional flow reserve. Med Eng Phys 2023; 111:103942. [PMID: 36792237 DOI: 10.1016/j.medengphy.2022.103942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate measurement of intracoronary blood flow rate is of great significance for the diagnosis of ischemic heart disease (IHD). Computational fluid dynamic (CFD) method, combining coronary angiography images and fractional flow reserve (FFR), provides a new way to calculate the mean flow rate. However, due to the incomplete boundary conditions obtained by FFR, side branches were ignored which was likely to have a significant impact on the accuracy. In this paper, a novel CFD based method for calculating the mean intracoronary flow rate under incomplete pressure boundary conditions was proposed, in order to improve the accuracy by including the side branches. METHODS A pressure-flow curve based flow resistance model was employed to model resistance of the epicardial arteries. A series of steady flow simulations were performed to extract the parameters of the flow resistance model, which implicitly specified constraints for splitting flow between branches and thus enabled the mean intracoronary blood flow rate to be calculated in two or more branches under incomplete pressure boundary conditions. Simulation experiments were designed to validate the proposed method in both idealized and reconstructed 3D models of coronary branches, and the impact of the assumed coefficient of the Murray's Law for splitting flow between branches was also investigated. RESULTS The mean percentage error of the proposed method was +2.05%±0.04% for idealized models and +2.24%±0.01% for reconstructed models, and it was much lower than that of the method ignoring side branches (+38.48%±10.45% for idealized models and +30.54%±6.12% for reconstructed models). When the assumed coefficient of the Murray's Law was inconsistent with the real blood flow condition, the percentage errors still maintained less than about 3.00%. CONCLUSIONS The proposed method provided an easy and accurate way to measure the mean intracoronary flow rate and would facilitate the accurate diagnosis of IHD.
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25
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Avtaar Singh SS, Nappi F. Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study. Biomedicines 2022; 10:biomedicines10123010. [PMID: 36551766 PMCID: PMC9775403 DOI: 10.3390/biomedicines10123010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies. METHODS A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework. RESULTS The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon. CONCLUSION The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.
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Affiliation(s)
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord of Saint-Denis, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-(14)-9334104; Fax: +33-149334119
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Varrichione G, Biccirè FG, Di Pietro R, Prati F, Battisti P. The risk of acute coronary events in microvascular disease. Eur Heart J Suppl 2022; 24:I127-I130. [PMID: 36380795 PMCID: PMC9653131 DOI: 10.1093/eurheartjsupp/suac103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The microvascular disease represents a widespread clinical entity in the general population, especially among women. The dysfunction of the microcirculation is often responsible for myocardial ischaemia and angina in the absence of significant stenosis of the epicardial district, while in other cases it can represent a contributing cause of angina even in the presence of coronary artery disease, cardiomyopathies or heart failure. The cardiovascular risk factors of people with microvascular disease are similar to those who develop epicardial atherosclerotic disease. However, the prognostic significance of microvascular disease remains a matter of debate. An element to be clarified, in fact, is whether subjects with dysfunction of the microcirculation and coronary tree without significant stenoses present an increased risk of myocardial infarction and sudden death. In recent years, several studies seem to confirm an association between microvascular disease and progression of coronary epicardial atherosclerosis. The prognosis of microvascular disease would therefore not be benign as was previously believed, but associated with an increased risk of cardiovascular events including revascularization, heart attack, and cardiac death.
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Liu T, Wang C, Yin J, Wang L, Xuan H, Yan Y, Chen J, Bao J, Li D, Xu T. Comparison of Diagnostic Value Between STE+LDDSE and CMR-FT for Evaluating Coronary Microvascular Obstruction in Post-PCI Patients for STEMI. Ther Clin Risk Manag 2022; 18:813-823. [PMID: 35996553 PMCID: PMC9391944 DOI: 10.2147/tcrm.s374866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Coronary microvascular obstruction (CMVO) is closely associated with poor prognosis of ST-segment elevation myocardial infarction (STEMI) patients. However, data showing the comparison between cardiac magnetic resonance feature tracking (CMR-FT) and speckle tracking echocardiography (STE) combined with low-dose dobutamine stress echocardiography (LDDSE) in evaluating CMVO was scarcely available. We aimed to explore and compare the predictive value between CMR-FT and STE+LDDSE in detecting CMVO. Methods Sixty-one STEMI patients were executed cardiac magnetic resonance and echocardiography within the first 5–7 days after primary percutaneous coronary intervention (PCI). The myocardial strain analysis was performed in STE, STE+LDDSE, and CMR-FT, and strain parameters included radial strain (RS), circumferential strain (CS), and longitudinal strain (LS). ROC curves were performed to predict infarcted myocardium segments with CMVO. Results Finally, 324 infarcted myocardium segments were analyzed, including 100 infarcted segments with CMVO and 224 segments without CMVO by the gold standard assessment of late gadolinium-enhancement cardiac magnetic resonance imaging (LGE-CMR). The results showed that CS was generally superior to RS and LS in identifying CMVO. CS in CMR-FT facilitated the detection of CMVO, with a sensitivity, specificity, and accuracy of 78.00%, 81.25%, and 80.25%, respectively. The sensitivity, specificity, and accuracy of CS in STE combined with LDDSE were better than STE alone (76.00% vs 60.00%, 79.91% vs 64.29%, and 78.70% vs 62.96%, P < 0.05). In addition, CMR-FT is not superior to STE+LDDSE for detection of CMVO (P > 0.05). Conclusion Low-dose dobutamine can improve the clinical value of STE for evaluating CMVO in STEMI patients. Compared with CMR-FT, STE+LDDSE might be a better choice for STEMI patients because of its safety, convenience, and low-cost.
