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Tsai TY, Aldujeli A, Haq A, Knokneris A, Briedis K, Hughes D, Unikas R, Renkens M, Revaiah PC, Tobe A, Miyashita K, Sharif F, Garg S, Onuma Y, Serruys PW. The Impact of Microvascular Resistance Reserve on the Outcome of Patients With STEMI. JACC Cardiovasc Interv 2024; 17:1214-1227. [PMID: 38752970 DOI: 10.1016/j.jcin.2024.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) can characterize coronary microvascular dysfunction (CMD); however, its prognostic impact in ST-segment elevation myocardial infarction (STEMI) patients remains undefined. OBJECTIVES This study sought to investigate the prevalence of CMD in STEMI patients and to elucidate the prognostic performance of MRR. METHODS This prospective cohort study enrolled 210 STEMI patients with multivessel disease who underwent successful revascularization and returned at 3 months for coronary physiology assessments with bolus thermodilution. The prevalence of CMD (MRR <3) and the association between MRR and major adverse cardiovascular and cerebrovascular events (MACCEs) at 12 months were investigated. RESULTS The median age of patients was 65 years, and 59.5% were men. At the 3-month follow-up, 56 patients (27%) had CMD (MRR <3.0). The number of MACCEs at 12 months was higher in patients with vs without CMD (48.2% vs 11.0%; P < 0.001). MRR was independently associated with 12-month MACCEs (HR: 0.45 per unit increase; 95% CI: 0.31-0.67; P < 0.001) and with stroke, heart failure, and poorer recovery in left ventricular systolic function. The areas under the receiver-operating characteristic curves for predicting MACCEs at 12 months with fractional flow reserve, coronary flow reserve (CFR), the index of microvascular resistance (IMR), and MRR were 0.609, 0.762, 0.781, and 0.743, respectively. The prognostic performance of CFR, IMR, and MRR were all comparable. CONCLUSIONS The novel parameter MRR is a prognostic marker of MACCEs in STEMI patients with a comparable performance to CFR and IMR. (Impact of TMAO Serum Levels on Hyperemic IMR in STEMI Patients [TAMIR]; NCT05406297).
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Affiliation(s)
- Tsung-Ying Tsai
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ali Aldujeli
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | | | | | | | - Ramunas Unikas
- Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mick Renkens
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Akihiro Tobe
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Kotaro Miyashita
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, University Hospital Galway, University of Galway, Galway, Ireland
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Yoshinobu Onuma
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland; Department of Cardiology, University Hospital Galway, University of Galway, Galway, Ireland
| | - Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Lab, University of Galway, Galway, Ireland.
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Hanif A, Edin ML, Zeldin DC, Nayeem MA. Overexpression of Human Soluble Epoxide Hydrolase Exacerbates Coronary Reactive Hyperemia Reduction in Angiotensin-II-Treated Mouse Hearts. J Cardiovasc Pharmacol 2024; 83:46-54. [PMID: 37788350 PMCID: PMC10841723 DOI: 10.1097/fjc.0000000000001490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023]
Abstract
ABSTRACT Coronary reactive hyperemia (CRH) is impaired in cardiovascular diseases, and angiotensin-II (Ang-II) exacerbates it. However, it is unknown how Ang-II affects CRH in Tie2-sEH Tr (human-sEH-overexpressed) versus wild-type (WT) mice. sEH-overexpression resulted in CRH reduction in Tie2-sEH Tr versus WT. We hypothesized that Ang-II exacerbates CRH reduction in Tie2-sEH Tr versus WT. The Langendorff system measured coronary flow in Tie2-sEH Tr and WT. The hearts were exposed to 15-second ischemia, and CRH was assessed in 10 mice each. Repayment volume was reduced by 40.50% in WT treated with Ang-II versus WT (7.42 ± 0.8 to 4.49 ± 0.8 mL/g) and 48% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (5.18 ± 0.4 to 2.68 ± 0.3 mL/g). Ang-II decreased repayment duration by 50% in WT-treated with Ang-II versus WT (2.46 ± 0.5 to 1.24 ± 0.4 minutes) and 54% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (1.66 ± 0.4 to 0.76 ± 0.2 minutes). Peak repayment flow was reduced by 11.2% in WT treated with Ang-II versus WT (35.98 ± 0.7 to 32.11 ± 1.4 mL/g) and 4% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (32.18 ± 0.6 to 30.89 ± 1.5 mL/g). Furthermore, coronary flow was reduced by 43% in WT treated with Ang-II versus WT (14.2 ± 0.5 to 8.15 ± 0.8 mL/min/g) and 32% in Tie2-sEH Tr treated with Ang-II versus Tie2-sEH Tr (12.1 ± 0.8 to 8.3 ± 1.2 mL/min/g). Moreover, the Ang-II-AT 1 -receptor and CYP4A were increased in Tie2-sEHTr. Our results demonstrate that Ang-II exacerbates CRH reduction in Tie2-sEH Tr mice.
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Affiliation(s)
- Ahmad Hanif
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Matthew L. Edin
- Division of Intramural Research, NIEHS/NIH, Research Triangle Park, NC, USA
| | - Darryl C. Zeldin
- Division of Intramural Research, NIEHS/NIH, Research Triangle Park, NC, USA
| | - Mohammed A. Nayeem
- Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
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Nayeem MA, Geldenhuys WJ, Hanif A. Role of cytochrome P450-epoxygenase and soluble epoxide hydrolase in the regulation of vascular response. ADVANCES IN PHARMACOLOGY 2023; 97:37-131. [DOI: 10.1016/bs.apha.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Nayeem MA, Hanif A, Geldenhuys WJ, Agba S. Crosstalk between adenosine receptors and CYP450-derived oxylipins in the modulation of cardiovascular, including coronary reactive hyperemic response. Pharmacol Ther 2022; 240:108213. [PMID: 35597366 DOI: 10.1016/j.pharmthera.2022.108213] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
Adenosine is a ubiquitous endogenous nucleoside or autacoid that affects the cardiovascular system through the activation of four G-protein coupled receptors: adenosine A1 receptor (A1AR), adenosine A2A receptor (A2AAR), adenosine A2B receptor (A2BAR), and adenosine A3 receptor (A3AR). With the rapid generation of this nucleoside from cellular metabolism and the widespread distribution of its four G-protein coupled receptors in almost all organs and tissues of the body, this autacoid induces multiple physiological as well as pathological effects, not only regulating the cardiovascular system but also the central nervous system, peripheral vascular system, and immune system. Mounting evidence shows the role of CYP450-enzymes in cardiovascular physiology and pathology, and the genetic polymorphisms in CYP450s can increase susceptibility to cardiovascular diseases (CVDs). One of the most important physiological roles of CYP450-epoxygenases (CYP450-2C & CYP2J2) is the metabolism of arachidonic acid (AA) and linoleic acid (LA) into epoxyeicosatrienoic acids (EETs) and epoxyoctadecaenoic acid (EpOMEs) which generally involve in vasodilation. Like an increase in coronary reactive hyperemia (CRH), an increase in anti-inflammation, and cardioprotective effects. Moreover, the genetic polymorphisms in CYP450-epoxygenases will change the beneficial cardiovascular effects of metabolites or oxylipins into detrimental effects. The soluble epoxide hydrolase (sEH) is another crucial enzyme ubiquitously expressed in all living organisms and almost all organs and tissues. However, in contrast to CYP450-epoxygenases, sEH converts EETs into dihydroxyeicosatrienoic acid (DHETs), EpOMEs into dihydroxyoctadecaenoic acid (DiHOMEs), and others and reverses the beneficial effects of epoxy-fatty acids leading to vasoconstriction, reducing CRH, increase in pro-inflammation, increase in pro-thrombotic and become less cardioprotective. Therefore, polymorphisms in the sEH gene (Ephx2) cause the enzyme to become overactive, making it more vulnerable to CVDs, including hypertension. Besides the sEH, ω-hydroxylases (CYP450-4A11 & CYP450-4F2) derived metabolites from AA, ω terminal-hydroxyeicosatetraenoic acids (19-, 20-HETE), lipoxygenase-derived mid-chain hydroxyeicosatetraenoic acids (5-, 11-, 