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Dankar R, Wehbi J, Atasi MM, Alam S, Refaat MM. Coronary microvascular dysfunction, arrythmias, and sudden cardiac death: A literature review. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 41:100389. [PMID: 38584700 PMCID: PMC10998042 DOI: 10.1016/j.ahjo.2024.100389] [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: 12/30/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
The coronary vascular system has a unique structure and function that is adaptive to myocardial demand. It is composed of a continuous network of vessels receding in size from epicardial arteries to the microvascular circulation. Failure to meet myocardial demand results in ischemia, angina, and adverse myocardial outcomes. It is evident that 50 % of patients with angina have a non-obstructive coronary disease and 66 % of these patients have coronary microvascular dysfunction (CMD). The impact of CMD on the atria and ventricles is exhibited through its association with atrial fibrillation and distortion of ventricular repolarization. Ultimately, this influence increases the risk of mortality, morbidity, and sudden cardiac arrest. CMD serves as an independent risk for atrial fibrillation, increases ventricular electrical inhomogeneity, and contributes to the progression of cardiac disease. The underlying pathogenesis may be attributed to oxidative stress evident through reactive oxygen species, impaired vasoactive function, and structural disorders such as fibrotic changes. Myocardial ischemia, brought about by a demand-supply mismatch in CMD, may create a milieu for ventricular arrythmia and sudden cardiac arrest through distortion of ventricular repolarization parameters such as QT dispersion and corrected QT dispersion.
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Affiliation(s)
- Razan Dankar
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jad Wehbi
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Montaser Atasi
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samir Alam
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan M. Refaat
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Marchini F, Pompei G, D'Aniello E, Marrone A, Caglioni S, Biscaglia S, Campo G, Tebaldi M. Shedding Light on Treatment Options for Coronary Vasomotor Disorders: A Systematic Review. Cardiovasc Drugs Ther 2024; 38:151-161. [PMID: 35678926 PMCID: PMC10876767 DOI: 10.1007/s10557-022-07351-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Coronary vasomotor dysfunction embraces two specific clinical entities: coronary (micro)vascular spasm and microvascular dysfunction. The clinical manifestations of these entities are respectively called vasospastic angina (VSA) and microvascular angina (MVA). Over the years, these diseases have become more and more prominent and several studies aimed to investigate the best diagnostic and therapeutic strategies. Patients with coronary vasomotor disorders are often undertreated due to the absence of evidence-based guidelines. The purpose of this overview is to illustrate the various therapeutic options available for the optimized management of these patients. METHODS A Medline search of full-text articles published in English from 1980 to April 2022 was performed. The main analyzed aspects of vasomotor disorders were treatment options. We also performed research on "Clinicaltrial.gov" for ongoing trials. CONCLUSION Coronary (micro)vascular spasm and microvascular dysfunction are clinical entities characterized by high prevalence and clinical representation. Several therapeutic strategies, both innovative and established, are available to optimize treatment and improve the quality of life of these patients.
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Affiliation(s)
- Federico Marchini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Graziella Pompei
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Emanuele D'Aniello
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Andrea Marrone
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Serena Caglioni
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy
| | - Matteo Tebaldi
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Via Aldo Moro 8, 44124, Cona, FE, Italy.
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Chakrala T, Prakash R, Valdes C, Pepine CJ, Keeley EC. Circulating Biomarkers in Coronary Microvascular Dysfunction. J Am Heart Assoc 2023:e029341. [PMID: 37301749 DOI: 10.1161/jaha.122.029341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Coronary microvascular dysfunction is an underdiagnosed pathologic process that is associated with adverse clinical outcomes. Biomarkers, molecules measurable in the blood, could inform the clinician by aiding in the diagnosis and management of coronary microvascular dysfunction. We present an updated review of circulating biomarkers in coronary microvascular dysfunction representing key pathologic processes, including inflammation, endothelial dysfunction, oxidative stress, coagulation, and other mechanisms.
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Affiliation(s)
- Teja Chakrala
- Department of Medicine University of Florida Gainesville FL USA
| | - Roshni Prakash
- Department of Medicine University of Florida Gainesville FL USA
| | - Carlos Valdes
- Department of Medicine University of Florida Gainesville FL USA
| | - Carl J Pepine
- Department of Medicine University of Florida Gainesville FL USA
- Division of Cardiovascular Medicine University of Florida Gainesville FL USA
| | - Ellen C Keeley
- Department of Medicine University of Florida Gainesville FL USA
- Division of Cardiovascular Medicine University of Florida Gainesville FL USA
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Willems LH, Thijssen DHJ, Groh LA, Kooijman NI, Ten Cate H, Spronk HMH, Donders ART, van der Vijver-Coppen RJ, van Hoek F, Nagy M, Reijnen MMPJ, Warlé MC. Dual pathway inhibition as compared to acetylsalicylic acid monotherapy in relation to endothelial function in peripheral artery disease, a phase IV clinical trial. Front Cardiovasc Med 2022; 9:979819. [PMID: 36277757 PMCID: PMC9583941 DOI: 10.3389/fcvm.2022.979819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/20/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Dual pathway inhibition (DPI) by combining acetylsalicylic acid (ASA) with low-dose rivaroxaban has been shown to reduce cardiovascular events in patients with peripheral arterial disease (PAD) when compared to ASA monotherapy. A potential explanation is that inhibition of factor Xa improves endothelial function through crosstalk between coagulation and inflammatory pathways, subsequently attenuating the occurrence of cardiovascular events. We hypothesize that the addition of rivaroxaban to ASA in PAD patients leads to improved endothelial function. Design An investigator-initiated, multicentre trial investigating the effect of DPI on endothelial function. Methods Patients, diagnosed with PAD, were enrolled in two cohorts: cohort A (Rutherford I-III) and cohort B (Rutherford IV-VI). Participants received ASA monotherapy for a 4-weeks run-in period, followed by 12 weeks of DPI. Macro- and microvascular endothelial dysfunction were studied by measuring carotid artery reactivity upon sympathetic stimulus and by measuring plasma endothelin-1 concentrations, respectively. All measurements were performed during the use of ASA (baseline) and after 12 weeks of DPI. Results 159 PAD patients (111 cohort A, 48 cohort B) were enrolled. Twenty patients discontinued study drugs early. Carotid artery constriction upon sympathetic stimulation at baseline (ASA) and after 12 weeks of DPI was similar in the total group, 22.0 vs. 22.7% (p = 1.000), and in the subgroups (Cohort A 22.6 vs. 23.7%, p = 1.000; cohort B 20.5 vs. 20.5%, p = 1.000), respectively. The mean concentration of plasma endothelin-1 at baseline and after 12 weeks of DPI did not differ, 1.70 ± 0.5 vs. 1.66 ± 0.64 pmol/L (p = 0.440) in the total group, 1.69 ± 0.59 vs. 1.62 ± 0.55 pmol/L in cohort A (p = 0.202), and 1.73 ± 0.53 vs. 1.77 ± 0.82 pmol/L in cohort B (p = 0.682), respectively. Conclusion Macro- and microvascular endothelial dysfunction, as reflected by carotid artery reactivity and plasma endothelin-1 concentrations, are not influenced in PAD patients by addition of low-dose rivaroxaban to ASA monotherapy for 12 weeks. Trial registration https://clinicaltrials.gov/ct2/show/NCT04218656.
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Affiliation(s)
- Loes H. Willems
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands,*Correspondence: Loes H. Willems
| | - Dick H. J. Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands,Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Laszlo A. Groh
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nina I. Kooijman
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hugo Ten Cate
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands,Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Henri M. H. Spronk
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands
| | - A. Rogier T. Donders
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Frank van Hoek
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Magdolna Nagy
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Michel M. P. J. Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, Netherlands,Multi-Modality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Michiel C. Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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Abraham GR, Morrow AJ, Oliveira J, Weir-McCall JR, Davenport EE, Berry C, Davenport AP, Hoole SP. Mechanistic study of the effect of Endothelin SNPs in microvascular angina – Protocol of the PRIZE Endothelin Sub-Study. IJC HEART & VASCULATURE 2022; 39:100980. [PMID: 35242999 PMCID: PMC8885580 DOI: 10.1016/j.ijcha.2022.100980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 11/17/2022]
Abstract
Microvascular angina is a common cause of ischemia with non-obstructive coronary arteries (INOCA). Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathophysiology of microvascular angina. Zibotentan, an Endothelin Receptor Antagonist is being tested as a treatment for microvascular angina in the ‘PRIZE’ trial using a genetic ‘precision medicine’ approach. The PRIZE ET Sub-study will provide a comprehensive genotype and phenotype bio-resource for microvascular angina patients.
Introduction Microvascular angina is a common cause of ischemia with non-obstructive coronary arteries (INOCA) and limited therapeutic options are available to those affected. Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathophysiology of microvascular angina. A large randomised, double blinded, placebo controlled crossover trial, the PRecIsion medicine with ZibotEntan in microvascular angina (PRIZE) trial is currently underway, investigating an endothelin receptor antagonist – Zibotentan, as a new drug treatment for microvascular angina. The trial uses a 'precision medicine' approach by preferential selection of those with higher ET-1 expression conferred by the PHACTR1 minor G allele single nucleotide polymorphism (SNP). The incidence of this SNP occurs in approximately one third of the population therefore a considerable number of screened patients will be ineligible for randomisation and the treatment phase of the trial. Methods In the PRIZE Endothelin (ET) Sub-Study, patients screened out of the PRIZE trial will be genotyped for other genetic variants in the ET-1 pathway. These will be correlated with phenotypic characteristics including exercise tolerance, angina severity and quantitative measures of microvascular function on cardiovascular MRI as well as mechanistic data on endothelin pathway signalling. Conclusions The study will provide a comprehensive genotype and phenotype bio-resource identifying novel ET-1 genotypes to inform the potential wider use of endothelin receptor antagonists for this indication.
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Sucato V, Corrado E, Manno G, Amata F, Testa G, Novo G, Galassi AR. Biomarkers of Coronary Microvascular Dysfunction in Patients With Microvascular Angina: A Narrative Review. Angiology 2021; 73:395-406. [PMID: 34338554 DOI: 10.1177/00033197211034267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current gold standard for diagnosis of coronary microvascular dysfunction (CMD) in the absence of myocardial diseases, whose clinical manifestation is microvascular angina (MVA), is reactivity testing using adenosine or acetylcholine during coronary angiography. This invasive test can be difficult to perform, expensive, and harmful. The identification of easily obtainable blood biomarkers which reflect the pathophysiology of CMD, characterized by high reliability, precision, accuracy, and accessibility may reduce risks and costs related to invasive procedures and even facilitate the screening and diagnosis of CMD. In this review, we summarized the results of several studies that have investigated the possible relationships between blood biomarkers involved with CMD and MVA. More specifically, we have divided the analyzed biomarkers into 3 different groups, according to the main mechanisms underlying CMD: biomarkers of "endothelial dysfunction," "vascular inflammation," and "oxidative stress." Finally, in the last section of the review, we consider mixed mechanisms and biomarkers which are not included in the 3 major categories mentioned above, but could be involved in the pathogenesis of CMD.