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Affiliation(s)
- Tao Liu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Chaofan Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Jie Yin
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Lili Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Haochen Xuan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Yan Yan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Junhong Chen
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Jieli Bao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Dongye Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Tongda Xu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
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Sonaglioni A, Nicolosi GL, Rigamonti E, Lombardo M. Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results. J Cardiovasc Med (Hagerstown) 2022; 23:524-534. [PMID: 35905007 DOI: 10.2459/jcm.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The influence of chest wall shape on exercise stress echocardiography (ESE) results has been poorly investigated. We aimed at evaluating the main predictors of true positive (TP)-ESE in a population of subjects with suspected coronary artery disease (CAD), categorized according to chest wall conformation, assessed by modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine). METHODS All consecutive patients with suspected CAD referred to our EchoLab for performing ESE between September 2011 and October 2021 were retrospectively enrolled. Preliminary assessment of both pretest probability (PTP) and MHI was performed. All patients with positive ESE underwent coronary angiography. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. Outcome was TP ESE result. RESULTS One thousand two hundred and seventy-five consecutive patients (64.9 ± 13.0 years) entered the study. Subjects with concave-shaped chest wall (MHI > 2.5) (10.7%) and those with normal chest shape (MHI ≤ 2.5) (89.3%) were separately analyzed. PTP was similar in both groups (21.8 ± 13.2 vs. 23.5 ± 13.3%, P = 0.15). One hundred and seventy patients were diagnosed with positive ESE: 129 (75.9%) had obstructive CAD (TP), whereas the remaining 41 (24.1%) had no CAD. Only 2.3% of TP ESE was detected in subjects with MHI >2.5. PTP [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04], dyslipidemia (OR 4.37, 95% CI 2.81-6.80), dyssynergy in the left anterior descending territory (OR 8.21, 95% CI 5.07-13.3) were linearly correlated with TP ESE, whereas MHI >2.5 (OR 0.25, 95% CI 0.14-0.67) was inversely associated with outcome. CONCLUSIONS Subjects with MHI >2.5 have low prevalence of TP ESE, regardless of PTP. Preliminary MHI assessment may reduce overestimation of PTP of CAD.
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Popa-Fotea NM, Scafa-Udriste A, Dorobantu M. The Continuum of Invasive Techniques for the Assessment of Intermediate Coronary Lesions. Diagnostics (Basel) 2022; 12:diagnostics12061492. [PMID: 35741302 PMCID: PMC9221746 DOI: 10.3390/diagnostics12061492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Ischemic heart disease is one of the most important causes of mortality and morbidity worldwide. Revascularization of coronary stenosis inducing ischemia, either by percutaneous or surgical intervention, significantly reduces major adverse cardiovascular events and improves quality of life. However, in cases of intermediate lesions, classified by a diameter stenosis between 50 and 90% by European guidelines and 40–70% in American counterparts with no clear evidence of ischemia, the indication of revascularization and impact is determined using various methods that altogether comprehensively evaluate the lesions. This review will discuss the various techniques to assess intermediate stenoses, highlighting indications and advantages, but also drawbacks. Fractional flow rate (FFR) and instantaneous wave-free ratio (iFR) are the gold standard for the functional evaluation of intermediate lesions, but there are clinical circumstances in which these pressure-wire-derived indices are not accurate. Complementary invasive investigations, mainly intravascular ultrasound and/or optical coherence tomography, offer parameters that can be correlated with FFR/iFR and additional insights into the morphology of the plaque guiding the eventual percutaneous intervention in terms of length and size of stents, thus improving the outcomes of the procedure. The development of artificial intelligence and machine learning with advanced algorithms of prediction will offer multiple scenarios for treatment, allowing real-time selection of the best strategy for revascularization.
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Affiliation(s)
- Nicoleta-Monica Popa-Fotea
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Emergency Clinical Hospital, 10, Calea Floreasca, 014461 Bucharest, Romania
- Correspondence: ; Tel.: +40-724381385
| | - Alexandru Scafa-Udriste
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Emergency Clinical Hospital, 10, Calea Floreasca, 014461 Bucharest, Romania
| | - Maria Dorobantu
- Cardiothoracic Department, University of Medicine and Pharmacy “Carol Davila”, 8, Bulevardul Eroii Sanitari, 050474 Bucharest, Romania; (A.S.-U.); (M.D.)
- Romanian Academy, 010071 Bucharest, Romania
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Rocco E, Grimaldi MC, Maino A, Cappannoli L, Pedicino D, Liuzzo G, Biasucci LM. Advances and Challenges in Biomarkers Use for Coronary Microvascular Dysfunction: From Bench to Clinical Practice. J Clin Med 2022; 11:jcm11072055. [PMID: 35407662 PMCID: PMC8999821 DOI: 10.3390/jcm11072055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/27/2022] [Accepted: 04/02/2022] [Indexed: 02/01/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is related to a broad variety of clinical scenarios in which cardiac microvasculature is morphologically and functionally affected, and it is associated with impaired responses to vasoactive stimuli. Although the prevalence of CMD involves about half of all patients with chronic coronary syndromes and more than 20% of those with acute coronary syndrome, the diagnosis of CMD is often missed, leading to the underestimation of its clinical importance. The established and validated techniques for the measurement of coronary microvascular function are invasive and expensive. An ideal method to assess endothelial dysfunction should be accurate, non-invasive, cost-effective and accessible. There are varieties of biomarkers available, potentially involved in microvascular disease, but none have been extensively validated in this heterogeneous clinical population. The investigation of potential biomarkers linked to microvascular dysfunction might improve the assessment of the diagnosis, risk stratification, disease progression and therapy response. This review article offers an update about traditional and novel potential biomarkers linked to CMD.