12-, 15-HETEs), and the cyclooxygenase-derived prostanoids (prostaglandins: PGD2, PGF2α; thromboxane: Txs, oxylipins) are involved in vasoconstriction, hypertension, reduction in CRH, pro-inflammation and cardiac toxicity. Interestingly, the interactions of adenosine receptors (A2AAR, A1AR) with CYP450-epoxygenases, ω-hydroxylases, sEH, and their derived metabolites or oxygenated polyunsaturated fatty acids (PUFAs or oxylipins) is shown in the regulation of the cardiovascular functions. In addition, much evidence demonstrates polymorphisms in CYP450-epoxygenases, ω-hydroxylases, and sEH genes (Ephx2) and adenosine receptor genes (ADORA1 & ADORA2) in the human population with the susceptibility to CVDs, including hypertension. CVDs are the number one cause of death globally, coronary artery disease (CAD) was the leading cause of death in the US in 2019, and hypertension is one of the most potent causes of CVDs. This review summarizes the articles related to the crosstalk between adenosine receptors and CYP450-derived oxylipins in vascular, including the CRH response in regular salt-diet fed and high salt-diet fed mice with the correlation of heart perfusate/plasma oxylipins. By using A2AAR-/-, A1AR-/-, eNOS-/-, sEH-/- or Ephx2-/-, vascular sEH-overexpressed (Tie2-sEH Tr), vascular CYP2J2-overexpressed (Tie2-CYP2J2 Tr), and wild-type (WT) mice. This review article also summarizes the role of pro-and anti-inflammatory oxylipins in cardiovascular function/dysfunction in mice and humans. Therefore, more studies are needed better to understand the crosstalk between the adenosine receptors and eicosanoids to develop diagnostic and therapeutic tools by using plasma oxylipins profiles in CVDs, including hypertensive cases in the future.
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Affiliation(s)
- Mohammed A Nayeem
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA.
| | - Ahmad Hanif
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Werner J Geldenhuys
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Stephanie Agba
- Graduate student, Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
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Zhou J, Onuma Y, Garg S, Kotoku N, Kageyama S, Masuda S, Ninomiya K, Huo Y, Reiber JHC, Tu S, Piek JJ, Escaned J, Perera D, Bourantas C, Yan H, Serruys PW. Angiography derived assessment of the coronary microcirculation: is it ready for prime time? Expert Rev Cardiovasc Ther 2022; 20:549-566. [PMID: 35899781 DOI: 10.1080/14779072.2022.2098117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Non-obstructive coronary arteries (NOCA) are present in 39.7% to 62.4% of patients who undergo elective angiography. Coronary microcirculation (<400 µm) is not visible on angiography therefore functional assessment, invasive or non-invasive plays a prior role to help provide a more personalized diagnosis of angina. AREA COVERED In this review, we revise the pathophysiology, clinical importance and invasive assessment of the coronary microcirculation, and discuss angiography-derived indices of microvascular resistance. A comprehensive literature review over four decades is also undertaken. EXPERT OPINION The coronary microvasculature plays an important role in flow autoregulation and metabolic regulation. Invasive assessment of microvascular resistance is a validated modality with independent prognostic value, nevertheless, its routine application is hampered by the requirement of intravascular instrumentation and hyperaemic agents. The angiography-derived index of microvascular resistance has emerged as a promising surrogate in pilot studies, however, more data are needed to validate and compare the diagnostic and prognostic accuracy of different equations as well as to illustrate the relationship between angiography-derived parameters for epicardial coronary arteries and those for the microvasculature.
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Affiliation(s)
- Jinying Zhou
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China.,Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Scot Garg
- Department of CardiologyRoyal Blackburn Hospital, Blackburn, United Kingdom
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China; Department of Cardiology, Peking University First Hospital, Beijing, China; Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Johan H C Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Shengxian Tu
- School of Biomedical Engineering,Biomedical Instrument Institute Shanghai Jiao Tong University, Shanghai, China
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Javier Escaned
- Complutense University of Madrid Hospital Clinico San Carlos IDISCC, Madrid, Spain
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, UK
| | - Christos Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hongbing Yan
- Chinese Academy of Medical Sciences, Shenzhen, China; Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital,, Beijing, China
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6
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Kawashima H, Hara H, Wang R, Ono M, Gao C, Takahashi K, Suryapranata H, Walsh S, Cotton J, Carrie D, Sabate M, Steinwender C, Leibundgut G, Wykrzykowska J, Hamm C, Jüni P, Vranckx P, Valgimigli M, Windecker S, Winter RJ, Sharif F, Onuma Y, Serruys PW. Usefulness of updated logistic clinical SYNTAX score based on MI‐SYNTAX score in patients with ST‐elevation myocardial infarction. Catheter Cardiovasc Interv 2020; 97:E919-E928. [DOI: 10.1002/ccd.29383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/07/2020] [Accepted: 10/22/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Hideyuki Kawashima
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam Netherlands
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
| | - Hironori Hara
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam Netherlands
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
| | - Rutao Wang
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
- Department of Cardiology Radboudumc Nijmegen Netherlands
| | - Masafumi Ono
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam Netherlands
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
| | - Chao Gao
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
- Department of Cardiology Radboudumc Nijmegen Netherlands
| | - Kuniaki Takahashi
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam Netherlands
| | | | - Simon Walsh
- Department of Cardiology Belfast Health and Social Care Trust Belfast UK
| | - James Cotton
- Heart and Lung Centre New Cross Hospital Wolverhampton UK
| | - Didier Carrie
- Department of Cardiology, Rangueil hospital Paul Sabatier University Toulouse 3 Toulouse France
| | | | - Clemens Steinwender
- Department of Cardiology Kepler University Hospital Linz Medical Faculty Johannes Kepler University Linz Linz Austria
| | - Gregor Leibundgut
- Department of Cardiology Kantonsspital Baselland, Standort Liestal Liestal Switzerland
| | | | - Christian Hamm
- Kerckhoff Heart Center Campus University of Giessen Bad Nauheim Germany
| | - Peter Jüni
- Université Paris‐Diderot, Hôpital Bichat Assistance Publique–Hôpitaux de Paris, INSERM U‐1148, FACT (French Alliance for Cardiovascular Trials) Paris France
| | - Pascal Vranckx
- Jessa Ziekenhuis Faculty of Medicine and Life Sciences at the Hasselt University Hasselt Belgium
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Inselspital University of Bern Bern Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital University of Bern Bern Switzerland
| | - Robbert J. Winter
- Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam Netherlands
| | - Faisal Sharif
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
| | - Yoshinobu Onuma
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
| | - Patrick W. Serruys
- Department of Cardiology National University of Ireland, Galway (NUIG) Galway Ireland
- NHLI Imperial College London London UK
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7