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Affiliation(s)
- Vincenzo Sucato
- Unit of Cardiology, University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy.,Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Egle Corrado
- Unit of Cardiology, University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy.,Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Girolamo Manno
- Unit of Cardiology, University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy.,Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Francesco Amata
- Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Gabriella Testa
- Unit of Cardiology, University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy.,Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Giuseppina Novo
- Unit of Cardiology, University Hospital Paolo Giaccone, University of Palermo, Palermo, Italy.,Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Alfredo R Galassi
- Department of Excellence of Sciences for Health Promotion and Maternal-Child Care, Internal Medicine and Specialties (ProMISE), University of Palermo, Palermo, Italy
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Peix A, Padrón K, Cabrera LO, Pardo L, Sánchez J. Left ventricular mechanical dyssynchrony in patients with chest pain and normal epicardial coronary arteries. J Nucl Cardiol 2021; 28:1055-1063. [PMID: 31267412 DOI: 10.1007/s12350-019-01804-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND To detect ischemia in patients with angina and normal coronaries frequently represents a complex diagnosis. METHODS To investigate whether left ventricular mechanical dyssynchrony by phase analysis contributes in the evaluation of patients with chest pain and normal coronaries, gated-SPECT myocardial perfusion imaging (MPI) at rest and 30 minutes post-stress was performed in 218 patients with normal epicardial coronaries, who were divided into two groups: those with summed difference score (SDS) ≥ 4 (54 patients, Group 1), and those with SDS < 4 (164 patients, Group 2). Intraventricular synchronism-phase standard deviation (PSD) and histogram bandwidth (HBW)-was evaluated by phase analysis. RESULTS Women were significantly more frequent in Group 2 (those without ischemia in SPECT MPI): 113 (69%) vs 25 (46%), P = .00001. In males, left ventricular ejection fraction (LVEF) and ventricular volumes were not significantly different between patients with or without ischemia. However, ischemic females showed significantly higher ventricular volumes, minor post-stress LVEF and more negative delta LVEF (- 3.9 vs 0.34, P = .0008) than the non-ischemic ones. There was a significant post-stress increase of PSD and HBW among males, although not among females. According to SSS (≥ 4, with ischemia/necrosis; < 4, without ischemia/necrosis), post-stress PSD and HBW significantly increase both in male and female, and PSD and HBW were significantly higher in females with SSS ≥ 4 compared to those with SSS < 4 (PSD rest: 19.04° vs 11.72°, P < .0001; HBW rest: 58.85° vs 38.21°, P < .0001). PSD and HBW were also higher among males with SSS ≥ 4 compared to those with SSS < 4, although not significantly. CONCLUSION Higher ventricular volumes in females and dyssynchrony are associated with inducible ischemia in MPI in patients with chest pain and normal coronaries. Stress-induced ischemia increases degree of dyssynchrony.
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Affiliation(s)
- Amalia Peix
- Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba.
- Nuclear Medicine Department, Institute of Cardiology, 17 No. 702, Vedado, CP 10 400, Havana, Cuba.
| | - Kenia Padrón
- Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
- Nuclear Medicine Department, Institute of Cardiology, 17 No. 702, Vedado, CP 10 400, Havana, Cuba
| | - Lázaro O Cabrera
- Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
- Nuclear Medicine Department, Institute of Cardiology, 17 No. 702, Vedado, CP 10 400, Havana, Cuba
| | - Leticia Pardo
- Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
- Nuclear Medicine Department, Institute of Cardiology, 17 No. 702, Vedado, CP 10 400, Havana, Cuba
| | - Jesús Sánchez
- Institute of Cybernetics, Mathematics and Physics, Havana, Cuba
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Elevated serum endothelin-1 is an independent predictor of coronary microvascular dysfunction in non-obstructive territories in patients with coronary artery disease. Heart Vessels 2021; 36:917-923. [PMID: 33484293 DOI: 10.1007/s00380-020-01767-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
Endothelin-1 contributes to the constrictor response of the coronary arteries in patients with ischemia with normal coronary arteries. There is thus increasing evidence that endothelin-1 plays a role in coronary microvascular dysfunction (CMD). We investigated whether elevated endothelin-1 is associated with CMD in patients with coronary artery disease (CAD). We prospectively studied 49 consecutive CAD patients with 1- or 2-vessel disease (age 71 ± 10 years, 43 males). Myocardial blood flow (MBF) was measured by 15O-water PET/CT at rest and during stress, and the coronary flow reserve (CFR) was calculated by dividing the stress MBF by the rest MBF. A CFR of less than 2.0 in non-obstructive regions was defined as a marker of CMD. Eighteen out of 49 (37%) CAD patients had CMD. Endothelin-1 in patients with CMD was significantly higher than in those without CMD (2.27 ± 0.81 vs. 1.64 ± 0.48 pg/mL, P = 0.001). Accordingly, univariate ROC analysis showed that the continuous endothelin-1 levels significantly discriminated between the presence and absence of CMD (area under the curve = 0.746 [95%CI 0.592-0.899]). The dichotomous treatment of elevated endothelin-1 as 1.961 pg/mL or more yielded the optimal discriminatory capacity, with a sensitivity of 72.2% and a specificity of 71.0%. High endothelin-1 was still a significant predictor of CMD after adjusting for diabetes mellitus (odds ratio = 6.64 [1.75-25.22], P = 0.005). Endothelin-1 is associated with CMD in non-obstructive territories in patients with CAD, suggesting that endothelin-1 is a potential target for treating CMD in CAD patients.
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Zymliński R, Sierpiński R, Metra M, Cotter G, Sokolski M, Siwołowski P, Garus M, Gajewski P, Tryba J, Samorek M, Jankowska EA, Biegus J, Ponikowski P. Elevated plasma endothelin-1 is related to low natriuresis, clinical signs of congestion, and poor outcome in acute heart failure. ESC Heart Fail 2020; 7:3536-3544. [PMID: 33063475 PMCID: PMC7755016 DOI: 10.1002/ehf2.13064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Endothelin-1 (ET-1) is a potent vasoconstrictor, which regulates renal and vascular function. We aimed to relate plasma levels of ET-1 with the clinical picture and outcomes in acute heart failure (AHF). METHODS AND RESULTS We studied 113 patients with AHF [mean age 65 ± 13 (years), median (upper and lower quartiles) N-terminal pro-B-type natriuretic peptide, 5422 (2689; 8582) (pg/mL)], in whom plasma levels of ET-1 were serially measured at admission (10.8 ± 5.2), Day 1 (9.5 ± 3.4), and Day 2 (8.9 ± 3.8) (pg/mL). The population was divided into tertiles across baseline ET-1 levels. Patients in the highest ET-1 tertile had predominant clinical signs of peripheral congestion; however, no difference was observed in pulmonary congestion and severity of dyspnoea. They also presented lower spot urine sodium at admission (75 ± 35 vs. 99 ± 43 vs. 108 ± 30), 6 h (84 ± 34 vs. 106 ± 43 vs. 106 ± 35), and Day 1 (75 ± 38 vs. 96 ± 36 vs. 100 ± 35) (mmol/L), when compared with the second and first tertile, respectively (all P < 0.05); furthermore, they received higher doses of intravenous furosemide from Day 2 and had longer intravenous diuretics, as median switch to oral furosemide was 4 (3; 4) vs. 3 (2; 4) vs. 2 (2; 3) (days), respectively, P < 0.05. There was no difference in serum creatinine, urea, and renal injury biomarkers (kidney injury molecule-1, serum cystatin C, and urine neutrophil gelatinase-associated lipocalin) between the ET-1 tertiles. Higher values of ET-1 measured at each time point were related with a higher risk of 1 year mortality. CONCLUSIONS Elevation of ET-1 is related to clinical signs of peripheral congestion, low urine sodium excretion, and poor outcome in AHF.