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Affiliation(s)
- Erica Rocco
- Department of Medical-Surgical Sciences and Biotechnologies, Cardiology Unit, ICOT Hospital, Sapienza University of Rome, 04110 Latina, Italy;
| | - Maria Chiara Grimaldi
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Alessandro Maino
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
| | - Luigi Cappannoli
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
| | - Daniela Pedicino
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanna Liuzzo
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Luigi Marzio Biasucci
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.M.); (L.C.); (D.P.); (G.L.); (L.M.B.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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Seitz A, Pereyra VM, Sechtem U, Ong P. Update on coronary artery spasm 2022 – A narrative review. Int J Cardiol 2022; 359:1-6. [DOI: 10.1016/j.ijcard.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/07/2022] [Accepted: 04/04/2022] [Indexed: 12/31/2022]
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Rizzoni D, De Ciuceis C, Szczepaniak P, Paradis P, Schiffrin EL, Guzik TJ. Immune System and Microvascular Remodeling in Humans. Hypertension 2022; 79:691-705. [PMID: 35098718 DOI: 10.1161/hypertensionaha.121.17955] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low-grade inflammatory processes and related oxidative stress may have a key role in the pathogenesis of hypertension and hypertension-mediated organ damage. Innate immune cells, such as neutrophils, dendritic cells, monocytes/macrophages, as well as unconventional T lymphocytes like γδ T cells contribute to hypertension and may trigger vascular inflammation. Adaptive immunity has been demonstrated to participate in elevation of blood pressure and in vascular and kidney injury. In particular, effector T lymphocytes (Th1, Th2, and Th17) may play a relevant role in promoting hypertension and microvascular remodeling, whereas T-regulatory lymphocytes may have a protective role. Effector cytokines produced by these immune cells lead to increased oxidative stress, endothelial dysfunction and contribute to target organ damage in hypertension. A possible role of immune cell subpopulations in the development and regression of microvascular remodeling has also been proposed in humans with hypertension. The present review summarizes the key immune mechanisms that may participate in the pathophysiology of hypertension-mediated inflammation and vascular remodeling; advances in this field may provide the basis for novel therapeutics for hypertension.
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Affiliation(s)
- Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.D.C.).,Division of Medicine, Spedali Civili di Brescia, Montichiari, Italy (D.R.)
| | - Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.D.C.)
| | - Piotr Szczepaniak
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (P.S., T.J.G.).,Department of Medicine, Jagiellonian University Medical College, Krakow, Poland (P.S., T.J.G.)
| | - Pierre Paradis
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, Montreal, Québec, Canada (P.P., E.L.S.)
| | - Ernesto L Schiffrin
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, Montreal, Québec, Canada (P.P., E.L.S.).,Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Québec, Canada (E.L.S.)
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (P.S., T.J.G.).,Department of Medicine, Jagiellonian University Medical College, Krakow, Poland (P.S., T.J.G.)
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Feng C, Abdu FA, Mohammed AQ, Zhang W, Liu L, Yin G, Feng Y, Mohammed AA, Mareai RM, Lv X, Shi T, Xu Y, Yu X, Che W. Prognostic impact of coronary microvascular dysfunction assessed by caIMR in overweight with chronic coronary syndrome patients. Front Endocrinol (Lausanne) 2022; 13:922264. [PMID: 36034462 PMCID: PMC9399838 DOI: 10.3389/fendo.2022.922264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Coronary microvascular dysfunction (CMD) may associate with adverse cardiovascular events in obese patients. Coronary angiography-derived index of microcirculatory resistance (caIMR) is proposed as a less-invasive and pressure-wire-free index to assess CMD. We aimed to investigate the impact of coronary microvascular function assessed by caIMR in patients with overweight and chronic coronary syndrome (CCS). METHODS CCS patients who underwent coronary angiography between 2015 to 2018 were included. Overweight was defined as BMI≥24.0kg/m². Impaired coronary microvascular function was defined as caIMR≥25U. The patients were classified according to BMI and caIMR. The primary endpoint was major adverse cardiac events (MACE). Kaplan-Meier and Cox regression analyses evaluated the association between caIMR and MACE. RESULTS Two hundred and eighty-two CCS patients were enrolled. Among these, 169 (59.93%) were overweight. Impaired coronary microvascular function was higher in overweight patients than in patients with normal weight (49.70% vs. 38.05%; P=0.035). During 35 months of follow-up, 33 MACE had occurred. Among the total CCS population, MACE was higher in patients with high caIMR than in low caIMR (18.11% vs. 6.45%, P=0.003). In subgroups analysis, MACE was higher in overweight patients with high caIMR than low caIMR (20.24% vs. 7.06%, P=0.014), while there were no significant differences in normal-weight patients. Multivariate Cox analysis demonstrated that caIMR≥25 was independently associated with MACE in overweight patients (HR, 2.87; 95% CI, 1.12-7.30; P=0.027) but not in the normal-weight patients. In addition, caIMR showed a significant predictive value for adverse outcomes in overweight patients and provided an incremental prediction when added to a prediction model with BMI. CONCLUSIONS Impaired coronary microvascular function assessed by caIMR was common and is an independent predictor of MACE in overweight patients with CCS.
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Affiliation(s)
- Cailin Feng
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A. Abdu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Zhang
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | | | - Ayman A. Mohammed
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Redhwan M. Mareai
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tingting Shi
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuejing Yu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Wenliang Che, ; Xuejing Yu,
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Cardiology, Shanghai Tenth People’s Hospital Chongming Branch, Shanghai, China
- *Correspondence: Wenliang Che, ; Xuejing Yu,
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Sonaglioni A, Nicolosi GL, Rigamonti E, Lombardo M, Gensini GF, Ambrosio G. Does chest shape influence exercise stress echocardiographic results in patients with suspected coronary artery disease? Intern Emerg Med 2022; 17:101-112. [PMID: 34052977 DOI: 10.1007/s11739-021-02773-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/22/2021] [Indexed: 10/20/2022]
Abstract
Despite the good specificity of exercise stress echocardiography (ESE) for the detection of coronary artery disease (CAD), false positive (FP) results may occur. We have previously reported that chest abnormalities may affect parameters of cardiac contractility. The influence of chest shape on ESE results has never been previously investigated. We retrospectively analyzed 160 consecutive patients (64.4 ± 13.0-year old, 91 women) who had undergone coronary angiography at our Institution because of positive ESE, between June 2014 and May 2020. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥ 70% stenosis in any epicardial coronary artery. Outcome was false-positivity at ESE. 80.6% of patients were diagnosed with obstructive CAD, while 19.4% had no CAD (FP). We separately analyzed patients with normal chest shape (MHI ≤ 2.5) and those with concave-shaped chest wall (MHI > 2.5). These latter were mostly women with small cardiac chambers, mitral valve prolapse (MVP) and exercise-induced ST-segment changes. Likelihood of false-positivity was significantly higher in subjects with MHI > 2.5 than those with MHI ≤ 2.5 (30.7% vs 9.4%, p = 0.001). By multivariate logistic regression analysis, MHI > 2.5 (OR 4.04, 95%CI 1.45-11.2, p = 0.007), MVP (OR 3.47, 95%CI 1.32-9-12, p = 0.01) and dyssynergy in the left circumflex territory (OR = 3.35, 95%CI 1.26-8.93, p = 0.01) were independently associated with false-positivity. Concave-shaped chest wall (MHI > 2.5) may be associated with false-positive stress echocardiographic result. Mechanisms underpinning this finding need to be further explored.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milano, Italy.