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Serruys PW, Chichareon P, Modolo R, Leaman DM, Reiber JH, Emanuelsson H, Di Mario C, Pijls NH, Morel MA, Valgimigli M, Farooq V, van Klaveren D, Capodanno D, Andreini D, Bourantas CV, Davies J, Banning AP, Escaned J, Piek JJ, Echavarría-Pinto M, Taylor CA, Thomsen B, Collet C, Pompilio G, Bartorelli AL, Glocker B, Dressler O, Stone GW, Onuma Y. The SYNTAX score on its way out or … towards artificial intelligence: part I. EUROINTERVENTION 2020; 16:44-59. [DOI: 10.4244/eij-d-19-00543a] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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8
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Montisci R, Ruscazio M, Tona F, Corbetti F, Sarais C, Marchetti MF, Cacciavillani L, Iliceto S, Perazzolo Marra M, Meloni L. Coronary flow reserve is related to the extension and transmurality of myocardial necrosis and predicts functional recovery after acute myocardial infarction. Echocardiography 2019; 36:844-853. [PMID: 31002185 DOI: 10.1111/echo.14337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/06/2019] [Accepted: 03/21/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Few studies have examined the effect of transmurality of myocardial necrosis on coronary microcirculation. The aim of this study was to examine the influence of cardiac magnetic resonance-derived (GE-MRI) structural determinants of coronary flow reserve (CFR) after anterior myocardial infarction (STEMI), and their predictive value on regional functional recovery. METHODS Noninvasive CFR and GE-MRI were studied in 37 anterior STEMI patients after primary coronary angioplasty. The wall motion score index in the left descending anterior coronary artery territory (A-WMSI) was calculated at admission and follow-up (FU). Recovery of regional left ventricular (LV) function was defined as the difference in A-WMSI at admission and FU. The necrosis score index (NSI) and transmurality score index (TSI) by GE-MRI were calculated in the risk area. Baseline (BMR) and hyperemic (HMR) microvascular resistance, arteriolar resistance index (ARI), and coronary resistance reserve (CRR) were calculated at the Doppler echocardiography. RESULTS Bivariate analysis indicated that the CPK and troponin I peak, heart rate, NSI, TSI, BMR, the ARI, and CRR were related to CFR. Multivariable analysis revealed that TSI was the only independent determinant of CFR. The CFR value of >2.27, identified as optimal by ROC analysis, was 77% specific and 73% sensitive with accuracy of 76% in identifying patients with functional recovery. CONCLUSIONS Preservation of microvascular function after AMI is related to the extent of transmurality of myocardial necrosis, is an important factor influencing regional LV recovery, and can be monitored by noninvasive CFR.
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Affiliation(s)
- Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Massimo Ruscazio
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Tona
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Cristiano Sarais
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Maria Francesca Marchetti
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Luisa Cacciavillani
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Martina Perazzolo Marra
- Clinical Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Luigi Meloni
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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9
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Rosenberry R, Chung S, Nelson MD. Skeletal Muscle Neurovascular Coupling, Oxidative Capacity, and Microvascular Function with 'One Stop Shop' Near-infrared Spectroscopy. J Vis Exp 2018. [PMID: 29553570 DOI: 10.3791/57317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Exercise represents a major hemodynamic stress that demands a highly coordinated neurovascular response in order to match oxygen delivery to metabolic demand. Reactive hyperemia (in response to a brief period of tissue ischemia) is an independent predictor of cardiovascular events and provides important insight into vascular health and vasodilatory capacity. Skeletal muscle oxidative capacity is equally important in health and disease, as it determines the energy supply for myocellular processes. Here, we describe a simple, non-invasive approach using near-infrared spectroscopy to assess each of these major clinical endpoints (reactive hyperemia, neurovascular coupling, and muscle oxidative capacity) during a single clinic or laboratory visit. Unlike Doppler ultrasound, magnetic resonance images/spectroscopy, or invasive catheter-based flow measurements or muscle biopsies, our approach is less operator-dependent, low-cost, and completely non-invasive. Representative data from our lab taken together with summary data from previously published literature illustrate the utility of each of these end-points. Once this technique is mastered, application to clinical populations will provide important mechanistic insight into exercise intolerance and cardiovascular dysfunction.
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Affiliation(s)
- Ryan Rosenberry
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington
| | - Susie Chung
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington
| | - Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, Department of Kinesiology, University of Texas at Arlington;
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10
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Rosenberry R, Munson M, Chung S, Samuel TJ, Patik J, Tucker WJ, Haykowsky MJ, Nelson MD. Age-related microvascular dysfunction: novel insight from near-infrared spectroscopy. Exp Physiol 2017; 103:190-200. [PMID: 29114952 DOI: 10.1113/ep086639] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/06/2017] [Indexed: 12/31/2022]
Abstract
NEW FINDINGS What is the central question of this study? Can near-infrared spectroscopy (NIRS)-derived post-occlusion tissue oxygen saturation recovery kinetics be used to study age-related impairments in microvascular function? What is the main finding and its importance? Using a previously established 5 min cuff occlusion protocol, we found that NIRS-derived indices of microvascular function were markedly reduced in elderly compared with young participants. However, when we controlled for the absolute level of vasodilatory stimulus and matched the tissue desaturation level between groups, we found similar responses in young and elderly participants. Overall, these data highlight the important role NIRS can serve in clinical vascular biology, but also establish the need for assessing tissue ischaemia during cuff occlusion protocols. Near-infrared spectroscopy (NIRS) has emerged as a promising tool to evaluate vascular reactivity in vivo. Whether this approach can be used to assess age-related impairments in microvascular function has not been tested. Tissue oxygen saturation (StO2) post-occlusion recovery kinetics were measured in two distinct age groups (<35 and >65 years of age) using NIRS placed over the flexor digitorum profundus. Key end-points included the following: (i) the desaturation rate during cuff occlusion; (ii) the lowest StO2 value obtained during ischaemia (StO2min); (iii) StO2 reperfusion rate; (iv) the highest StO2 value reached after cuff release (StO2max); and (v) the reactive hyperaemia area under the curve (AUC). At first, using a conventional 5 min cuff occlusion protocol, the elderly participants achieved a much slower rate of oxygen recovery (1.5 ± 0.2 versus 2.5 ± 0.2% s-1 ), lower StO2max (85.2 ± 2.9 versus 92.3 ± 1.5%) and lower reactive hyperaemia AUC (2651.8 ± 307.0 versus 4940.0 ± 375.8% s-1 ). However, owing to a lower skeletal muscle resting metabolic rate, StO2min was also significantly attenuated in the elderly participants compared with the young control subjects (55.7 ± 3.5 versus 41.0 ± 3.4%), resulting in a much lower ischaemic stimulus. To account for this important difference between groups, we then matched the level of tissue ischaemia in a subset of young healthy participants by reducing the cuff occlusion protocol to 3 min. Remarkably, when we controlled for tissue ischaemia, we observed no differences in any of the hyperaemic end-points between the young and elderly participants. These data highlight the important role NIRS can serve in vascular biology, but also establish the need for assessing tissue ischaemia during cuff occlusion protocols.