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Affiliation(s)
- Robert Zymliński
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | | | - Marco Metra
- Cardiology, The Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | | | - Mateusz Sokolski
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | | | - Mateusz Garus
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | - Piotr Gajewski
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | - Joanna Tryba
- Student Scientific Organization, Department of Heart DiseasesWroclaw Medical UniversityWrocławPoland
| | - Maria Samorek
- Student Scientific Organization, Department of Heart DiseasesWroclaw Medical UniversityWrocławPoland
| | - Ewa A. Jankowska
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | - Jan Biegus
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
| | - Piotr Ponikowski
- Department of Heart DiseasesWroclaw Medical UniversityBorowska 213Wrocław50‐556Poland
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Ford TJ, Corcoran D, Padmanabhan S, Aman A, Rocchiccioli P, Good R, McEntegart M, Maguire JJ, Watkins S, Eteiba H, Shaukat A, Lindsay M, Robertson K, Hood S, McGeoch R, McDade R, Yii E, Sattar N, Hsu LY, Arai AE, Oldroyd KG, Touyz RM, Davenport AP, Berry C. Genetic dysregulation of endothelin-1 is implicated in coronary microvascular dysfunction. Eur Heart J 2020; 41:3239-3252. [PMID: 31972008 PMCID: PMC7557475 DOI: 10.1093/eurheartj/ehz915] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/12/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Endothelin-1 (ET-1) is a potent vasoconstrictor peptide linked to vascular diseases through a common intronic gene enhancer [(rs9349379-G allele), chromosome 6 (PHACTR1/EDN1)]. We performed a multimodality investigation into the role of ET-1 and this gene variant in the pathogenesis of coronary microvascular dysfunction (CMD) in patients with symptoms and/or signs of ischaemia but no obstructive coronary artery disease (CAD). METHODS AND RESULTS Three hundred and ninety-one patients with angina were enrolled. Of these, 206 (53%) with obstructive CAD were excluded leaving 185 (47%) eligible. One hundred and nine (72%) of 151 subjects who underwent invasive testing had objective evidence of CMD (COVADIS criteria). rs9349379-G allele frequency was greater than in contemporary reference genome bank control subjects [allele frequency 46% (129/280 alleles) vs. 39% (5551/14380); P = 0.013]. The G allele was associated with higher plasma serum ET-1 [least squares mean 1.59 pg/mL vs. 1.28 pg/mL; 95% confidence interval (CI) 0.10-0.53; P = 0.005]. Patients with rs9349379-G allele had over double the odds of CMD [odds ratio (OR) 2.33, 95% CI 1.10-4.96; P = 0.027]. Multimodality non-invasive testing confirmed the G allele was associated with linked impairments in myocardial perfusion on stress cardiac magnetic resonance imaging at 1.5 T (N = 107; GG 56%, AG 43%, AA 31%, P = 0.042) and exercise testing (N = 87; -3.0 units in Duke Exercise Treadmill Score; -5.8 to -0.1; P = 0.045). Endothelin-1 related vascular mechanisms were assessed ex vivo using wire myography with endothelin A receptor (ETA) antagonists including zibotentan. Subjects with rs9349379-G allele had preserved peripheral small vessel reactivity to ET-1 with high affinity of ETA antagonists. Zibotentan reversed ET-1-induced vasoconstriction independently of G allele status. CONCLUSION We identify a novel genetic risk locus for CMD. These findings implicate ET-1 dysregulation and support the possibility of precision medicine using genetics to target oral ETA antagonist therapy in patients with microvascular angina. TRIAL REGISTRATION ClinicalTrials.gov: NCT03193294.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- Department of Cardiology, Gosford Hospital, NSW, Australia
- Faculty of Medicine, University of Newcastle, NSW, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Sandosh Padmanabhan
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
| | - Alisha Aman
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
| | - Paul Rocchiccioli
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Richard Good
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Janet J Maguire
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Level 6, Addenbrooke's Centre for Clinical Investigation (ACCI), Box 110, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Aadil Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Keith Robertson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Stuart Hood
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Ross McGeoch
- Laboratory for Advanced Cardiovascular Imaging, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Robert McDade
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Eric Yii
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
| | - Li-Yueh Hsu
- Laboratory for Advanced Cardiovascular Imaging, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew E Arai
- Laboratory for Advanced Cardiovascular Imaging, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | - Rhian M Touyz
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
| | - Anthony P Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Level 6, Addenbrooke's Centre for Clinical Investigation (ACCI), Box 110, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 9DH, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
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11
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Bairey Merz CN, Pepine CJ, Shimokawa H, Berry C. Treatment of coronary microvascular dysfunction. Cardiovasc Res 2020; 116:856-870. [PMID: 32087007 PMCID: PMC7061279 DOI: 10.1093/cvr/cvaa006] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/18/2019] [Indexed: 12/30/2022] Open
Abstract
Contemporary data indicate that patients with signs and symptoms of ischaemia and non-obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD) with elevated risk for adverse outcomes. Coronary endothelial (constriction with acetylcholine) and/or microvascular (limited coronary flow reserve with adenosine) dysfunction are well-documented, and extensive non-obstructive atherosclerosis is often present. Despite these data, patients with INOCA currently remain under-treated, in part, because existing management guidelines do not address this large, mostly female population due to the absence of evidence-based data. Relatively small sample-sized, short-term pilot studies of symptomatic mostly women, with INOCA, using intense medical therapies targeting endothelial, microvascular, and/or atherosclerosis mechanisms suggest symptom, ischaemia, and coronary vascular functional improvement, however, randomized, controlled outcome trials testing treatment strategies have not been completed. We review evidence regarding CMD pharmacotherapy. Potent statins in combination with angiotensin-converting enzyme inhibitor (ACE-I) or receptor blockers if intolerant, at maximally tolerated doses appear to improve angina, stress testing, myocardial perfusion, coronary endothelial function, and microvascular function. The Coronary Microvascular Angina trial supports invasive diagnostic testing with stratified therapy as an approach to improve symptoms and quality of life. The WARRIOR trial is testing intense medical therapy of high-intensity statin, maximally tolerated ACE-I plus aspirin on longer-term outcomes to provide evidence for guidelines. Novel treatments and those under development appear promising as the basis for future trial planning.
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Affiliation(s)
- C Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai, 127 S. San Vicente Blvd, Suite A3600, Los Angeles, CA 90048, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, 1329 SW 16th Street, PO Box 100288, Gainesville, FL 32610-0288, USA
| | - Hiroki Shimokawa
- Division of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
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12
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Smith LR, Salifu MO, McFarlane IM. Non-Obstructive Coronary Artery Disease in Women: Current Evidence and Future Directions. INTERNATIONAL JOURNAL OF CLINICAL RESEARCH & TRIALS 2020; 5:152. [PMID: 33447689 PMCID: PMC7806203 DOI: 10.15344/2456-8007/2020/152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Over half of women who present with angina are found to have negative coronary angiographic assessments. Of these patients, up to 50% are diagnosed with coronary microvascular dysfunction (CMD), which refers to pathologic changes within the small vessels of the coronary circulation. The hallmark of the pathophysiology of CMD is that endothelial damage, which occurs due to a multitude of conditions and risk factors, is the inciting event for the development and progression of CMD. CMD leads to a mismatch in myocardial demand and perfusion, leading to signs and symptoms of cardiac ischemia in the absence of obstructive lesions in the major vessels. CMD can be diagnosed through a variety of both invasive methods that allow a more specific evaluation of the microvasculature and non-invasive imaging techniques, such as cardiac positron emission tomography (PET) and magnetic resonance imaging (MRI). Risk factors for CMD overlap significantly with those of obstructive coronary artery disease (CAD) - hypertension, hypercholesterolemia, and diabetes remain salient predictors. However, these conditions only account for 20% of CMD cases in females. FINDINGS Women have sex-specific risk factors such as menopause, pregnancy, polycystic ovarian syndrome (PCOS), and a higher proclivity toward chronic inflammatory disorders. Estrogen has a cardioprotective effect by increasing production of nitric oxide, a potent vasodilator released by endothelial cells. As a result, the hormonal changes of menopause may accelerate endothelial damage, and in turn, CMD. Current treatments focus on addressing the risk factors of cardiovascular disease, such as anti-hypertensive drugs, weight loss, and glucose control. CONCLUSION Given the multifactorial nature of CMD in women, and the extensive atypical risk factors for cardiac disease, a more nuanced approach is needed that addresses the varied pathophysiology of CMD.
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Affiliation(s)
| | | | - Isabel M. McFarlane
- Corresponding Author: Dr. Isabel M. McFarlane, Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, USA, Tel: 718-270-2390, Fax: 718-270-1324;
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13
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Moroni C, Tolone S, Bondanini F, Schillaci O, Affricano C, Cassone R, Gaspardone A, Gaudio C. Endothelin-1 in hypertensive patients with ischemic heart disease. Intern Emerg Med 2019; 14:1119-1124. [PMID: 31069633 DOI: 10.1007/s11739-019-02095-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 04/27/2019] [Indexed: 11/25/2022]
Abstract
This study was aimed at evaluating whether transient dipyridamole-induced myocardial ischemia in hypertensive patients reflects on endothelin-1 plasma levels by comparing normotensives and hypertensives with or without stable angina. Endothelin-1 plasma levels were assessed in baseline conditions and after provocative stress test by dipyridamole. Four groups of ten age- and sex-matched subjects were retrospectively considered among patients referred for chest pain evaluation and submitted to high-dose Dipyridamole Echocardiographic-Scintigraphic combined test (DES). On the basis of DES results we considered: (1) control normotensives subjects; (2) essential hypertensives (for both groups negative result of DES); (3) essential hypertensives with stable angina; and (4) normotensives with stable angina (for both groups concordant DES detection of myocardial ischemia). Our data showed a marked post-DES increase of endothelin-1 plasma levels in hypertensives with stable angina (mean levels = 16.50 ± 4.19 pg/ml p < 0.001 vs. baseline = 9.05 ± 1.37 pg/ml) and a minor increase in stable angina pts (mean levels = 8.3 ± 1.75 pg/ml p < 0.01 vs. baseline = 6.74 ± 0.61 pg/ml) whereas non significant increase was observed both in control (mean levels = 5.09 ± 0.83 pg/ml p = n.s. vs. baseline = 4.91 ± 1.04 pg/ml) and hypertensives groups (mean levels = 6.34 ± 1.72 pg/ml p = n.s. vs. baseline = 5.95 ± 1.04 pg/ml). ET-1 involvement in hypertension-related ischemic heart disease patho-physiology appears to be considered.
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Affiliation(s)
- Carlo Moroni
- Cardiovascular Sciences Department, Sapienza University, Rome, Italy.
| | - Stefano Tolone
- Cardiovascular Sciences Department, Sapienza University, Rome, Italy
| | | | - Orazio Schillaci
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | | | - Rosario Cassone
- Cardiovascular Sciences Department, Sapienza University, Rome, Italy
| | | | - Carlo Gaudio
- Cardiovascular Sciences Department, Sapienza University, Rome, Italy
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14
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The Biochemical Markers Associated with the Occurrence of Coronary Spasm. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4834202. [PMID: 31637257 PMCID: PMC6766173 DOI: 10.1155/2019/4834202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/28/2019] [Accepted: 08/09/2019] [Indexed: 12/15/2022]
Abstract
Coronary artery spasm (CAS) is one of the mechanisms of angina pectoris. Unlike the diagnosis of acute myocardial infarction which is based on the elevation of cardiac markers, the diagnosis of CAS is difficult and sometimes requires sophisticated and risky provocative test which is not widely accepted in China. There is no well-established biomarker for the diagnosis or prediction of CAS. However, there are some biomarkers proven to be associated with the occurrence of CAS. For example, inflammatory factors including C-reactive protein and cytokines, lipoprotein (a), and cystatin-C might be precipitating factor for CAS. Rho-kinase as a mediator involved in multiple mechanisms of CAS, serotonin, and endothelin-1 as powerful vasoconstrictors leading to vasospasm were all observed being elevated in patients with CAS. Thioredoxin and nitrotyrosine reflected the oxidative status and could be observed to be elevated after the occurrence of CAS. In some cases doubted to be CAS without the evidence of provocative test, the blood test for the biomarkers mentioned above could be useful for the diagnosis of CAS.
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15
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Xu BL, Zhou WL, Zhu TP, Cheng KY, Li YJ, Zhan HJ, Jiang LG, Tong YH. A full-width half-maximum method to assess retinal vascular structural changes in patients with ischemic heart disease and microvascular anginga. Sci Rep 2019; 9:11019. [PMID: 31358869 PMCID: PMC6662796 DOI: 10.1038/s41598-019-47194-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/04/2019] [Indexed: 11/09/2022] Open
Abstract
Chest pain patients without obstructive ischemic heart disease (IHD) have increased attention in the clinical practice as carrying higher cardiovascular (CV) risk and impaired life quality. Retinal vasculature is a novel but reliable risk factor of atherosclerosis and systemic vascular diseases. However, the association of retinal blood vessels and unobstructed IHD, as known as microvascular anginga (MA) is poorly understood. This study compared retinal vascular structures of obstructive IHD and MA using spectral domain optical coherence tomography (SD-OCT) and full-width half-maximum (FWHM) methods to provide new risk predictive evidence of MA. Fundus vessels of 120 IHD patients, including 91epicardial IHD and 29 MA patients, and 66 control subjects were evaluated. Significant differences in the retinal arterial lumen diameter (RALD), retinal arterial outer diameter (RAOD), and arteriovenous ratio (AVR) have been found (P < 0.05). The severity of IHD was negatively correlated with diameters of RAOD, RALD and AVR (P < 0.05). In conclusion, there were significant differences in the retinal vascular structure between IHD patients and patients with MA. Thus, assessment of retinal vascular structure is suggested to evaluate CV risk of IHD patients, despite having no obstructive IHD.