| | | | - Elisabetta Rigamonti
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milano, Italy
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milano, Italy
| | - Gian Franco Gensini
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milano, Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria "S. Maria Della Misericordia", Perugia, Italy
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Zhang H, Che W, Shi K, Huang Y, Xu C, Fei M, Fan X, Zhang J, Hu X, Hu F, Qin S, Zhang X, Huang Q, Yu F. FT4/FT3 ratio: A novel biomarker predicts coronary microvascular dysfunction (CMD) in euthyroid INOCA patients. Front Endocrinol (Lausanne) 2022; 13:1021326. [PMID: 36187090 PMCID: PMC9520241 DOI: 10.3389/fendo.2022.1021326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Ischemia and no obstructive coronary artery disease (INOCA) patients who presented coronary microvascular dysfunction (CMD) demonstrate a poor prognosis, yet the risk factors for CMD remain unclear. Subtle changes in thyroid hormone levels within the normal range, especially the free thyroxine (FT4)/free triiodothyronine (FT3) ratio, have been shown to regulate the cardiovascular system. This prospective study investigated the correlation between FT4/FT3 ratio and CMD in euthyroid patients with INOCA. METHODS This prospective study (www.chictr.org.cn/, ChiCTR2000037112) recruited patients with myocardial ischemia symptoms who underwent both coronary angiography (CAG) and myocardial perfusion imaging (MPI) with dynamic single-photon emission computed tomography (D-SPECT). INOCA was defined as coronary stenosis< 50% and CMD was defined as coronary flow reserve (CFR)<2.5. All patients were excluded from abnormal thyroid function and thyroid disease history. RESULTS Among 71 INOCA patients (15 [21.1%] CMD), FT4 and FT4/FT3 ratio in CMD group were significantly higher and both showed significantly moderate correlation with CFR (r=-0.25, p=0.03; r=-0.34, p=0.003, respectively). The ROC curve revealed that FT4/FT3 ratio had the highest efficacy for predicting CMD with an optimized cutoff value>3.39 (AUC 0.78, p<0.001, sensitivity, 80.0%; specificity, 71.4%). Multivariate logistic regression showed that FT4/FT3 ratio was an independent predictor of CMD (OR 7.62, 95% CI 1.12-51.89, p=0.038, P for trend=0.006). CONCLUSION In euthyroid INOCA patients, increased FT4/FT3 ratio levels are associated with the occurrence of CMD, presenting a novel biomarker for improving the risk stratification.
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Affiliation(s)
- Han Zhang
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kuangyu Shi
- Department of Nuclear Medicine, University of Bern, Bern, Switzerland
- Department of Informatics, Technical University of Munich, Munich, Germany
| | - Yan Huang
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Chong Xu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Mengyu Fei
- Department of Radiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Fan
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Jiajia Zhang
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Xueping Hu
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Fan Hu
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Shanshan Qin
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Xiaoying Zhang
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, China
| | - Qingqing Huang
- Shanghai Key Laboratory of Molecular Imaging, Shanghai University of Medicine and Health Sciences, Shanghai, China
- *Correspondence: Qingqing Huang, ; Fei Yu,
| | - Fei Yu
- Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Molecular Imaging, Shanghai University of Medicine and Health Sciences, Shanghai, China
- *Correspondence: Qingqing Huang, ; Fei Yu,
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Mangiacapra F, Viscusi MM, Verolino G, Paolucci L, Nusca A, Melfi R, Ussia GP, Grigioni F. Invasive Assessment of Coronary Microvascular Function. J Clin Med 2021; 11:jcm11010228. [PMID: 35011968 PMCID: PMC8745537 DOI: 10.3390/jcm11010228] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
The critical role of the coronary microvascular compartment and its invasive functional assessment has become apparent in light of the significant proportion of patients presenting signs and symptoms of myocardial ischemia, despite the absence of epicardial disease, or after the adequate treatment of it. However, coronary microvascular dysfunction (CMD) represents a diagnostic challenge because of the small dimensions of the coronary microvasculature, which prevents direct angiographic visualization. Several diagnostic tools are now available for the invasive assessment of the coronary microvascular function, which, in association with the physiological indices used to investigate the epicardial department, may provide a comprehensive evaluation of the coronary circulation as a whole. Recent evidence suggests that the physiology-guided management of CMD, although apparently costly and time-consuming, may offer a net clinical benefit in terms of symptom improvement among patients with angina and ischemic heart disease. However, despite the results of several observational studies, the prognostic effect of the physiology-driven management of CMD within this population is currently a matter of debate, and therefore represents an unmet clinical need that urgently deserves further investigation.