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Affiliation(s)
- Ryan Rosenberry
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - Madison Munson
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - Susie Chung
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - T Jake Samuel
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - Jordan Patik
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA
| | - Wesley J Tucker
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA.,College of Nursing, University of Texas at Arlington, Arlington, TX, USA
| | - Mark J Haykowsky
- College of Nursing, University of Texas at Arlington, Arlington, TX, USA
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington, Arlington, TX, USA.,Department of Bioengineering, University of Texas at Arlington, Arlington, TX, USA
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11
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Erthal F, Aleksova N, Chong AY, de Kemp RA, Beanlands RSB. Microvascular function, is there a link to myocardial viability: Is this another piece to the puzzle? J Nucl Cardiol 2017; 24:1651-1656. [PMID: 27379503 DOI: 10.1007/s12350-016-0575-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Fernanda Erthal
- National Cardiac PET Centre and the CAPITAL Interventional investigator group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Natasha Aleksova
- National Cardiac PET Centre and the CAPITAL Interventional investigator group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Aun Yeong Chong
- National Cardiac PET Centre and the CAPITAL Interventional investigator group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Robert A de Kemp
- National Cardiac PET Centre and the CAPITAL Interventional investigator group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Rob S B Beanlands
- National Cardiac PET Centre and the CAPITAL Interventional investigator group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
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12
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Hassell M, Bax M, van Lavieren M, Nijveldt R, Hirsch A, Robbers L, Marques K, Tijssen J, Zijlstra F, van Rossum A, Delewi R, Piek J. Microvascular dysfunction following ST-elevation myocardial infarction and its recovery over time. EUROINTERVENTION 2017; 13:e578-e584. [DOI: 10.4244/eij-d-16-00818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Hanif A, Edin ML, Zeldin DC, Morisseau C, Nayeem MA. Deletion of soluble epoxide hydrolase enhances coronary reactive hyperemia in isolated mouse heart: role of oxylipins and PPARγ. Am J Physiol Regul Integr Comp Physiol 2016; 311:R676-R688. [PMID: 27488890 DOI: 10.1152/ajpregu.00237.2016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
The relationship between soluble epoxide hydrolase (sEH) and coronary reactive hyperemia (CRH) response to a brief ischemic insult is not known. Epoxyeicosatrienoic acids (EETs) exert cardioprotective effects in ischemia/reperfusion injury. sEH converts EETs into dihydroxyeicosatrienoic-acids (DHETs). Therefore, we hypothesized that knocking out sEH enhances CRH through modulation of oxylipin profiles, including an increase in EET/DHET ratio. Compared with sEH+/+, sEH-/- mice showed enhanced CRH, including greater repayment volume (RV; 28% higher, P < 0.001) and repayment/debt ratio (32% higher, P < 0.001). Oxylipins from the heart perfusates were analyzed by LC-MS/MS. The 14,15-EET/14,15-DHET ratio was 3.7-fold higher at baseline (P < 0.001) and 5.6-fold higher post-ischemia (P < 0.001) in sEH-/- compared with sEH+/+ mice. Likewise, the baseline 9,10- and 12,13-EpOME/DiHOME ratios were 3.2-fold (P < 0.01) and 3.7-fold (P < 0.001) higher, respectively in sEH-/- compared with sEH+/+ mice. 13-HODE was also significantly increased at baseline by 71% (P < 0.01) in sEH-/- vs. sEH+/+ mice. Levels of 5-, 11-, 12-, and 15-hydroxyeicosatetraenoic acids were not significantly different between the two strains (P > 0.05), but were decreased postischemia in both groups (P = 0.02, P = 0.04, P = 0.05, P = 0.03, respectively). Modulation of CRH by peroxisome proliferator-activated receptor gamma (PPARγ) was demonstrated using a PPARγ-antagonist (T0070907), which reduced repayment volume by 25% in sEH+/+ (P < 0.001) and 33% in sEH-/- mice (P < 0.01), and a PPARγ-agonist (rosiglitazone), which increased repayment volume by 37% in both sEH+/+ (P = 0.04) and sEH-/- mice (P = 0.04). l-NAME attenuated CRH in both sEH-/- and sEH+/+ These data demonstrate that genetic deletion of sEH resulted in an altered oxylipin profile, which may have led to an enhanced CRH response.
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Affiliation(s)
- Ahmad Hanif
- Basic Pharmaceutical Sciences, School of Pharmacy, Center for Basic and Translational Stroke Research, West Virginia University, Morgantown, West Virginia
| | - Matthew L Edin
- Division of Intramural Research, National Institute of Environmental Health Sciences/National Institutes of Health, Research Triangle Park, North Carolina; and
| | - Darryl C Zeldin
- Division of Intramural Research, National Institute of Environmental Health Sciences/National Institutes of Health, Research Triangle Park, North Carolina; and
| | | | - Mohammed A Nayeem
- Basic Pharmaceutical Sciences, School of Pharmacy, Center for Basic and Translational Stroke Research, West Virginia University, Morgantown, West Virginia;
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14
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Zhou X, Teng B, Mustafa SJ. Sex Difference in Coronary Endothelial Dysfunction in Apolipoprotein E Knockout Mouse: Role of NO and A2A Adenosine Receptor. Microcirculation 2016. [PMID: 26201383 DOI: 10.1111/micc.12222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Sex plays an important role in the pathophysiology of cardiovascular diseases. This study aims to investigate how sex impacts on the coronary flow regulation during atherosclerosis. METHODS ApoE KO mouse fed with western diet were used for atherosclerosis model. Coronary RH and flow response were measured using Langendorff-perfused isolated hearts. RESULTS Coronary RH and A23187-induced NO-dependent flow increases were significantly reduced in female (by ~28% and 48%, respectively), but not in male atherosclerotic mice. However, SNP-induced coronary vasodilation remains intact in both sexes of ApoE KO mice. L-NAME (NOS inhibitor) reduced baseline flow and RH to a lesser extent in ApoE KO (by ~19% and 31%) vs. WT (~30% and 59%, respectively), and abolished the sex difference in RH. In contrast, SCH58261 (a selective A2A AR antagonist) reduced the baseline flow and RH to a greater extent in atherosclerotic mice, but did not affect the sex difference. Immunofluorescent staining of coronary arteries showed a similar A2A AR upregulation in both sexes of ApoE KO mice. CONCLUSIONS Our results suggest that during atherosclerosis, female mice are more susceptible to NO-dependent endothelial dysfunction and the upregulation of A2A AR may serve as a compensatory mechanism to counteract the compromised endothelial function.