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Affiliation(s)
- Bo Lun Xu
- Quzhou Central Hospital of Zhejiang Chinese Medical University, Quzhou People's Hospital, Quzhou, Zhejiang Province, China
| | - Wen Li Zhou
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong, SAR, China
| | - Tie Pei Zhu
- Eye Center of Affiliated Second Hospital, Medical College of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Ke Yun Cheng
- Quzhou Central Hospital of Zhejiang Chinese Medical University, Quzhou People's Hospital, Quzhou, Zhejiang Province, China
| | - Yi Jie Li
- The First Affiliated Hospital of Jiangxi Medical College, Shangrao, Jiangxi, Province, China
| | - Hai Jing Zhan
- Quzhou Central Hospital of Zhejiang Chinese Medical University, Quzhou People's Hospital, Quzhou, Zhejiang Province, China
| | - Li Gang Jiang
- Quzhou Central Hospital of Zhejiang Chinese Medical University, Quzhou People's Hospital, Quzhou, Zhejiang Province, China
| | - Yu Hua Tong
- Quzhou Central Hospital of Zhejiang Chinese Medical University, Quzhou People's Hospital, Quzhou, Zhejiang Province, China.
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16
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Berry C, Sidik N, Pereira AC, Ford TJ, Touyz RM, Kaski J, Hainsworth AH. Small-Vessel Disease in the Heart and Brain: Current Knowledge, Unmet Therapeutic Need, and Future Directions. J Am Heart Assoc 2019; 8:e011104. [PMID: 30712442 PMCID: PMC6405580 DOI: 10.1161/jaha.118.011104] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical SciencesUniversity of GlasgowUnited Kingdom
- The Queen Elizabeth Hospital Discipline of MedicineUniversity of AdelaideCentral Adelaide Local Health NetworkCoronary Vasomotion Disorders International Study Group (COVADIS)AdelaideAustralia
| | - Novalia Sidik
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical SciencesUniversity of GlasgowUnited Kingdom
- The Queen Elizabeth Hospital Discipline of MedicineUniversity of AdelaideCentral Adelaide Local Health NetworkCoronary Vasomotion Disorders International Study Group (COVADIS)AdelaideAustralia
| | - Anthony C. Pereira
- Department of NeurologySt George's University Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Thomas J. Ford
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical SciencesUniversity of GlasgowUnited Kingdom
- The Queen Elizabeth Hospital Discipline of MedicineUniversity of AdelaideCentral Adelaide Local Health NetworkCoronary Vasomotion Disorders International Study Group (COVADIS)AdelaideAustralia
- Faculty of MedicineUNSWUniversity of New South WalesSydneyNSWAustralia
| | - Rhian M. Touyz
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical SciencesUniversity of GlasgowUnited Kingdom
| | - Juan‐Carlos Kaski
- The Queen Elizabeth Hospital Discipline of MedicineUniversity of AdelaideCentral Adelaide Local Health NetworkCoronary Vasomotion Disorders International Study Group (COVADIS)AdelaideAustralia
- Department of CardiologySt George's University Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Atticus H. Hainsworth
- Department of NeurologySt George's University Hospitals NHS Foundation TrustLondonUnited Kingdom
- Molecular and Clinical Sciences Research InstituteSt Georges University of LondonUnited Kingdom
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17
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Tsai SH, Lu G, Xu X, Ren Y, Hein TW, Kuo L. Enhanced endothelin-1/Rho-kinase signalling and coronary microvascular dysfunction in hypertensive myocardial hypertrophy. Cardiovasc Res 2017; 113:1329-1337. [PMID: 28575410 PMCID: PMC5852513 DOI: 10.1093/cvr/cvx103] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 04/07/2017] [Accepted: 05/25/2017] [Indexed: 01/19/2023] Open
Abstract
AIMS Hypertensive cardiac hypertrophy is associated with reduced coronary flow reserve, but its impact on coronary flow regulation and vasomotor function remains incompletely understood and requires further investigation. METHODS AND RESULTS Left ventricular hypertrophy was induced in mice by transverse aortic coarctation (TAC) for 4 weeks. The left coronary artery blood velocity (LCABV) and myocardium lactate level were measured following the metabolic activation by isoproterenol. Septal coronary arterioles were isolated and pressurized for functional studies. In TAC mice, the heart-to-body weight ratio was increased by 45%, and cardiac fractional shortening and LCABV were decreased by 51 and 14%, respectively. The resting myocardial lactate level was 43% higher in TAC mice. Isoproterenol (5 µg/g, i.p.) increased heart rate by 20% in both groups of animals, but the corresponding increase in LCABV was not observed in TAC mice. The ventricular hypertrophy was associated with elevation of myocardial endothelin-1 (ET-1), increased vascular expression of rho-kinases (ROCKs), and increased superoxide production in the myocardium and vasculature. In coronary arterioles from TAC mice, the endothelial nitric oxide (NO)-mediated dilation to acetylcholine (ACh) was reversed to vasoconstriction and the vasoconstriction to ET-1 was augmented. Inhibition of ROCK by H-1152 alleviated oxidative stress and abolished enhanced vasoconstriction to ET-1. Both H-1152 and superoxide scavenger Tempol abolished coronary arteriolar constriction to ACh in a manner sensitive to NO synthase blocker NG-nitro-L-arginine methyl ester. CONCLUSIONS Myocardial hypertrophy induced by pressure overload leads to cardiac and coronary microvascular dysfunction and ischaemia possibly due to oxidative stress, enhanced vasoconstriction to ET-1 and compromised endothelial NO function via elevated ROCK signalling.
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Affiliation(s)
- Shu-Huai Tsai
- Department of Medical Physiology, Texas A&M University Health Science Center, Temple, TX, USA
| | - Guangrong Lu
- Department of Surgery, Texas A&M University Health Science Center and Baylor Scott & White Health, Temple, TX, USA
| | - Xin Xu
- Department of Medical Physiology, Texas A&M University Health Science Center, Temple, TX, USA
| | - Yi Ren
- Department of Surgery, Texas A&M University Health Science Center and Baylor Scott & White Health, Temple, TX, USA
| | - Travis W. Hein
- Department of Surgery, Texas A&M University Health Science Center and Baylor Scott & White Health, Temple, TX, USA
| | - Lih Kuo
- Department of Medical Physiology, Texas A&M University Health Science Center, Temple, TX, USA
- Department of Surgery, Texas A&M University Health Science Center and Baylor Scott & White Health, Temple, TX, USA
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18
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Rasmi Y, Majidinia M, Khosravifar F, Kheradmand F. A Brief History of Cardiac Syndrome X: A Biochemical View. J Tehran Heart Cent 2017; 12:46-48. [PMID: 28469694 PMCID: PMC5409951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Yousef Rasmi
- Professor of Clinical Biochemistry, Department of Clinical Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences (UMSU), Urmia, Iran. 5715799313. Tel: +98 44 32770698. Fax: +98 44 33362520. E-mail: .
| | - Maryam Majidinia
- Student Research Committee, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. 5165665931. Tel: +98 9360488846. Fax: +98 4133364666. E-mail:
| | - Fariba Khosravifar
- Department of Biology, Tehran Payam-e- Noor University, Tehran, Iran. 19395-4697. Tel: +98 23320000. Fax: +9822441511. E-mail: .
| | - Fatemeh Kheradmand
- Associated Professor of Clinical Biochemistry, Department of Clinical Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences (UMSU), Urmia, Iran. 5715799313. Tel: +98 44 32770698. Fax: +98 44 33362520. E-mail:
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19
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Rasmi Y, Rouhrazi H, Khayati-Shal E, Shirpoor A, Saboory E. Association of endothelial dysfunction and cytotoxin-associated gene A-positive Helicobacter pylori in patients with cardiac syndrome X. Biomed J 2016; 39:339-345. [PMID: 27884380 PMCID: PMC6138800 DOI: 10.1016/j.bj.2016.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 01/21/2016] [Indexed: 01/07/2023] Open
Abstract
Background Existence of coronary endothelial dysfunction has been demonstrated in patients with cardiac syndrome X (CSX). In addition, Helicobacter pylorus (H. pylori) has been associated with CSX. We aimed to assess the possible association of endothelial dysfunction and cytotoxin-associated gene A-positive H. pylori (CagA+) infection in CSX patients. Methods Fifty-six patients with CSX (23 male/33 female; age: 51.25 ± 8.86 years) who were anti-H. pylori IgG-positive [H. pylori(+)] and 24 CSX patients (7 male/17 female; age: 52.79 ± 9.88 years) who were H. pylori(−) were included. Also, anti-H. pylori IgG-positive patients were determined by the presence of IgG antibody to CagA. Levels of endothelin-1 (ET-1), E-selectin and intercellular adhesion molecule-1 (ICAM-1) were measured. Results Endothelial dysfunction biomarkers were higher in H. pylori(+) than in H. pylori(−) patients (ET-1: 54.60 ± 25.39 vs. 42.59 ± 18.37 pg/ml, p = 0.04; E-selectin: 42.68 ± 14.26 vs. 31.72 ± 8.26 ng/ml, p = 0.001; ICAM-1: 339.68 ± 135.8 vs. 266.51 ± 125.1 ng/ml, p = 0.02). Among H. pylori(+) subjects, 28 cases were CagA(+) and 28 cases were CagA(−). There were significant differences in measured levels of E-selectin between CagA(+) and CagA(−) groups (48.00 ± 16.37 vs. 37.37 ± 9.37 ng/ml, p = 0.004). For ET-1 and ICAM-1 levels, the difference between CagA(+) and CagA(−) was insignificant (p = 0.174 and p = 0.07, respectively). Conclusion High levels of endothelial dysfunction biomarkers are found in CSX patients with anti-CagA(+). These findings suggest the infection with CagA(+) H. pylori strain may play a role as a risk factor in development of CSX through provocation of endothelial dysfunction. Therefore, a long term follow up to investigate the outcomes of these patients is proposed.
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Affiliation(s)
- Yousef Rasmi
- Cellular and Molecular Research Center, Urmia University of Medical Sciences, Urmia, Iran; Department of Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
| | - Hadi Rouhrazi
- Department of Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Ebrahim Khayati-Shal
- Department of Cardiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Alireza Shirpoor
- Department of Physiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Ehsan Saboory
- Department of Physiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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20
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Hung OY, Lee SK, Eshtehardi P, Samady H. Novel biomarkers of coronary microvascular disease. Future Cardiol 2016; 12:497-509. [PMID: 27291585 PMCID: PMC5941701 DOI: 10.2217/fca-2016-0012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/06/2016] [Indexed: 01/20/2023] Open
Abstract
Coronary microvascular disease in the absence of myocardial diseases has traditionally been diagnosed through coronary reactivity testing in the cardiac catheterization laboratory. Compared with invasive procedures, blood-based biomarkers may have reduced cost, less risk of physical harm and greater accessibility, making them ideal for an outpatient management strategy. There are a variety of biomarkers available with potential utility in the management of microvascular disease; however, none have yet been extensively validated or established in this clinical patient population.