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Seitz A, McChord J, Bekeredjian R, Sechtem U, Ong P. Definitions and Epidemiology of Coronary Functional Abnormalities. Eur Cardiol 2021; 16:e51. [PMID: 34950247 PMCID: PMC8674628 DOI: 10.15420/ecr.2021.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Coronary functional abnormalities are frequent causes of angina pectoris, particularly in patients with unobstructed coronary arteries. There is a spectrum of endotypes of functional coronary abnormalities with different mechanisms of pathology including enhanced vasoconstriction (i.e. coronary artery spasm) or impaired vasodilatation, such as impaired coronary flow reserve or increased microvascular resistance. These vasomotor abnormalities can affect various compartments of the coronary circulation such as the epicardial conduit arteries and/or the coronary microcirculation. Unequivocal categorisation and nomenclature of the broad spectrum of disease endotypes is crucial both in clinical practice as well as in clinical trials. This article describes the definitions of coronary functional abnormalities with currently accepted cut-off values, as well as diagnostic methods to identify and distinguish endotypes. The authors also provide a summary of contemporary data on the prevalence of the different endotypes of coronary functional abnormalities and their coexistence.
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Affiliation(s)
- Andreas Seitz
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Johanna McChord
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Raffi Bekeredjian
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Udo Sechtem
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
| | - Peter Ong
- Robert-Bosch-Krankenhaus, Department of Cardiology and Angiology, Stuttgart, Germany
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Godo S, Takahashi J, Yasuda S, Shimokawa H. Endothelium in Coronary Macrovascular and Microvascular Diseases. J Cardiovasc Pharmacol 2021; 78:S19-S29. [PMID: 34840261 PMCID: PMC8647695 DOI: 10.1097/fjc.0000000000001089] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/05/2021] [Indexed: 01/09/2023]
Abstract
ABSTRACT The endothelium plays a pivotal role in the regulation of vascular tone by synthesizing and liberating endothelium-derived relaxing factors inclusive of vasodilator prostaglandins (eg, prostacyclin), nitric oxide (NO), and endothelium-dependent hyperpolarization factors in a distinct blood vessel size-dependent manner. Large conduit arteries are predominantly regulated by NO and small resistance arteries by endothelium-dependent hyperpolarization factors. Accumulating evidence over the past few decades has demonstrated that endothelial dysfunction and coronary vasomotion abnormalities play crucial roles in the pathogenesis of various cardiovascular diseases. Structural and functional alterations of the coronary microvasculature have been coined as coronary microvascular dysfunction (CMD), which is highly prevalent and associated with adverse clinical outcomes in many clinical settings. The major mechanisms of coronary vasomotion abnormalities include enhanced coronary vasoconstrictive reactivity at epicardial and microvascular levels, impaired endothelium-dependent and endothelium-independent coronary vasodilator capacities, and elevated coronary microvascular resistance caused by structural factors. Recent experimental and clinical research has highlighted CMD as the systemic small artery disease beyond the heart, emerging modulators of vascular functions, novel insights into the pathogenesis of cardiovascular diseases associated with CMD, and potential therapeutic interventions to CMD with major clinical implications. In this article, we will summarize the current knowledge on the endothelial modulation of vascular tone and the pathogenesis of coronary macrovascular and microvascular diseases from bench to bedside, with a special emphasis placed on the mechanisms and clinical implications of CMD.
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Affiliation(s)
- Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; and
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; and
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; and
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; and
- Graduate School, International University of Health and Welfare, Narita, Japan
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Wang M, Shan Y, Sun W, Han J, Tong H, Fan M, Chen J, Yu P, Shen L, Chen X. Effects of Shexiang Baoxin Pill for Coronary Microvascular Function: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:751050. [PMID: 34795585 PMCID: PMC8592925 DOI: 10.3389/fphar.2021.751050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022] Open
Abstract
Background: The coronary microvascular dysfunction has attracted more and more attention in recent years, but there is still a lack of effective treatment. Shexiang Baoxin Pill is one of the commonly used drugs for the treatment of coronary artery disease in China. More recently, some studies found that it has the effect of improving coronary microvascular function. Objective: To evaluate the effects of Shexiang Baoxin Pill for coronary microvascular function. Methods: Databases including MEDLINE, Web of Science, CNKI, Wanfang, The Cochrane Library, EMbase, VIP and CBM were searched from inception to June 2021 to screen out relevant clinical studies. The 2019 version 2 of the Cochrane risk of bias tool (RoB2) were used to assess the methodological quality of the included studies. RevMan 5.3 software was used for meta-analysis. Results: Eleven studies meeting the criteria were included, with a total of 1,075 patients. The results of meta-analysis showed that compared with conventional treatment alone, combination of Shexiang Baoxin Pill and conventional treatment can further increase the coronary flow reserve (CFR) [mean difference (MD) = 0.43, 95%CI (0.28, 0.58), p < 0.000 01], decrease the index of microvascular resistance (IMR) [MD = -4.23, 95%CI (-5.49, -2.97), p < 0.000 01], increase serum nitric oxide (NO) [MD = 11.96, 95%CI (2.74, 21.18), p = 0.001] and decrease serum hypersensitive C-reactive protein (hs-CRP) [MD = -2.49, 95%CI (-3.08, -1.90), p < 0.000 01], but did not increase the time of duration on the exercise testing (TET) [MD = 3.64, 95%CI (-1.17, 8.45), p = 0.14]. In terms of safety, a total of 10 patients developed adverse reactions in the intervention group and 17 patients developed adverse reactions in the control group. Conclusion: Current evidence suggests that Shexiang Baoxin Pill may be effective in the improvement of coronary microvascular function when used in combination with conventional treatment. However, due to the low quality of the included studies, lack of placebo control and high heterogeneity among different studies, we should take a cautious attitude towards this conclusion. Moreover, the safety of Shexiang Baoxin Pill remains uncertain, more high-quality clinical studies are needed to verify the efficacy and safety of this drug in the future. Systematic Review Registration: [website], identifier [registration number: CRD42021265113].