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Affiliation(s)
- Xueping Zhou
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
| | - Bunyen Teng
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
| | - S J Mustafa
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia, USA.,Center for Cardiovascular and Respiratory Sciences and West Virginia Clinical & Translational Science Institute, Morgantown, West Virginia, USA
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15
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Teunissen PFA, Timmer SAJ, Danad I, de Waard GA, van de Ven PM, Raijmakers PG, Lammertsma AA, Van Rossum AC, van Royen N, Knaapen P. Coronary vasomotor function in infarcted and remote myocardium after primary percutaneous coronary intervention. Heart 2015; 101:1577-83. [DOI: 10.1136/heartjnl-2015-307825] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/09/2015] [Indexed: 11/04/2022] Open
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16
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Zhou X, Teng B, Tilley S, Mustafa SJ. A1 adenosine receptor negatively modulates coronary reactive hyperemia via counteracting A2A-mediated H2O2 production and KATP opening in isolated mouse hearts. Am J Physiol Heart Circ Physiol 2013; 305:H1668-79. [PMID: 24043252 DOI: 10.1152/ajpheart.00495.2013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We previously demonstrated that A2A, but not A2B, adenosine receptors (ARs) mediate coronary reactive hyperemia (RH), possibly by producing H2O2 and, subsequently, opening ATP-dependent K(+) (KATP) channels in coronary smooth muscle cells. In this study, A1 AR knockout (KO), A3 AR KO, and A1 and A3 AR double-KO (A1/A3 DKO) mice were used to investigate the roles and mechanisms of A1 and A3 ARs in modulation of coronary RH. Coronary flow of isolated hearts was measured using the Langendorff system. A1 KO and A1/A3 DKO, but not A3 KO, mice showed a higher flow debt repayment [~30% more than wild-type (WT) mice, P < 0.05] following a 15-s occlusion. SCH-58261 (a selective A2A AR antagonist, 1 μM) eliminated the augmented RH, suggesting the involvement of enhanced A2A AR-mediated signaling in A1 KO mice. In isolated coronary arteries, immunohistochemistry showed an upregulation of A2A AR (1.6 ± 0.2 times that of WT mice, P < 0.05) and a higher magnitude of adenosine-induced H2O2 production in A1 KO mice (1.8 ± 0.3 times that of WT mice, P < 0.05), which was blocked by SCH-58261. Catalase (2,500 U/ml) and glibenclamide (a KATP channel blocker, 5 μM), but not N(G)-nitro-l-arginine methyl ester, also abolished the enhanced RH in A1 KO mice. Our data suggest that A1, but not A3, AR counteracts the A2A AR-mediated CF increase and that deletion of A1 AR results in upregulation of A2A AR and/or removal of the negative modulatory effect of A1 AR, thus leading to an enhanced A2A AR-mediated H2O2 production, KATP channel opening, and coronary vasodilation during RH. This is the first report implying that A1 AR has a role in coronary RH.
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Affiliation(s)
- Xueping Zhou
- Department of Physiology and Pharmacology, West Virginia University, Morgantown, West Virginia
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17
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Activation of hypoxia response in endothelial cells contributes to ischemic cardioprotection. Mol Cell Biol 2013; 33:3321-9. [PMID: 23775121 DOI: 10.1128/mcb.00432-13] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Small-molecule inhibition of hypoxia-inducible factor prolyl 4-hydroxylases (HIF-P4Hs) is being explored for the treatment of anemia. Previous studies have suggested that HIF-P4H-2 inhibition may also protect the heart from an ischemic insult. Hif-p4h-2(gt/gt) mice, which have 76 to 93% knockdown of Hif-p4h-2 mRNA in endothelial cells, fibroblasts, and cardiomyocytes and normoxic stabilization of Hif-α, were subjected to ligation of the left anterior descending coronary artery (LAD). Hif-p4h-2 deficiency resulted in increased survival, better-preserved left ventricle (LV) systolic function, and a smaller infarct size. Surprisingly, a significantly larger area of the LV remained perfused during LAD ligation in Hif-p4h-2(gt/gt) hearts than in wild-type hearts. However, no difference was observed in collateral vessels, while the size of capillaries, but not their number, was significantly greater in Hif-p4h-2(gt/gt) hearts than in wild-type hearts. Hif-p4h-2(gt/gt) mice showed increased cardiac expression of endothelial Hif target genes for Tie-2, apelin, APJ, and endothelial nitric oxide (NO) synthase (eNOS) and increased serum NO concentrations. Remarkably, blockage of Tie-2 signaling was sufficient to normalize cardiac apelin and APJ expression and resulted in reversal of the enlarged-capillary phenotype and ischemic cardioprotection in Hif-p4h-2(gt/gt) hearts. Activation of the hypoxia response by HIF-P4H-2 inhibition in endothelial cells appears to be a major determinant of ischemic cardioprotection and justifies the exploration of systemic small-molecule HIF-P4H-2 inhibitors for ischemic heart disease.
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18
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Serruys PW. Full circle: from thrombolysis to PCI post-thrombolysis, to thrombolysis with PCI, to PCI alone to thrombectomy alone, to nanothrombolysis. EUROINTERVENTION 2013; 8:1112-3. [PMID: 23425534 DOI: 10.4244/eijv8i10a171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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19
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Comparison of magnetic resonance imaging findings in non-ST-segment elevation versus ST-segment elevation myocardial infarction patients undergoing early invasive intervention. Int J Cardiovasc Imaging 2011; 28:1487-97. [PMID: 22072243 DOI: 10.1007/s10554-011-9975-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 11/02/2011] [Indexed: 10/15/2022]
Abstract
To define causes and pathological mechanisms underlying differences in clinical outcomes, we compared the findings of contrast-enhanced magnetic resonance imaging (CE-MRI) between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). In 168 patients undergoing early invasive intervention for STEMI (n = 113) and NSTEMI (n = 55), CE-MRI was performed a median of 6 days after the index event. Infarct size was measured on delayed-enhancement imaging, and area at risk (AAR) was quantified on T2-weighted images. The median infarct size was significantly smaller in the NSTEMI group than in the STEMI group (10.7% [5.6-18.1] vs. 19.2% [10.3-30.7], P < 0.001). Although there was a trend toward a greater myocardial salvage index ([AAR - infarct size] × 100/AAR) in the NSTEMI group compared to the STEMI group (48.2 [30.4-66.8] vs. 40.5 [24.8-53.5], P = 0.056), myocardial salvage index was similar between the groups in patients with anterior infarction (39.6 [20.0-54.9] vs. 35.5 [23.2-53.4], P = 0.96). The NSTEMI group also had a significantly lower extent of microvascular obstruction and a smaller number of segments with >75% of infarct transmurality relative to the STEMI group (0% [0-0.6] vs. 0.9% [0-2.3], P < 0.001 and 3.0 ± 2.3 vs. 4.6 ± 2.9, P = 0.001, respectively). Myocardial hemorrhage was detected less frequently in the NSTEMI group than the STEMI group (22.6% vs. 43.8%, P = 0.029). In the multivariate analysis, baseline Thrombolysis In Myocardial Infarction flow grade 3 and hemorrhagic infarction were closely associated with ST-segment elevation (OR 0.32, 95% CI 0.13-0.81, P = 0.017; OR 5.66, 95% CI 1.77-18.12, P = 0.003, respectively). In conclusion, in vivo pathophysiological differences revealed by CE-MRI assessment include more favorable infarct size, AAR, myocardial salvage and reperfusion injury in patients with NSTEMI compared to those with STEMI undergoing early invasive intervention.