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Affiliation(s)
- Olivia Y Hung
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Suegene K Lee
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Parham Eshtehardi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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21
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Assessment of 25-OH vitamin D levels and abnormal blood pressure response in female patients with cardiac syndrome X. Anatol J Cardiol 2016; 16:961-966. [PMID: 27271477 PMCID: PMC5324918 DOI: 10.14744/anatoljcardiol.2016.6862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: Vitamin D deficiency is associated with coronary artery disease, hypertension, heart failure, endothelial dysfunction, and metabolic syndrome. The pathophysiology of cardiac syndrome X (CSX) involves many pathways that are influenced by vitamin D levels. This study aimed to investigate the relationship between vitamin D deficiency and abnormal blood pressure response to exercise in patients with CSX. Methods: This was a cross-sectional and observational study. Fifty females with normal epicardial coronary arteries who presented with typical symptoms of rest or effort angina and 41 healthy age-matched female controls, were included. Patients with cardiomyopathy, severe valvular disease, congenital heart disease, and left ventricular hypertrophy were excluded. All patients underwent stress electrocardiography examination and 25-hydroxy (OH) vitamin D level measurements. Results: Levels of 25-OH vitamin D were significantly lower in CSX patients (9.8±7.3 ng/mL vs. 18.1±7.9 ng/mL; p<0.001). Systolic blood pressure (SBP) (188±15 mm Hg vs. 179±17 mm Hg; p=0.013) and diastolic blood pressure (DBP) (98±9 mm Hg vs. 88±9 mm Hg; p<0.001) during peak exercise were higher in CSX patients. Levels of 25-OH vitamin D were negatively correlated with peak SBP (r=–0.310, p=0.004) and peak DBP (r=–0.535, p<0.001) during exercise. To discard the multicollinearity problem, two different models were used for multivariate analyses. In the first model, metabolic equivalents (METs) (p=0.003) and 25-OH vitamin D levels (p=0.001) were independent predictors. METs (p=0.007), 25-OH vitamin D levels (p=0.008), and peak DBP were determined as independent predictors in the second multivariate model. Conclusion: In patients with CSX, 25-OH vitamin D levels were lower than those in controls; moreover, 25-OH vitamin D deficiency was also associated with higher levels of peak DBP during exercise. (Anatol J Cardiol 2016; 16: 961-6)
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Majidinia M, Rasmi Y, Khadem Ansari MH, Seyed-Mohammadzad M, Saboory E, Shirpoor A. Metoprolol Improves Endothelial Function in Patients with Cardiac Syndrome X. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2016; 15:561-566. [PMID: 27980592 PMCID: PMC5149044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endothelial dysfunction which is manifested by the loss of nitric oxide bioavailability, is an increasingly recognized cause of cardiac syndrome X (CSX) and beta blockers are used for the treatment of this syndrome. Thus, the aim of this study was to investigate effects of metoprolol, as a beta blocker, on endothelial function in CSX patients. The study included 25 CSX patients (20 female/ 5 male, mean age: 55.36±10.31 years) who received metoprolol (50 mg BID) for one month. In addition, 25 healthy controls (20 female/ 5 male, mean age: 54.32 ±9.27 years) were enrolled. Levels of endothelin-1, E-selectin, and vascular cell adhesion molecule-1 (VCAM-1) in controls and CSX patients were measured, both at the baseline and after the treatment, by the enzyme-linked immunosorbent assay. In CSX patients, at the baseline, levels of E-selectin and VCAM-1 were significantly higher than those of the controls. In addition, levels of these biomarkers in CSX patients after the treatment significantly decreased compared to the baseline. In spite of similar tendency, these differences were not significant for endothelin-1. In conclusion, metoprolol therapy improves endothelial function. Thus, it may be a suggested choice for CSX treatment. However, further studies are needed to confirm the clinical significance of metoprolol therapy for CSX patients.
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Affiliation(s)
- Maryam Majidinia
- Department of Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
| | - Yousef Rasmi
- Department of Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.,Cellular and Molecular Research Center, Urmia University of Medical Sciences,Urmia, Iran. ,Corresponding author: E-mail:
| | | | | | - Ehsan Saboory
- Nurophysiology Research Center, Urmia University of Medical Sciences, Urmia, Iran. ,Department of Physiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
| | - Alireza Shirpoor
- Department of Physiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
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Shaw J, Anderson T. Coronary endothelial dysfunction in non-obstructive coronary artery disease: Risk, pathogenesis, diagnosis and therapy. Vasc Med 2015; 21:146-55. [PMID: 26675331 DOI: 10.1177/1358863x15618268] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Up to half of patients with signs and symptoms of stable ischemic heart disease have non-obstructive coronary artery disease (NoCAD). Recent evidence demonstrates that two-thirds of patients with NoCAD have demonstrable coronary endothelial dysfunction represented by microvascular or diffuse epicardial spasm following acetylcholine challenge. Patients with coronary endothelial dysfunction are recognized to have significant health services use and morbidity as well as increased risk of developing flow-limiting coronary artery disease and myocardial events, including death. Currently, there are few centers that test for this etiology owing to lack of knowledge, limited evidence for treatment options and invasive diagnostic strategies. This article reviews the pathophysiology, epidemiology, diagnosis and treatment of coronary endothelial dysfunction as a subgroup of NoCAD.
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Affiliation(s)
- Jeffrey Shaw
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
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Thengchaisri N, Hein TW, Ren Y, Kuo L. Endothelin-1 impairs coronary arteriolar dilation: Role of p38 kinase-mediated superoxide production from NADPH oxidase. J Mol Cell Cardiol 2015. [PMID: 26211713 DOI: 10.1016/j.yjmcc.2015.07.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Elevated levels of endothelin-1 (ET-1), a potent vasoactive peptide, are implicated as a risk factor for cardiovascular diseases by exerting vasoconstriction. The aim of this study was to address whether ET-1, at sub-vasomotor concentrations, elicits adverse effects on coronary microvascular function. Porcine coronary arterioles (50-100μm) were isolated, cannulated and pressurized without flow for in vitro study. Diameter changes were recorded using a videomicrometer. Arterioles developed basal tone (60±3μm) and dilated to the endothelium-dependent nitric oxide (NO)-mediated vasodilators serotonin (1nmol/L to 0.1μmol/L) and adenosine (1nmol/L to 10μmol/L). Treating the vessels with a clinically relevant sub-vasomotor concentration of ET-1 (10pmol/L, 60min) significantly attenuated arteriolar dilations to adenosine and serotonin but not to endothelium-independent vasodilator sodium nitroprusside. The arteriolar wall contains ETA receptors and the adverse effect of ET-1 was prevented by ETA receptor antagonist BQ123, the superoxide scavenger Tempol, the NADPH oxidase inhibitors apocynin and VAS2870, the NOX2-based NADPH oxidase inhibitor gp91 ds-tat, or the p38 kinase inhibitor SB203580. However, ETB receptor antagonist BQ788, H2O2 scavenger catalase, scrambled gp91 ds-tat, or inhibitors of xanthine oxidase (allopurinol), PKC (Gö 6983), Rho kinase (Y27632), and c-Jun N-terminal kinase (SP600125) did not protect the vessel. Immunohistochemical staining showed that ET-1 elicited Tempol-, apocynin- and SB203580-sensitive superoxide productions in the arteriolar wall. Our results indicate that exposure of coronary arterioles to a pathophysiological, sub-vasomotor concentration of ET-1 leads to vascular dysfunction by impairing endothelium-dependent NO-mediated dilation via p38 kinase-mediated production of superoxide from NADPH oxidase following ETA receptor activation.
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Affiliation(s)
- Naris Thengchaisri
- Department of Medical Physiology, Cardiovascular Research Institute, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA; Department of Companion Animal Clinical Sciences, Faculty of Veterinary Medicine, Kasetsart University, Bangkok 10900, Thailand
| | - Travis W Hein
- Department of Surgery, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA
| | - Yi Ren
- Department of Surgery, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA
| | - Lih Kuo
- Department of Medical Physiology, Cardiovascular Research Institute, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA; Department of Surgery, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA.
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25
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Evaluation of adiponectin and lipoprotein(a) levels in cardiac syndrome X. Herz 2015; 40 Suppl 3:291-7. [DOI: 10.1007/s00059-014-4191-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/09/2014] [Accepted: 11/23/2014] [Indexed: 10/24/2022]
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Andishmand A, Ansari Z, Soltani MH, Mirshamsi H, Raafat S. Vitamin D replacement therapy in patients with cardiac syndrome X. Perfusion 2014; 30:60-3. [PMID: 24722851 DOI: 10.1177/0267659114526629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS The aim of present study was to assess whether vitamin D, with proven beneficial effects on the cardiovascular system, has any effect on angina and exercise-induced ischemia in patients with cardiac syndrome X and low serum vitamin D. METHODS Patients with cardiac syndrome X and low serum vitamin D3 were studied before and after treatment with an intramuscular injection of vitamin D3 (300,000 units, every other week for 2 months). We determined the angina episode (per day) and several indices of exercise capacity. RESULTS At the end of the treatment course (75±6 day), a significant increase of serum vitamin D3 occurred and was within the normal range (45±8 ng/ml) and the frequency of angina improved significantly (p=0.003). Exercise duration and maximal work capacity increased significantly (p<0.001). Maximal ST-segment depression (mm) decreased significantly (p=0.001). The calculated Duck treadmill score improved significantly (p=0.001). CONCLUSIONS Our findings show that vitamin D replacement therapy in patients with cardiac syndrome X and vitamin D deficiency dramatically improves symptoms and signs of ischemia.
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Affiliation(s)
- A Andishmand
- Cardiovascular Research Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Z Ansari
- Cardiovascular Research Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - M H Soltani
- Cardiovascular Research Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - H Mirshamsi
- Cardiovascular Research Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - S Raafat
- Cardiovascular Research Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Gil-Ortega I, Marzoa Rivas R, Ríos Vázquez R, Kaski JC. Role of inflammation and endothelial dysfunction in the pathogenesis of cardiac syndrome X. Future Cardiol 2012; 2:63-73. [PMID: 19804133 DOI: 10.2217/14796678.2.1.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chest pain with normal coronary arteriograms represents a major diagnostic and therapeutic challenge to contemporary cardiology. Cardiac syndrome X (CSX), defined as typical angina-like chest pain, a positive response to exercise stress testing and normal coronary arteriograms, encompasses patients with a variety of pathogenic mechanisms. Cardiac ischemia has been documented in approximately 25% of CSX patients and is associated with endothelial dysfunction and microvascular vasodilator abnormalities. Increased endothelin-1, a powerful vasoconstrictor, has been suggested to play a pathogenic role. There is a high prevalence of postmenopausal women with CSX and thus estrogen deficiency has also been proposed to represent a possible pathogenic mechanism. Inflammatory mechanisms and endothelial dysfunction at the coronary microvascular level appear to be important in the pathogenesis of CSX. Treatment with agents that have protective effects on the vasculature and also anti-inflammatory properties, such as statins and angiotensin-converting enzyme inhibitors have been effective in improving both symptoms and electrocardiographic signs of myocardial ischemia in patients with CSX. This review discusses the roles for endothelial dysfunction and inflammation in the pathogenesis of CSX, as well as the potential therapeutic implications of these mechanisms.