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Affiliation(s)
- Mengxi Wang
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yiwen Shan
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Weixin Sun
- Department of Cardiology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Jie Han
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Huaqin Tong
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Manlu Fan
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.,First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jiandong Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Peng Yu
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Le Shen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Xiaohu Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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Schroder J, Prescott E. Doppler Echocardiography Assessment of Coronary Microvascular Function in Patients With Angina and No Obstructive Coronary Artery Disease. Front Cardiovasc Med 2021; 8:723542. [PMID: 34778394 PMCID: PMC8585781 DOI: 10.3389/fcvm.2021.723542] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023] Open
Abstract
Echocardiographic evaluation is an essential part of the diagnostic work-up in patients with known or suspected cardiovascular disease. Transthoracic Doppler echocardiography (TTDE) enables straightforward and reliable visualization of flow in the left anterior descending artery. In the absence of obstructive coronary artery disease, low TTDE-derived coronary flow velocity reserve (CFVR) is considered a marker of coronary microvascular dysfunction (CMD). TTDE CFVR is free from ionizing radiation and widely available, utilizing high-frequency transducers, pharmacologic vasodilator stress, and pulsed-wave Doppler quantification of diastolic peak flow velocities. European Society of Cardiology guidelines recommend TTDE CFVR evaluation only following preceding anatomic invasive or non-invasive coronary imaging excluding obstructive CAD. Accordingly, clinical use of TTDE CFVR is limited and CMD frequently goes undiagnosed. An evolving body of evidence underlines that low CFVR is an important and robust predictor of adverse prognosis and continuing symptoms in angina patients both with and without obstructive CAD. The majority of angina patients have no obstructive CAD, particularly among women. This has led to the suggestion that there may be a gender-specific female atherosclerotic phenotype with less epicardial obstruction, and a low CFVR signifying CMD instead. Nevertheless, available evidence indicates low CFVR is an equally important prognostic marker in both men and women. In this review, TTDE CFVR was evaluated regarding indication, practical and technical aspects, and interpretation of results. Association with symptoms and prognosis, comparison with alternative invasive and non-invasive imaging modalities, and possible interventions in angina patients with low CFVR were discussed, and key research questions were proposed.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Takahashi J, Suda A, Nishimiya K, Godo S, Yasuda S, Shimokawa H. Pathophysiology and Diagnosis of Coronary Functional Abnormalities. Eur Cardiol 2021; 16:e30. [PMID: 34603510 PMCID: PMC8478147 DOI: 10.15420/ecr.2021.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/07/2021] [Indexed: 01/17/2023] Open
Abstract
Approximately one-half of patients undergoing diagnostic coronary angiography for angina have no significant coronary atherosclerotic stenosis. This clinical condition has recently been described as ischaemia with non-obstructive coronary arteries (INOCA). Coronary functional abnormalities are central to the pathogenesis of INOCA, including epicardial coronary spasm and coronary microvascular dysfunction composed of a variable combination of increased vasoconstrictive reactivity and/or reduced vasodilator function. During the last decade - in INOCA patients in particular - evidence for the prognostic impact of coronary functional abnormalities has accumulated and various non-invasive and invasive diagnostic techniques have enabled the evaluation of coronary vasomotor function in a comprehensive manner. In this review, the authors briefly summarise the recent advances in the understanding of pathophysiology and diagnosis of epicardial coronary artery spasm and coronary microvascular dysfunction.
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Affiliation(s)
- Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Akira Suda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Kensuke Nishimiya
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai, Japan
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43
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Del Buono MG, Montone RA, Camilli M, Carbone S, Narula J, Lavie CJ, Niccoli G, Crea F. Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1352-1371. [PMID: 34556322 PMCID: PMC8528638 DOI: 10.1016/j.jacc.2021.07.042] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/12/2022]
Abstract
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
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Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy. https://twitter.com/marcodelbuono3
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia, USA; VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, Ochsner Clinical School, New Orleans, Louisiana, USA
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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44
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MacRitchie N, Noonan J, Guzik TJ, Maffia P. Molecular Imaging of Cardiovascular Inflammation. Br J Pharmacol 2021; 178:4216-4245. [PMID: 34378206 DOI: 10.1111/bph.15654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/22/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
Cardiovascular diseases (CVD), including atherosclerosis, are chronic inflammatory diseases characterised by a complex and evolving tissue micro-environment. Molecular heterogeneity of inflammatory responses translates into clinical outcomes. However, current medical imaging modalities are unable to reveal the cellular and molecular events at a level of detail that would allow more accurate and timely diagnosis and treatment. This is an inherent limitation of the current imaging tools which are restricted to anatomical or functional data. Molecular imaging - the visualization and quantification of molecules in the body - is already established in the clinic in the form of Positron Emitted Tomography (PET), yet the use of PET in CVD is limited. In this visual review, we will guide you through the current state of molecular imaging research, assessing the respective strengths and weaknesses of molecular imaging modalities, including those already being used in the clinic such as PET and magnetic resonance imaging (MRI) and emerging technologies at pre-clinical stage, such as photoacoustic imaging. We discuss the basic principles of each technology and provide key examples of their application in imaging inflammation in CVD and the added value into the diagnostic decision-making process. Finally, we discuss barriers for rapid successful clinical translation of these novel diagnostic modalities.
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Affiliation(s)
- Neil MacRitchie
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | | | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Department of Internal Medicine, Jagiellonian University, Collegium Medicum, Kraków, Poland
| | - Pasquale Maffia
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Department of Pharmacy, University of Naples Federico II, Naples, Italy
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45
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Zenger B, Good WW, Bergquist JA, Rupp LC, Perez M, Stoddard GJ, Sharma V, MacLeod RS. Pharmacological and simulated exercise cardiac stress tests produce different ischemic signatures in high-resolution experimental mapping studies. J Electrocardiol 2021; 68:56-64. [PMID: 34339897 DOI: 10.1016/j.jelectrocard.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Test the hypothesis that exercise and pharmacological cardiac stressors create different electrical ischemic signatures. INTRODUCTION Current clinical stress tests for detecting ischemia lack sensitivity and specificity. One unexplored source of the poor detection is whether pharmacological stimulation and regulated exercise produce identical cardiac stress. METHODS We used a porcine model of acute myocardial ischemia in which animals were instrumented with transmural plunge-needle electrodes, an epicardial sock array, and torso arrays to simultaneously measure cardiac electrical signals within the heart wall, the epicardial surface, and the torso surface, respectively. Ischemic stress via simulated exercise and pharmacological stimulation were created with rapid electrical pacing and dobutamine infusion, respectively, and mimicked clinical stress tests of five 3-minute stages. Perfusion to the myocardium was regulated by a hydraulic occluder around the left anterior descending coronary artery. Ischemia was measured as deflections to the ST-segment on ECGs and electrograms. RESULTS Across eight experiments with 30 (14 simulated exercise and 16 dobutamine) ischemic interventions, the spatial correlations between exercise and pharmacological stress diverged at stage three or four during interventions (p<0.05). We found more detectable ST-segment changes on the epicardial surface during simulated exercise than with dobutamine (p<0.05). The intramyocardial ischemia formed during simulated exercise had larger ST40 potential gradient magnitudes (p<0.05). CONCLUSION We found significant differences on the epicardium between cardiac stress types using our experimental model, which became more pronounced at the end stages of each test. A possible mechanism for these differences was the larger ST40 potential gradient magnitudes within the myocardium during exercise. The presence of microvascular dysfunction during exercise and its absence during dobutamine stress may explain these differences.