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20
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Sadauskiene E, Zakarkaite D, Ryliskyte L, Celutkiene J, Rudys A, Aidietiene S, Laucevicius A. Non-invasive evaluation of myocardial reperfusion by transthoracic Doppler echocardiography and single-photon emission computed tomography in patients with anterior acute myocardial infarction. Cardiovasc Ultrasound 2011; 9:16. [PMID: 21619676 PMCID: PMC3123269 DOI: 10.1186/1476-7120-9-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 05/28/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The study was designed to evaluate whether the preserved coronary flow reserve (CFR) 72 hours after reperfused acute myocardial infarction (AMI) is associated with less microvascular dysfunction and is predictive of left ventricular (LV) functional recovery and the final infarct size at follow-up. METHODS In our study, CFR was assessed by transthoracic Doppler echocardiography (TDE) in 44 patients after the successful percutaneous coronary intervention during the acute AMI phase. CFR was correlated with contractile reserve assessed by low-dose dobutamine echocardiography and with the total perfusion defect measured by single-photon emission computed tomography 72 hours after reperfusion and at 5 months follow-up. The ROC analysis was performed to determine test sensitivity and specificity based on CFR. Categorical data were compared by an χ² analysis, continuous variables were analysed with the independent Student's t test. In order to analyse correlation between CFR and the parameters of LV function and perfusion, the Pearson correlation analysis was conducted. The linear regression analysis was used to assess the relationship between CFR and myocardial contractility as well as the final infarct size. RESULTS We estimated the CFR cut-off value of 1.75 as providing the maximal accuracy to distinguish between patients with preserved and impaired CFR during the acute AMI phase (sensitivity 91.7%, specificity 75%). Wall motion score index was better in the subgroup with preserved CFR as compared to the subgroup with reduced CFR: 1.74 (0.29) vs. 1.89 (0.17) (p < 0.001) during the acute phase and 1.47 (0.30) vs. 1.81 (0.20) (p < 0.001) at follow-up, respectively. LV ejection fraction was 47.78% (8.99) in preserved CFR group vs. 40.79% (7.25) in impaired CFR group (p = 0.007) 72 hours after reperfusion and 49.78% (8.70) vs. 40.36% (7.90) (p = 0.001) after 5 months at follow-up, respectively. The final infarct size was smaller in patients with preserved as compared to patients with reduced CFR: 5.26% (6.14) vs. 23.28% (12.19) (p < 0.001) at follow-up. CONCLUSION The early measurement of CFR by TDE can be of high value for the assessment of successful reperfusion in AMI and can be used to predict LV functional recovery, myocardial viability and the final infarct size.
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Affiliation(s)
- Egle Sadauskiene
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Diana Zakarkaite
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Ligita Ryliskyte
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Jelena Celutkiene
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Alfredas Rudys
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Sigita Aidietiene
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
| | - Aleksandras Laucevicius
- Department of Cardiovascular Medicine, Vilnius University Hospital Santariskiu Klinikos, Santariskiu 2, Vilnius, LT-08661, Lithuania
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, M.K. Ciurlionio 21, Vilnius, LT-03101, Lithuania
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21
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Park SM, Hong SJ, Kim YH, Ahn CM, Lim DS, Shim WJ. Predicting myocardial functional recovery after acute myocardial infarction: relationship between myocardial strain and coronary flow reserve. Korean Circ J 2010; 40:639-44. [PMID: 21267386 PMCID: PMC3025337 DOI: 10.4070/kcj.2010.40.12.639] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 05/26/2010] [Accepted: 05/31/2010] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives The purpose of this study was to evaluate the relationship between myocardial strain and coronary flow reserve (CFR) in the prediction of myocardial functional recovery after acute myocardial infarction (AMI). Subjects and Methods Consecutive patients with anterior ST elevation AMI were analyzed. Left ventricular (LV) strain, determined by 2-dimensional speckle tracking imaging and CFR, determined by intracoronary flow measurement, were obtained on the same day, 3-5 days after primary percutaneous coronary intervention. A-strain was defined as the mean systolic longitudinal strain of 11 LV segments (out of 18) assumed to be supplied by the left anterior descending coronary artery (LAD). Functional recovery was defined as improved wall motion >1 grade seen in at least 2 contiguous dysfunctional segments by echocardiography at the 6-month follow-up. Results Of 20 patients, 8 patients had preserved CFR (>2.0) and 12 patients had impaired CFR (≤2.0). There were no differences between the 2 CFR groups in LV ejection fractions and wall motion score indices in the LAD territory. However, A-strain was greater in patients with preserved CFR than in patients with impaired CFR (-6.4±2.0% vs. -4.6±1.4%, p=0.03). A-strain and CFR correlated well with each other (r=-0.49, p=0.03). Ten of 20 patients showed functional recovery at 6 months. Of clinical and echocardiographic parameters, A-strain was the only predictor of recovery (odds ratio 2.02, 95% confidence interval=1.03-3.97, p=0.04). For predicting recovery, the sensitivity and specificity were 80.0% and 80.0%, respectively, for CFR (cutoff=1.60), and 60.0% and 90.0%, respectively, for A-strain (cutoff=-6.13%). Conclusion Myocardial strain correlates well with the extent of microvascular integrity and can be used as a noninvasive method for predicting recovery after AMI.