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Affiliation(s)
- Ignacio Gil-Ortega
- Coronary Artery Disease Research Unit, Cardiovascular Biology Research Centre, Division of Cardiac and Vascular Sciences,St. George s, University of LondonLondon, UK
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Parsyan A, Pilote L. Cardiac syndrome X: mystery continues. Can J Cardiol 2012; 28:S3-6. [PMID: 22424282 DOI: 10.1016/j.cjca.2011.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/19/2011] [Accepted: 09/19/2011] [Indexed: 10/28/2022] Open
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Modulation by endothelin-1 of spontaneous activity and membrane currents of atrioventricular node myocytes from the rabbit heart. PLoS One 2012; 7:e33448. [PMID: 22479400 PMCID: PMC3315568 DOI: 10.1371/journal.pone.0033448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 02/10/2012] [Indexed: 11/19/2022] Open
Abstract
Background The atrioventricular node (AVN) is a key component of the cardiac pacemaker-conduction system. Although it is known that receptors for the peptide hormone endothelin-1 (ET-1) are expressed in the AVN, there is very little information available on the modulatory effects of ET-1 on AVN electrophysiology. This study characterises for the first time acute modulatory effects of ET-1 on AVN cellular electrophysiology. Methods Electrophysiological experiments were conducted in which recordings were made from rabbit isolated AVN cells at 35–37°C using the whole-cell patch clamp recording technique. Results Application of ET-1 (10 nM) to spontaneously active AVN cells led rapidly (within ∼13 s) to membrane potential hyperpolarisation and cessation of spontaneous action potentials (APs). This effect was prevented by pre-application of the ETA receptor inhibitor BQ-123 (1 µM) and was not mimicked by the ETB receptor agonist IRL-1620 (300 nM). In whole-cell voltage-clamp experiments, ET-1 partially inhibited L-type calcium current (ICa,L) and rapid delayed rectifier K+ current (IKr), whilst it transiently activated the hyperpolarisation-activated current (If) at voltages negative to the pacemaking range, and activated an inwardly rectifying current that was inhibited by both tertiapin-Q (300 nM) and Ba2+ ions (2 mM); each of these effects was sensitive to ETA receptor inhibition. In cells exposed to tertiapin-Q, ET-1 application did not produce membrane potential hyperpolarisation or immediate cessation of spontaneous activity; instead, there was a progressive decline in AP amplitude and depolarisation of maximum diastolic potential. Conclusions Acutely applied ET-1 exerts a direct modulatory effect on AVN cell electrophysiology. The dominant effect of ET-1 in this study was activation of a tertiapin-Q sensitive inwardly rectifying K+ current via ETA receptors, which led rapidly to cell quiescence.
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Activation of polymorphonuclear leukocytes and increased plasma vasoconstrictors in vasospastic and nonvasospastic angina. Can J Cardiol 2011; 27:601-5. [PMID: 21705187 DOI: 10.1016/j.cjca.2011.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 06/17/2010] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The cause of coronary vasoconstriction in patients with angina at rest, nonsignificant coronary stenosis, and endothelial dysfunction remains unknown. Our objective was to investigate the association between enhanced coronary vasoconstriction and increased circulating levels of vasoconstrictor agents. METHODS Plasma levels of big endothelin-1, serotonin, and superoxide produced by polymorphonuclear leukocytes were measured in 38 patients with stable angina at rest without significant coronary artery stenosis-23 with nonvasospastic angina and 15 with vasospastic angina-and were compared with 10 patients with stable coronary disease and 20 age-matched controls. RESULTS Patients with angina at rest showed higher big endothelin-1 (1.28 vs 0.72 fmol/mL, P < 0.001), serotonin (18.0 vs 9.1 ng/mL, P = 0.002), and superoxide produced by polymorphonuclear leukocytes (177 vs 67 nmol/10 × E8 × minutes, P = 0.001) than did controls. Serotonin and superoxide produced by polymorphonuclear leukocytes were also higher than in coronary disease patients (5.4 ng/mL, P = 0.001, and 97 nmol/10 x E8 x minutes, P = 0.005), and big endothelin-1 levels tended to be higher (0.99 fmol/mL, P = 0.073). Moreover, there were no significant differences in these 3 parameters between patients with vasospastic and nonvasospastic angina, and among the latter, between patients with a positive and those with a negative exercise stress test. CONCLUSION Systemic plasma levels of agents with the potential to produce coronary vasoconstriction are increased in patients with stable vasospastic or nonvasospastic angina and, hence, may contribute to their angina, increased coronary tone, and impaired vasodilatory capacity. Furthermore, they may establish a mechanistic link between the 2 conditions.
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Abstract
There are gender differences in the presentation, diagnosis, and treatment of chest pain. When compared to men, women may have more atypical presentations of chest pain. In addition, current diagnostic tools are often not definitive regarding cardiac etiology for chest pain in women. The current diagnostic model of chest pain focuses on significant obstructions within the large coronary arteries as the cause for angina. Microvascular angina (MVA) represents an under-recognized pathophysiologic mechanism that may explain the apparent disparities and elucidate an etiology for the common finding in women of chest pain, ischemia on stress testing, and no obstructive coronary artery disease (CAD) on angiography in the presence of abnormal coronary reactivity testing. Endothelial dysfunction, estrogen deficiency, and abnormal nociception play a role in the pathophysiology of MVA. Treatments are targeted toward these underlying mechanisms. Recognizing the role gender and other pathophysiologic models of chest pain can play in the work-up and treatment of angina may identify a treatable cardiac condition, that would otherwise be discounted as non-cardiac in origin.
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Affiliation(s)
- Lynn Nugent
- Women's Heart Center, Preventive Cardiac Center, Heart Institute, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, Los Angeles, California 90048, USA
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Osugi T, Saitoh SI, Matumoto K, Muto M, Aikawa K, Ohkawara H, Sugimoto K, Kamioka M, Ishibashi T, Maruyama Y. Preventive Effect of Chronic Endothelin Type A Receptor Antagonist on Coronary Microvascular Spasm Induced by Repeated Epicardial Coronary Artery Endothelial Denudation in Pigs. J Atheroscler Thromb 2010; 17:54-63. [DOI: 10.5551/jat.2147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Microvascular angina and the continuing dilemma of chest pain with normal coronary angiograms. J Am Coll Cardiol 2009; 54:877-85. [PMID: 19712795 DOI: 10.1016/j.jacc.2009.03.080] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 03/10/2009] [Accepted: 03/17/2009] [Indexed: 12/20/2022]
Abstract
Since initial reports over 4 decades ago, cases of patients with angina-like chest pain whose coronary angiograms show no evidence of obstructive coronary artery disease and who have no structural heart disease continue to be a common occurrence for cardiologists. Many features of this patient population have remained constant with successive reports over time: a female predominance, onset of symptoms commonly between 40 and 50 years of age, pain that is severe and disabling, and inconsistent responses to conventional anti-ischemic therapy. Because patients may have had abnormal noninvasive testing that led to performance of coronary angiography, investigators have sought to show an association of this syndrome with myocardial ischemia. Abnormalities in coronary flow and metabolic responses to stress have been reported by several groups, findings consistent with a microvascular etiology for ischemia and symptoms, but others have questioned the presence of ischemia, even in patients selected for abnormal noninvasive testing. Despite considerable efforts by many groups over 4 decades, the syndrome remains controversial with regard to pathophysiology, diagnosis, and management.
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Infusino F, Lanza GA, Sestito A, Sgueglia GA, Crea F, Maseri A. Combination of variant and microvascular angina. Clin Cardiol 2009; 32:E40-5. [PMID: 19610123 PMCID: PMC6653756 DOI: 10.1002/clc.20502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Accepted: 06/23/2008] [Indexed: 11/11/2022] Open
Abstract
Prinzmetal's variant angina (VA) and cardiac syndrome X (CSX) are two distinct, usually easily recognizable, forms of angina syndromes, caused by epicardial spasm, usually responsible for transient transmural myocardial ischemia at rest and by coronary microvascular dysfunction (CMVD), usually responsible for effort induced subendocardial ischemia, respectively. In this article we report clinical evidence in three patients of the simultaneous occurrence of angina episodes typical of both VA and CSX, suggesting that common pathogenetic factors may be responsible for clinical manifestations both of functional macrovascular and microvascular coronary artery abnormalities in some angina patients.
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Affiliation(s)
- Fabio Infusino
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Gaetano A. Lanza
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alfonso Sestito
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Filippo Crea
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Attilio Maseri
- Dipartimento di Cardiologia, Università Vita e Salute, Milano, Italy
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Peix A, González A, García EJ, Valiente J, Cabrera LO, Sixto S, Filgueiras CE, Cabalé B, Hechavarría S, González I, Carrillo R, García-Barreto D. Left ventricular dysfunction secondary to ischemia in women with angina and normal coronary angiograms. J Womens Health (Larchmt) 2009; 18:155-61. [PMID: 19183086 DOI: 10.1089/jwh.2008.0844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Microvascular disease is proposed as a cause of segmental myocardial blood flow abnormalities and heterogeneous myocardial perfusion in cardiac syndrome X. OBJECTIVE To assess if myocardial ischemia can be evidenced through both perfusion abnormalities and poststress left ventricular ejection fraction (LVEF) reduction by gated single photon emission tomography (SPECT) myocardial scintigraphy in women with syndrome X in a similar way to those with epicardial coronary lesions. METHODS Three groups of postmenopausal women were studied: group I, 20 women with angina, perfusion defects, and normal coronary angiography; group II, 20 women with epicardial coronary lesions (> or =50% of coronary lumen reduction); group III, 15 volunteers without signs or symptoms of ischemia (control group). Each underwent technetium-99m ((99m)TC) methoxyisobutylisonitrile gated SPECT myocardial scintigraphy (protocol: exercise-stress-rest), brachial artery endothelial function measured by ultrasonography, and lipidogram. RESULTS Groups I and III patients had a higher body mass index (BMI). There were more smokers in groups I and II. Very low density lipoprotein cholesterol (VLDL-C) and triglycerides were higher in group II patients. The brachial artery vasodilator responsiveness after 5 minutes of ischemia was similarly lower in patients of groups I and II compared with those of group III (3% vs. 6.5%, respectively; p = 0.03 group III vs. group I and group II). Mean DeltaLVEF (LVEF poststress minus LVEF at rest) was -3.86%, -2.90%, and 4.18% in groups I, II, and III, respectively (p = NS between I and II, p = 0.005 between II and III, and p = 0.003 between I and III). In 43% of group I patients and in 10 of 18 group III patients with perfusion defects, there was a poststress LVEF reduction >5%. CONCLUSIONS Stress-induced ischemia is associated with poststress LVEF reduction as a probable manifestation of myocardial stunning in postmenopausal women with typical angina and normal coronary angiography.