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Affiliation(s)
- Brian Zenger
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, SLC, UT, USA; Department of Biomedical Engineering, University of Utah, SLC, UT, USA; School of Medicine, University of Utah, SLC, UT, USA.
| | - Wilson W Good
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, SLC, UT, USA; Department of Biomedical Engineering, University of Utah, SLC, UT, USA
| | - Jake A Bergquist
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, SLC, UT, USA; Department of Biomedical Engineering, University of Utah, SLC, UT, USA
| | - Lindsay C Rupp
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, SLC, UT, USA; Department of Biomedical Engineering, University of Utah, SLC, UT, USA
| | - Maura Perez
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA
| | | | - Vikas Sharma
- School of Medicine, University of Utah, SLC, UT, USA
| | - Rob S MacLeod
- Scientific Computing and Imaging Institute, University of Utah, SLC, UT, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, SLC, UT, USA; Department of Biomedical Engineering, University of Utah, SLC, UT, USA
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46
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King O, Sunyovszki I, Terracciano CM. Vascularisation of pluripotent stem cell-derived myocardium: biomechanical insights for physiological relevance in cardiac tissue engineering. Pflugers Arch 2021; 473:1117-1136. [PMID: 33855631 PMCID: PMC8245389 DOI: 10.1007/s00424-021-02557-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022]
Abstract
The myocardium is a diverse environment, requiring coordination between a variety of specialised cell types. Biochemical crosstalk between cardiomyocytes (CM) and microvascular endothelial cells (MVEC) is essential to maintain contractility and healthy tissue homeostasis. Yet, as myocytes beat, heterocellular communication occurs also through constantly fluctuating biomechanical stimuli, namely (1) compressive and tensile forces generated directly by the beating myocardium, and (2) pulsatile shear stress caused by intra-microvascular flow. Despite endothelial cells (EC) being highly mechanosensitive, the role of biomechanical stimuli from beating CM as a regulatory mode of myocardial-microvascular crosstalk is relatively unexplored. Given that cardiac biomechanics are dramatically altered during disease, and disruption of myocardial-microvascular communication is a known driver of pathological remodelling, understanding the biomechanical context necessary for healthy myocardial-microvascular interaction is of high importance. The current gap in understanding can largely be attributed to technical limitations associated with reproducing dynamic physiological biomechanics in multicellular in vitro platforms, coupled with limited in vitro viability of primary cardiac tissue. However, differentiation of CM from human pluripotent stem cells (hPSC) has provided an unlimited source of human myocytes suitable for designing in vitro models. This technology is now converging with the diverse field of tissue engineering, which utilises in vitro techniques designed to enhance physiological relevance, such as biomimetic extracellular matrix (ECM) as 3D scaffolds, microfluidic perfusion of vascularised networks, and complex multicellular architectures generated via 3D bioprinting. These strategies are now allowing researchers to design in vitro platforms which emulate the cell composition, architectures, and biomechanics specific to the myocardial-microvascular microenvironment. Inclusion of physiological multicellularity and biomechanics may also induce a more mature phenotype in stem cell-derived CM, further enhancing their value. This review aims to highlight the importance of biomechanical stimuli as determinants of CM-EC crosstalk in cardiac health and disease, and to explore emerging tissue engineering and hPSC technologies which can recapitulate physiological dynamics to enhance the value of in vitro cardiac experimentation.
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Affiliation(s)
- Oisín King
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK.