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Affiliation(s)
- Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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23
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Reperfusión satisfactoria: del rescate epicárdico al miocárdico. Rev Esp Cardiol (Engl Ed) 2010; 63:757-9. [DOI: 10.1016/s0300-8932(10)70176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Park SM, Hong SJ, Park JS, Lim SY, Ahn CM, Lim DS, Shim WJ. Relationship between Strain Rate Imaging and Coronary Flow Reserve in Assessing Myocardial Viability after Acute Myocardial Infarction. Echocardiography 2010; 27:977-84. [DOI: 10.1111/j.1540-8175.2010.01178.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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25
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Kitabata H, Imanishi T, Kubo T, Takarada S, Kashiwagi M, Matsumoto H, Tsujioka H, Ikejima H, Arita Y, Okochi K, Kuroi A, Ueno S, Kataiwa H, Tanimoto T, Yamano T, Hirata K, Nakamura N, Tanaka A, Mizukoshi M, Akasaka T. Coronary Microvascular Resistance Index Immediately After Primary Percutaneous Coronary Intervention as a Predictor of the Transmural Extent of Infarction in Patients With ST-Segment Elevation Anterior Acute Myocardial Infarction. JACC Cardiovasc Imaging 2009; 2:263-72. [DOI: 10.1016/j.jcmg.2008.11.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 10/27/2008] [Accepted: 11/05/2008] [Indexed: 10/21/2022]
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26
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Van Herck PL, Carlier SG, Claeys MJ, Haine SE, Gorissen P, Miljoen H, Bosmans JM, Vrints CJ. Coronary microvascular dysfunction after myocardial infarction: increased coronary zero flow pressure both in the infarcted and in the remote myocardium is mainly related to left ventricular filling pressure. Heart 2007; 93:1231-7. [PMID: 17395671 PMCID: PMC2000925 DOI: 10.1136/hrt.2006.100818] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the underlying mechanisms of a decreased coronary flow reserve after myocardial infarction (MI) by analysing the characteristics of the diastolic hyperaemic coronary pressure-flow relationship. DESIGN Prospective study. SETTING Tertiary care hospital. PATIENTS 68 patients with a recent MI and 27 patients with stable angina pectoris (AP; control group). MAIN OUTCOME MEASURES The intercept with the pressure axis (the zero flow pressure or Pzf) and slope index of the pressure-flow relationship (SIPF) were calculated from the simultaneously recorded hyperaemic intracoronary blood flow velocity and aortic pressure after successful coronary stenting. RESULTS A stepwise increase in Pzf from AP (14.6 (8.0) mm Hg), over non-Q-wave MI (22.5 (9.1) mm Hg), to Q-wave MI (37.1 (12.9) mm Hg; p<0.001) was observed. Similar changes in Pzf were found in a reference artery perfusing the non-infarcted myocardium. Multivariate analysis showed that in both regions the left ventricular end-diastolic pressure (LVEDP) was the most important determinant of the Pzf. The SIPF was not statistically different in the treated vessel between patients with MI and AP, but was increased in MI patients with a markedly increased LVEDP. CONCLUSIONS After an MI, the coronary pressure-flow relationship is shifted to the right both in the infarcted and in the non-infarcted remote myocardium, as shown by the increased Pzf. The correlation with Pzf suggests that elevated left ventricular filling pressures contribute to the impediment of myocardial perfusion in patients with infarction.
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Affiliation(s)
- P L Van Herck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.
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Ikeno F, Inagaki K, Rezaee M, Mochly-Rosen D. Impaired perfusion after myocardial infarction is due to reperfusion-induced deltaPKC-mediated myocardial damage. Cardiovasc Res 2006; 73:699-709. [PMID: 17234167 PMCID: PMC2180159 DOI: 10.1016/j.cardiores.2006.12.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 12/10/2006] [Accepted: 12/11/2006] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To improve myocardial flow during reperfusion after acute myocardial infarction and to elucidate the molecular and cellular basis that impedes it. According to the AHA/ACC recommendation, an ideal reperfusion treatment in patients with acute myocardial infarction (AMI) should not only focus on restoring flow in the occluded artery, but should aim to reduce microvascular damage to improve blood flow in the infarcted myocardium. METHODS Transgenic mouse hearts expressing the deltaPKC (protein kinase C) inhibitor, deltaV1-1, in their myocytes only were treated with or without the deltaPKC inhibitor after ischemia in an ex vivo AMI model. deltaV1-1 or vehicle was also delivered at reperfusion in an in vivo porcine model of AMI. Microvascular dysfunction was assessed by physiological and histological measurements. RESULTS deltaPKC inhibition in the endothelial cells improved myocardial perfusion in the transgenic mice. In the porcine in vivo AMI model, coronary flow reserve (CFR), which is impaired for 6 days following infarction, was improved immediately following a one-minute treatment at the end of the ischemic period with the deltaPKC-selective inhibitor, deltaV1-1 ( approximately 250 ng/kg), and was completely corrected by 24 h. Myocardial contrast echocardiography, electron microscopy studies, and TUNEL staining demonstrated deltaPKC-mediated microvascular damage. epsilonPKC-induced preconditioning, which also reduces infarct size by >60%, did not improve microvascular function. CONCLUSIONS These data suggest that deltaPKC activation in the microvasculature impairs blood flow in the infarcted tissue after restoring flow in the occluded artery and that AMI patients with no-reflow may therefore benefit from treatment with a deltaPKC inhibitor given in conjunction with removal of the coronary occlusion.
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Affiliation(s)
- Fumiaki Ikeno
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Koichi Inagaki
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305
| | - Mehrdad Rezaee
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305
| | - Daria Mochly-Rosen
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305
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Montisci R, Chen L, Ruscazio M, Colonna P, Cadeddu C, Caiati C, Montisci M, Meloni L, Iliceto S. Non-invasive coronary flow reserve is correlated with microvascular integrity and myocardial viability after primary angioplasty in acute myocardial infarction. Heart 2006; 92:1113-8. [PMID: 16449513 PMCID: PMC1861096 DOI: 10.1136/hrt.2005.078246] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To test whether preserved coronary flow reserve (CFR) two days after reperfused acute myocardial infarction (AMI) is associated with less microvascular dysfunction (" no-reflow" phenomenon) and is predictive of myocardial viability. DESIGN 24 patients with anterior AMI underwent CFR assessment in the left anterior descending coronary artery (LAD) with transthoracic echocardiography and myocardial contrast echocardiography (MCE) 48 h after primary angioplasty in the LAD (mean 4 (SD 2) and 3 (1) days, respectively). Low-dose dobutamine echocardiography was performed 6 (3) days after AMI and follow-up echocardiography at three months. RESULTS No-reflow extent was greater in patients with impaired CFR (< 2.5) than in those with preserved CFR (> 2.5) (55 (35)% v 11 (25)%, p < 0.001). MCE reflow was more common in patients with preserved CFR (8/12) than in those with reduced CFR (1/12, p < 0.05). Wall motion score index in the LAD territory (A-WMSI) was similar at the first echocardiography (2.14 (0.39) v 2.32 (0.47), NS), although it was better in patients with preserved CFR at dobutamine (1.38 (0.45) v 1.97 (0.67), p < 0.05) and follow-up echocardiography (1.36 (0.40) v 1.97 (0.64), p < 0.05). An inverse correlation was found between CFR and A-WMSI at dobutamine and follow-up echocardiography (r = -0.49, p = 0.016 and r = -0.55, p = 0.005) and between MCE and A-WMSI at dobutamine and follow-up echocardiography (r = -0.75, p < 0.001 and r = -0.75, p < 0.001). By multivariate analysis MCE reflow remained the only predictor of recovery at both dobutamine and follow-up echocardiography (odds ratio 1.06, 95% CI 1 to 1.1, p = 0.009). CONCLUSION CFR is inversely correlated with the extent of microvascular dysfunction at MCE two days after reperfused AMI. CFR and MCE reflow early after AMI are correlated with myocardial viability at follow up.