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Tousoulis D, Davies GJ, Asimakopoulos G, Homaei H, Zouridakis E, Ahmed N, Kaski JC. Vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 serum level in patients with chest pain and normal coronary arteries (syndrome X). Clin Cardiol 2009; 24:301-4. [PMID: 11303698 PMCID: PMC6654860 DOI: 10.1002/clc.4960240409] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Plasma levels of soluble vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) mediators of leukocyte adhesion to vascular endothelium may implicate in the pathogenesis of the syndrome of chest pain with normal coronary arteries. HYPOTHESIS We attempted to determine whether markers of endothelial activation are raised in patients with chest pain and normal coronary arteries. METHODS We measured plasma VCAM-1, ICAM-1 (ng/ ml) in 36 patients (34 men, 2 women, aged 62 +/- 9 years) with stable angina, coronary artery disease (CAD), and a positive response to exercise test; in 21 patients (6 men, 15 women, aged 56 +/- 9 years) with chest pain and normal coronary arteriograms (syndrome X); and in 11 healthy control subjects (8 men, 3 women, aged 49 +/- 14 years). RESULTS Plasma ICAM-1 levels were significantly higher both in patients with CAD (mean +/- standard error of the mean) (328 +/- 26, p < 0.05), and in syndrome X (362 +/- 22, p < 0.01) than in controls (225 +/- 29). VCAM-1 levels were also higher in syndrome X (656 +/- 42 ng/ml) and in patients with CAD (626 +/- 42 ng/ml) than in controls (551 +/- 60, p = 0.09). CONCLUSIONS ICAM-1 and VCAM-1 levels are increased both in patients with CAD and with syndrome X compared with control individuals. These findings may suggest the presence of chronic inflammation with involvement of the endothelium in patients with anginal chest pain and normal coronary angiograms.
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Affiliation(s)
- D Tousoulis
- Cardiology Unit, Hammersmith Hospital, Imperial College School of Medicine, London, UK
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Myocardial ischemia: Current concepts and future perspectives. J Cardiol 2008; 52:67-78. [DOI: 10.1016/j.jjcc.2008.07.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 07/18/2008] [Indexed: 11/22/2022]
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Li AH, Lee BC, Chen KC, Weng CS, Chu SH. Brachial artery flow-mediated vasodilation in patients with cardiac syndrome X. Angiology 2008; 59:581-6. [PMID: 18388101 DOI: 10.1177/0003319707308032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac syndrome X (CSX) differs from coronary artery disease (CAD) and is characterized by angina, positive stress test, and patent coronary arteries. The probable mechanism is a microvascular disorder associated with endothelial dysfunction. In this study, brachial artery flow-mediated vasodilation was used as well as the endothelin-1 assay to assess endothelial function in patients with cardiac syndrome X (CSX), coronary artery disease (CAD), and healthy controls. All subjects underwent a 2-step brachial artery flow-related vasodilatation test. Serum endothelin-1, one of the most potent constricting factors, was measured for all participants. Patients with CSX had a lower brachial artery dilation ratio than controls but higher than that of CAD patients. Control subjects and CSX patients had higher endothelin-1 levels than CAD patients. CSX patients were found to have worse endothelial function than healthy volunteers, but patients with CAD had even worse endothelium function than CSX patients.
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Affiliation(s)
- Ai-Hsien Li
- Department of Biomedical Engineering, Chung Yuan Christian University, Chung-Li City, Taiwan
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Sangle SR, D'Cruz DP. Syndrome X (angina pectoris with normal coronary arteries) and myocardial infarction in patients with anti-phospholipid (Hughes) syndrome. Lupus 2008; 17:83-5. [DOI: 10.1177/0961203307086036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- SR Sangle
- The Lupus Research Unit, The Rayne Institute, Lambeth Wing, St Thomas' Hospital, London, UK
| | - DP D'Cruz
- The Lupus Research Unit, The Rayne Institute, Lambeth Wing, St Thomas' Hospital, London, UK, david.d'
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40
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The pathophysiology and clinical course of the normal coronary angina syndrome (cardiac syndrome X). Prog Cardiovasc Dis 2008; 50:294-310. [PMID: 18156008 DOI: 10.1016/j.pcad.2007.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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41
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Cheng M, Li Y, Wu J, Nie Y, Li L, Liu X, Charoude HN, Chen H. IL-8 induces imbalances between nitric oxide and endothelin-1, and also between plasminogen activator inhibitor-1 and tissue-type plasminogen activator in cultured endothelial cells. Cytokine 2007; 41:9-15. [PMID: 18023202 DOI: 10.1016/j.cyto.2007.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 09/30/2007] [Accepted: 10/14/2007] [Indexed: 02/05/2023]
Abstract
Interleukin-8 (IL-8), a member of the CXC chemokine family, plays an important role in the modulation of multiple biological functions in endothelial cells containing the receptors CXCR1 and CXCR2. It has previously been shown that IL-8 directly enhances endothelial cell survival, and stimulates the production of matrix metalloproteinases, which in turn regulates angiogenesis. However, its role in the regulation of the production of vasoactive substances in endothelial cells is less well defined. In this study, we investigate the effects of IL-8 on the proliferation of human umbilical vein endothelial cells (HUVECs). In addition, we also study the effects of IL-8 on the production of vasodilator, vasoconstrictor and fibrinolytic factors in these cells. The results show that recombinant IL-8 (50-200ng/ml) induces neither HUVEC proliferation nor nitric oxide (NO) release. However, it significantly increases the production of endothelin-1 (ET-1) in a concentration-dependent manner. Furthermore, incubation of endothelial cells with IL-8 (200ng/ml) up-regulates the plasminogen activator inhibitor-1 (PAI-1) in HUVECs, while it down-regulates the tissue plasminogen activator (t-PA). These findings suggest that IL-8 offsets the balance between endothelial vasoconstrictors and vasodilators. Furthermore, IL-8 also leads to an imbalance between PAI-1 and t-PA, which causes the ECs to become procoagulative and hypofibrinolytic.
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Affiliation(s)
- Min Cheng
- Laboratory of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
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42
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Peix A, García EJ, Valiente J, Tornés F, Cabrera LO, Cabalé B, Carrillo R, García-Barreto D. Ischemia in women with angina and normal coronary angiograms. Coron Artery Dis 2007; 18:361-6. [PMID: 17627185 DOI: 10.1097/mca.0b013e3281689a3f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronary artery disease is frequent in postmenopausal women. Myocardial ischemia has been induced with stress testing, and a relationship between endothelial dysfunction and perfusion defects has been reported. OBJECTIVE To evaluate whether myocardial ischemia can be evidenced both by perfusion and function abnormalities using gated single-photon emission computed-tomography myocardial scintigraphy with technetium-labeled compounds in women with typical angina, normal coronary angiography, and endothelial dysfunction. METHODS AND RESULTS Fifty-nine postmenopausal patients were studied. Each underwent technetium-99m methoxy-isobutyl-isonitrile myocardial scintigraphy (protocol: exercise stress-rest), brachial artery endothelial function measured by ultrasonography, lipidogram, and 24-h ambulatory ECG recording (Holter). Twenty-one patients (group I) showed perfusion defects in myocardial scintigraphy, whereas the other 38 patients (group II) did not. Group I patients exhibited endothelial dysfunction more frequently (57 vs. 29%) than those of group II. Among group I patients, 12 showed a reversible perfusion defect that, in 75% of the cases, was associated with poststress left ventricular ejection fraction reduction greater than 5% and a regional hypokinesis. Nine patients had fixed defects, which in 56% of the cases were associated with poststress left ventricular ejection fraction reduction greater than 5%. Left ventricular ejection fraction poststress minus left ventricular ejection fraction at rest was -5.2% in group I patients versus -1.8% in group II (P<0.001). Three patients in group I showed evidence of ischemia by Holter compared with four in group II. CONCLUSION Stress-induced ischemia is associated with poststress left ventricular ejection fraction reduction in postmenopausal women with typical angina, normal coronary angiography, and a trend toward abnormal endothelial-mediated vasodilation.
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Abstract
Endothelins are powerful vasoconstrictor peptides that also play numerous other roles. The endothelin (ET) family consists of three peptides produced by a variety of tissues. Endothelin-1 (ET-1) is the principal isoform produced by the endothelium in the human cardiovascular system, and it exerts its actions through binding to specific receptors, the so-called type A (ET(A)) and type B (ET(B)) receptors. ET-1 is primarily a locally acting paracrine substance that appears to contribute to the maintenance of basal vascular tone. It is also activated in several diseases, including congestive heart failure, arterial hypertension, atherosclerosis, endothelial dysfunction, coronary artery diseases, renal failure, cerebrovascular disease, pulmonary arterial hypertension, and sepsis. Thus, ET-1 antagonists are promising new agents. They have been shown to be effective in the management of primary pulmonary hypertension, but disappointing in heart failure. Clinical trials are needed to determine whether manipulation of the ET system will be beneficial in other diseases.
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Affiliation(s)
- Rahman Shah
- Section of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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44
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Fujii H, Takiuchi S, Kamide K, Horio T, Niizuma SI, Tanaka N, Hashimoto S, Nakatani S, Fukagawa M, Kawano Y. Clinical implications of assessing coronary flow velocity reserve and plasma endothelin-1 in hypertensive patients. Hypertens Res 2006; 28:911-6. [PMID: 16555580 DOI: 10.1291/hypres.28.911] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Previous reports have indicated that hypertensive patients who have angina-like chest pain and normal coronary arteriograms have reduced coronary flow velocity reserve (CFVR) levels. In addition, elevated plasma endothelin-1 (ET-1) levels have been reported to be associated with microvascular angina. The purpose of this study was to evaluate the plasma ET-1 levels and CFVR in patients with chest pain but without coronary artery disease (CAD). A total of 66 patients were included in this study. CAD was ruled out by exercise stress test or coronary angiogram. Plasma ET-1 and CFVR measurements were performed in patients with (n=35) and without (n=31) a history of angina-like chest pain. CFVR was measured using adenosine-triphosphate stress transthoracic Doppler echocardiography. The mean ET-1 level was significantly higher and the CFVR was significantly lower in patients in the symptomatic group than in those in the asymptomatic group (ET-1: 3.85 +/- 1.24 pg/ml vs. 2.98 +/- 1.27 pg/ml, CFVR: 2.26 +/- 0.48 vs. 2.77 +/- 0.11, respectively). Plasma ET-1 level and CFVR were significantly correlated with each other (-r = 0.265, p = 0.033). Age, blood pressure, cardiovascular risk factors, and left ventricular mass index were similar between the two groups. The results of multiple regression analysis indicate that age (p = 0.008) and plasma ET-1 concentration (p = 0.031) had statistically independent associations with CFVR. Attenuated CFVR in the symptomatic hypertensive patients was associated with endothelial dysfunction, which results in elevated plasma ET-1 levels. The link between these two parameters may play a role in the genesis of chest pain in hypertensive patients without CAD.