| | - Ilona Sunyovszki
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK
| | - Cesare M Terracciano
- National Heart & Lung Institute, Imperial College London, Hammersmith Campus, ICTEM 4th floor, Du Cane Road, London, W12 0NN, UK
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Schroder J, Michelsen MM, Mygind ND, Suhrs HE, Bove KB, Bechsgaard DF, Aziz A, Gustafsson I, Kastrup J, Prescott E. Coronary flow velocity reserve predicts adverse prognosis in women with angina and no obstructive coronary artery disease: results from the iPOWER study. Eur Heart J 2021; 42:228-239. [PMID: 33477168 DOI: 10.1093/eurheartj/ehaa944] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS Many patients with angina, especially women, do not have obstructive coronary artery disease (CAD) yet have impaired prognosis. We investigated whether routine assessment of coronary microvascular dysfunction (CMD) is feasible and predicts adverse outcome in women with angina and no obstructive CAD. METHODS AND RESULTS After screening 7253, we included 1853 women with angina and no obstructive CAD on angiogram who were free of previous CAD, heart failure, or valvular heart disease in the prospective iPOWER (Improving Diagnosis and Treatment of Women with Angina Pectoris and Microvascular Disease) study. CMD was assessed by Doppler echocardiography in the left anterior descending artery as coronary flow velocity reserve (CFVR). Patients were followed for a composite outcome of cardiovascular death, myocardial infarction (MI), heart failure, stroke, and coronary revascularization. CFVR was obtained in 1681 patients (91%) and the median CFVR was 2.33 (quartiles 1-3: 2.00-2.74). During a median follow-up of 4.5 years, 96 events occurred. In univariate Cox regression, CFVR was associated with the composite outcome {hazard ratio (HR) 1.07 [95% confidence interval (CI) 1.03-1.11] per 0.1 unit decrease in CFVR; P < 0.001}, primarily driven by an increased risk of MI and heart failure. Results remained significant in multivariate analysis [HR 1.05 (95% CI 1.01-1.09) per 0.1 unit decrease in CFVR; P = 0.01]. In exploratory analyses, CFVR was also associated with the risk of repeated hospital admission for angina and all-cause mortality. CONCLUSION Assessment of CFVR by echocardiography is feasible and predictive of adverse outcome in women with angina and no obstructive CAD. Results support a more aggressive preventive management of these patients and underline the need for trials targeting CMD.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Naja D Mygind
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Hannah E Suhrs
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Kira B Bove
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Daria Frestad Bechsgaard
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, Hvidovre Hospital, Kettegaard Alle 30, 2650 Hvidovre Odense Hospital, J.B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Ahmed Aziz
- Department of Cardiology, Odense University Hospital, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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Sonaglioni A, Rigamonti E, Nicolosi GL, Lombardo M. Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease. Int J Cardiovasc Imaging 2021; 37:2917-2930. [PMID: 33961159 DOI: 10.1007/s10554-021-02274-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/03/2021] [Indexed: 01/02/2023]
Abstract
The hypothesis that modified Haller index (MHI) integration with the existing appropriate use criteria (AUC) categories may predict exercise stress echocardiography (ESE) results and outcome of patients with suspected coronary artery disease (CAD) has never been previously investigated. We retrospectively analyzed 1230 consecutive patients (64.8 ± 13.1 years, 58.9% men) who underwent ESE for suspected CAD between February 2011 and September 2019 at our institution. MHI (chest transverse diameter over the distance between sternum and spine) was assessed in all patients. A true positive (TP) ESE was a positive ESE with obstructive CAD according to subsequent coronary angiography. During follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations; (2) Cardiac death or sudden death. Overall, 734 (59.7%), 357 (29.0%) and 139 (11.3%) indications for ESE were classified as appropriate (Group 1), rarely appropriate (Group 2) and which may be appropriate (Group 3), respectively. A funnel chest (defined by an MHI > 2.5) was detected in 30.3%, 82.1% and 49.6% of Groups 1, 2 and 3 subjects, respectively (p < 0.0001). On multivariate logistic regression analysis, male sex (OR 1.41, 95%CI 1.02-2.03, p = 0.01) and type-2 diabetes (OR 3.63, 95%CI 2.49-5.55, p = 0.001) were directly correlated to a TP ESE, while "rarely appropriate" indication for ESE with MHI > 2.5 (OR 0.16, 95%CI 0.11-0.22, p < 0.0001) showed a significant inverse correlation with the outcome. During a mean follow-up of 2.5 ± 1.9 years, 299 CV events occurred: 76.4%, 3.5% and 20.1% in Groups 1, 2 and 3, respectively. On multivariate Cox regression analysis, smoking (HR 1.33, 95%CI 1.19-1.48), type 2 diabetes (HR 2.28, 95%CI 1.74-2.97), dyslipidemia (HR 3.51, 95%CI 2.33-5.15), beta-blockers (HR 0.55, 95%CI 0.41-0.75), statins (HR 0.60, 95%CI 0.45-0.80), peak exercise average E/e' ratio (HR 1.08, 95%CI 1.06-1.09), positive ESE (HR 3.12, 95%CI 2.43-4.01) and finally "rarely appropriate" indication for ESE with MHI > 2.5 (HR 0.15, 95%CI 0.08-0.23) were independently associated with CV events. The implementation of AUC categories with MHI assessment may select a group of patients with extremely low probability of both TP ESE and adverse CV events over a medium-term follow-up. A simple noninvasive chest shape assessment could reduce unnecessary exams.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy. .,Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Elisabetta Rigamonti
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy
| | | | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy
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49
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Affiliation(s)
- Michael Y Henein
- Institute of Public Health and Clinical Medicine, 8075Umea University, Sweden.,Brunel University, Middlesex, United Kingdom.,St George's University London, United Kingdom
| | - Federico Vancheri
- Department of Internal Medicine, S. Elia Hospital, Caltanissetta, Italy
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50
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Baghdasaryan P, Natarajan B, Nalbandian M, Varadarajan P, Pai RG. Myocardial Infarction with Nonobstructive Coronary Artery Disease—Definition, Etiopathogenesis, Diagnosis, and Management. Int J Angiol 2021. [DOI: 10.1055/s-0041-1724040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractMyocardial infarction with nonobstructive coronary arteries (MINOCA) is a complex clinical syndrome that is characterized by evidence of acute myocardial infarction in the absence of significant epicardial coronary artery disease on angiography. The term “MINOCA” encompasses a group of heterogeneous diseases with varying underlying mechanisms and each with its own pathophysiology. Overlooked plaque rupture or erosion and coronary vasospasm are the most common causes of MINOCA and can be diagnosed by routine intracoronary imaging and vasoreactivity testing, respectively. Coronary microvascular dysfunction is a less recognized, albeit an important cause of morbidity in patients presenting with MINOCA. Although MINOCA is a rare presentation of acute coronary syndrome, it is not a benign disorder and can have adverse consequences if untreated. In this article, we aim to review the pathogenesis, clinical characteristics, and finally propose a systematic approach in the diagnosis and management of patients with MINOCA.
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Affiliation(s)
- Patrick Baghdasaryan
- Division of Cardiology, University of California Riverside School of Medicine, CA
| | - Balaji Natarajan
- Division of Cardiology, University of California Riverside School of Medicine, CA
| | | | - Padmini Varadarajan
- Division of Cardiology, University of California Riverside School of Medicine, CA
| | - Ramdas G. Pai
- Division of Cardiology, University of California Riverside School of Medicine, CA
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