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Affiliation(s)
- Hideki Fujii
- Division of Hypertension and Nephrology, National Cardiovascular Center, Suita, Japan.
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Abstract
Cardiac syndrome X, the triad of angina pectoris, a positive exercise electrocardiogram for myocardial ischaemia and angiographically smooth coronary arteries, is frequently associated with debilitating symptomology, increased psychological morbidity and a poor quality of life. While various avenues of research have been undertaken, there are as yet no definitive conclusions regarding the exact pathogenesis of the condition. A number of physiological mechanisms have been explored, including the existence of underlying myocardial ischaemia, suggested endothelial dysfunction, abnormal pain perception, hormonal irregularities and insulin resistance, while the psychological impact of the condition has also been explored. Various treatment regimens have also been the subject of research with varying degrees of success. The heterogeneous nature of the patient population suggests that the mechanistic pathway may be multifactorial, while a comprehensive treatment regimen including both psychosocial and pharmacological interventions may offer the best outcome for patients with cardiac syndrome X.
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Affiliation(s)
- E A Asbury
- Department of Cardiac Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
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46
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Senen K, Ileri M, Alper A, Yetkin F, Atak R, Hisar I, Yetkin E, Turhan H, Bardakçi H, Demirkan D. Increased levels of soluble adhesion molecules E-selectin and P-selectin in patients with cardiac syndrome X. Angiology 2005; 56:273-7. [PMID: 15889194 DOI: 10.1177/000331970505600306] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The role of endothelial dysfunction and platelet activation in patients with cardiac syndrome X is controversial. The aim of this study was to investigate the plasma levels of circulating E- and P-selectin molecules in patients with syndrome X. The study included 21 patients with cardiac syndrome X (11 men and 10 women, mean age = 56 +/- 5 years) and 20 patients with significant coronary artery disease who had stable angina pectoris (11 men and 9 women, mean age = 60 +/- 8 years). Twenty-two age- and sex-matched subjects (12 men and 10 women, mean age = 58 +/- 8 years) undergoing diagnosis of atypical chest pain in whom coronary arteries were found normal and exercise test had no signs of ischemia served as the control group. Syndrome X was defined as presence of typical chest pain on exertion or at rest with positive exercise test and angiographically normal epicardial coronary arteries with no evidence of coronary spasm after intracoronary infusion of ergonovine maleate. The mean plasma concentrations of P-selectin were significantly elevated both in patients with coronary artery disease and syndrome X as compared with control subjects (49.15 +/-7.47 and 42.80 +/- 8.93 vs 22.63 +/-6.47 ng/mL, p < 0.001). Similarly, both patients with coronary artery disease and syndrome X had higher plasma concentrations of E-selectin than the control group (78.85 +/- 16.69 and 68.38 +/- 15.30 vs 36.43 +/- 4.72 ng/mL, p < 0.001). In conclusion, patients with syndrome X had increased plasma concentrations of soluble adhesion molecules, E-selectin and P-selectin, reflecting an ongoing chronic inflammation involved with endothelial dysfunction and enhanced platelet activation/damage in this setting.
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Affiliation(s)
- Kubilay Senen
- Türkiye Yüksek Ihtisas Hastanesi, Department of Cardiology, Ankara, Turkey
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Li JJ, Fang CH, Wang C, Hui RT. Effects of simvastatin on exercise-induced myocardial ischemia and plasma endothelin-1 concentrations in patients with stable angina. Clin Chim Acta 2005; 354:205-8. [PMID: 15748619 DOI: 10.1016/j.cccn.2004.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 10/21/2004] [Accepted: 10/22/2004] [Indexed: 11/27/2022]
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Abstract
Patients with cardiac syndrome X (typical chest pain and normal coronary arteriograms) represent a heterogeneous syndrome, which encompasses different pathogenic mechanisms. Although symptoms in most patients with cardiac syndrome X are non-cardiac, a sizable proportion of them have angina pectoris due to transient myocardial ischemia. Thus radionuclide myocardial perfusion defects, coronary sinus oxygen saturation abnormalities and pH changes, myocardial lactate production and stress-induced alterations of cardiac high energy phosphate suggest an ischemic origin of symptoms in at least a proportion of patients with cardiac syndrome X. Microvascular abnormalities, caused by endothelial dysfunction, appear to be responsible for myocardial ischemia in patients with cardiac syndrome X. Endothelial dysfunction is likely to be multifactorial in these patients and it is conceivable that risk factors such as hypertension, hypercholesterolemia, diabetes mellitus and smoking can contribute to its development. Most patients with cardiac syndrome X are postmenopausal women and estrogen deficiency has been therefore proposed as a pathogenic factor in female patients. Additional factors such as abnormal pain perception may contribute to the pathogenesis of chest pain in patients with angina pectoris and normal coronary angiograms. Although prognosis is good regarding survival, patients with cardiac syndrome X have an impaired quality of life. Management of this syndrome represents a major challenge to the treating physician. Understanding the mechanism underlying the condition is of vital importance for patient management. Thus diagnostic tests should aim at identifying the cause of the symptoms in the individual patient, i.e. myocardial ischemia, increased pain perception, abnormalities of adrenergic tone, non-cardiac mechanisms, etc. Moreover, it is important to bear in mind that treatment of cardiac syndrome X should be mainly directed towards improving quality of life, as prognosis is usually good in these patients. Conventional antianginal agents such nitrates, calcium channel antagonists, beta-adrenoceptor antagonists and nicorandil are effective particularly in patients in whom chest pain and ECG changes are clearly suggestive of myocardial ischemia and in those with objective documentation of ischemia. Angiotensin-converting enzyme inhibitors have been shown to be useful in syndrome X patients with increased adrenergic tone, borderline systemic hypertension, and those with documented endothelial dysfunction. Analgesic interventions of different sorts have been proposed based on the hypothesis that somatic and visceral perception of pain is altered in cardiac syndrome X patients. Pharmacological agents such as imipramine and aminophylline, and neural electrical stimulation techniques have been assessed in recent years with encouraging results. Psychological treatment, particularly cognitive therapy, appears to be useful in defined patient subsets. Relaxation techniques such as transcendental meditation have been successfully used in small studies and shown to improve not only chest pain but also exercise-induced ST segment changes. Reports indicate that these techniques improve quality of life.
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Affiliation(s)
- Juan Carlos Kaski
- Coronary Artery Disease Research Unit, Cardiological Sciences, St George's Hospital Medical School, London, UK.
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Houck CS, Khodorova A, Reale AM, Strichartz GR, Davar G. Sensory fibers resistant to the actions of tetrodotoxin mediate nocifensive responses to local administration of endothelin-1 in rats. Pain 2004; 110:719-726. [PMID: 15288413 DOI: 10.1016/j.pain.2004.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2003] [Revised: 04/27/2004] [Accepted: 05/12/2004] [Indexed: 11/21/2022]
Abstract
Endothelin-1 (ET-1) applied to the sciatic nerve or injected into the plantar hindpaw of rats induces pain behavior (ipsilateral hindpaw flinching) and selective excitation of nociceptors by activation of endothelin-A (ET(A)) receptors. To determine the pharmacological profile of the sensory fibers that mediate this pain behavior, we administered lidocaine (LID, a non-selective conduction blocker) or tetrodotoxin (TTX) prior to ET-1. LID (1 or 2%, 0.1 ml) was injected percutaneously into the sciatic notch, or TTX (10 microM, 4 microl) was injected into the sciatic nerve prior to the more distal application of ET-1 (400 microM, 40 microl) onto the sciatic nerve or subcutaneously into the plantar hindpaw (400 microM, 10 microl). LID inhibited ET-1-induced flinching in a dose-dependent manner; the mean total number of flinches was reduced by 39% for 1% LID and by 87% for 2% LID. In contrast, TTX failed to inhibit flinching behavior induced by sciatic nerve application of ET-1 despite a similar magnitude of motor and sensory blockade as that observed with 2% LID. Partial blockade of flinching behavior by intraneural TTX (mean total flinches were reduced by 51%) was observed after subcutaneous injection of ET-1. Unexpectedly, ET-1 prolonged the actions of 1% LID and, even when applied alone, produced clear signs of motor and sensory conduction block. These results are evidence that ET-1-induced pain is transmitted to the central nervous system via sensory fibers using tetrodotoxin-resistant sodium channels, and that ET-1 has analgesic actions that exist despite the activation of local pain pathways.
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Affiliation(s)
- Constance S Houck
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital, Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA Pain Research Center, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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50
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Lanza GA, Sestito A, Cammarota G, Grillo RL, Vecile E, Cianci R, Speziale D, Dobrina A, Maseri A, Crea F. Assessment of systemic inflammation and infective pathogen burden in patients with cardiac syndrome X. Am J Cardiol 2004; 94:40-4. [PMID: 15219506 DOI: 10.1016/j.amjcard.2004.03.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2004] [Revised: 03/04/2004] [Accepted: 03/04/2004] [Indexed: 02/06/2023]
Abstract
Inflammation plays a key role in coronary artery disease (CAD), but whether it is involved in the pathogenesis of syndrome X (SX) is not known. Thus, we assessed the presence of systemic inflammation in patients with SX and its possible relation to infections from Helicobacter pylori, Chlamydia pneumoniae, cytomegalovirus, and Epstein-Barr virus. We studied 55 patients with SX (57 +/- 8 years old; 27 women), 49 with stable angina and obstructive CAD (56 +/- 8 years old; 24 women), and 60 healthy controls (57 +/- 11 years old; 24 women). Plasma levels of high-sensitivity C-reactive protein and interleukin-1 receptor antagonist were measured in all patients. Infection from Helicobacter pylori, Chlamydia pneumoniae, cytomegalovirus, and Epstein-Barr virus was assessed in 43 patients with SX, 40 patients with CAD, and in 39 controls. Patients with SX had lower serum levels of C-reactive protein than did patients with CAD (4.06 +/- 6.8 vs 5.99 +/- 7.8 mg/L, p = 0.013) but higher levels of C-reactive protein than did controls (1.75 +/- 1.98 mg/L; p = 0.008). Plasma levels of interleukin-1 receptor antagonist were higher in patients with CAD (570 +/- 738 pg/ml) and patients with SX (494 +/- 677 pg/ml) than in controls (254 +/- 174, pg/ml; p = 0.0003 vs CAD and p = 0.013 vs SX) but did not differ significantly between patients with CAD or SX (p = 0.20). There were no differences across groups in the prevalence of infection from Helicobacter pylori, Chlamydia pneumoniae, cytomegalovirus, and Epstein-Barr virus and in the prevalence of 1, 2, 3, and 4 infections (p = 0.99). Among patients with SX, no correlation was found between markers of inflammation and indexes of disease activity (angina episodes, exercise test results). Our data show evidence of increased low-grade systemic inflammation in patients with cardiac SX, which was unrelated to an increased infectious pathogen burden.
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