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Affiliation(s)
- R Montisci
- Department of Cardiovascular and Neurological Sciences, University of Cagliari, Ospedale S Giovanni di Dio, via Ospedale 46, 09124, Cagliari, Italy.
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Katsouras CS, Kotsla A, Michalis LK. Coronary pressure measurements in post-myocardial infarction patients. ACUTE CARDIAC CARE 2006; 8:7-12. [PMID: 16720421 DOI: 10.1080/14628840500456522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The development of pressure monitoring guide-wires has facilitated the measurements of coronary pressures distal to a stenosis. The ratio of the distal coronary and aortic pressures (P(d)/P(a)) measured during maximal hyperaemia is a useful index for diagnosis and monitoring the treatment of patients with coronary artery disease and for guiding percutaneous coronary intervention. However, the role of coronary pressure measurements in post- myocardial infarction (MI) patients is not well established. Coronary pressure measurements should be used with caution during the acute phase of MI due to serious micro-vascular impairment. The hyperaemic pressure P(d)/P(a) ratio can identify ischaemic myocardial territories in patients with recent MI. Theoretically, coronary pressure measurements may be of value in predicting myocardial recovery after revascularization in post-MI patients with a moderate stenosis of the infarct-related artery and without angiographically evident collaterals.
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Affiliation(s)
- Christos S Katsouras
- Department of Cardiology, School of Medicine, Greece and Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece
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30
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Sorajja P, Gersh BJ, Costantini C, McLaughlin MG, Zimetbaum P, Cox DA, Garcia E, Tcheng JE, Mehran R, Lansky AJ, Kandzari DE, Grines CL, Stone GW. Combined prognostic utility of ST-segment recovery and myocardial blush after primary percutaneous coronary intervention in acute myocardial infarction. Eur Heart J 2005; 26:667-74. [PMID: 15734768 DOI: 10.1093/eurheartj/ehi167] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS ST-segment recovery (SigmaSTR) and myocardial blush (MB) evaluate different elements of microcirculatory integrity after reperfusion therapy in acute myocardial infarction (AMI). We sought to determine whether the combination of SigmaSTR and MB after primary percutaneous coronary intervention (PCI) in AMI has greater prognostic utility than either measure alone. METHODS AND RESULTS The 30 days and 1 year clinical outcomes of 456 patients were assessed as a function of SigmaSTR and MB after primary PCI from the CADILLAC trial. SigmaSTR and MB were concordant (> or =70% SigmaSTR and MB grade 2/3 or <70% SigmaSTR and MB grade 0/1) in 60.1% of patients and discordant in 39.9% of patients. The greatest survival was observed among patients with complete SigmaSTR (> or =70%) and MB grade 2/3 in whom the cumulative rates of death at 30 days and 1 year were 0.6 and 1.2%, respectively. Poorest survival was observed among patients with incomplete SigmaSTR (<70%) and reduced MB (grade 0/1), in whom 30 days and 1 year rates of death were 8.3 and 10.1%, respectively. Intermediate outcomes were present in patients with discordant MB and SigmaSTR. By multivariable analysis, however, SigmaSTR was an independent correlate of survival at 30 days and 1 year (P=0.05 and 0.01, respectively), whereas MB was no longer predictive (P=0.38 and 0.72, respectively). CONCLUSION SigmaSTR and MB are not infrequently discordant after primary PCI. By univariate analysis, both measures of reperfusion success strongly correlate with survival and assessment of both yields incremental prognostic information beyond either measure alone. By multivariable analysis, however, SigmaSTR is the stronger prognostic variable.
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Affiliation(s)
- Paul Sorajja
- The Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Werner GS, Emig U, Bahrmann P, Ferrari M, Figulla HR. Recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion. Heart 2004; 90:1303-9. [PMID: 15486127 PMCID: PMC1768535 DOI: 10.1136/hrt.2003.024620] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the potential for recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion and the determinants of this recovery. PATIENTS AND DESIGN 120 patients underwent a successful recanalisation of a chronic total coronary occlusion (duration > 2 weeks) and a follow up angiography after a mean (SD) of 5.0 (1.2) months. The coronary flow velocity reserve (CFVR) and the fractional flow reserve were measured after recanalisation and at follow up. Global and regional left ventricular (LV) function were analysed by quantitative angiography. RESULTS Microvascular dysfunction, defined by a CFVR < 2.0 and a fractional flow reserve > or = 0.75, was observed in 55 (46%) patients after recanalisation. Microvascular function improved during follow up in 24 (20%). The CFVR increased during follow up from 2.01 (0.58) to 2.50 (0.79) (p < 0.001), due to a decrease in basal average peak velocity from 30.7 (14.9) cm/s to 25.5 (13.3) cm/s (p = 0.001). Improved microvascular function was associated with an improved regional LV function, shown by a correlation between increased wall motion severity index and increased CFVR (r = 0.38, p = 0.003). The major determinant of microvascular dysfunction at baseline was the presence of diabetes mellitus (odds ratio 4.3, 95% confidence interval 1.8 to 10.2), which remained so at follow up (odds ratio 4.1, 95% confidence interval 1.3 to 13.4). Improvement of LV function was not impaired by the presence of microvascular dysfunction after recanalisation. CONCLUSIONS The frequently observed microvascular dysfunction after recanalisation of a chronic total coronary occlusion is a transient phenomenon in most patients and is influenced by the presence of diabetes mellitus. It does not impede the recovery of LV function. Improved regional LV function is associated with improved microvascular function.
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Affiliation(s)
- G S Werner
- Clinic for Internal Medicine I, Friedrich Schiller University Jena, Jena, Germany.
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Takahashi T, Hiasa Y, Ohara Y, Yamaguchi K, Tomokane T, Ogura R, Ogata T, Yuba K, Suzuki N, Hosokawa S, Kishi K, Ohtani R. Usefulness of coronary flow reserve immediately after primary coronary stenting in predicting wall motion recovery in patients with anterior wall acute myocardial infarction. Am J Cardiol 2004; 94:1033-7. [PMID: 15476619 DOI: 10.1016/j.amjcard.2004.06.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2004] [Revised: 06/25/2004] [Accepted: 06/25/2004] [Indexed: 11/25/2022]
Abstract
This study examined whether coronary flow reserve (CFR) measured immediately after primary coronary stenting could predict wall motion recovery in patients who have acute myocardial infarction. CFR significantly correlated with the change of wall motion score (r = 0.68, p <0.0001), and the optimal cut-off value of CFR for predicting wall motion recovery was 1.4 (sensitivity 85%, specificity 94%).
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Affiliation(s)
- Takefumi Takahashi
- Department of Cardiology, Tokushima Red Cross Hospital, Komatsushima, Japan.
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Hoffmann R, Lepper W, Heussen N, Elkelini M, Sieswerda GT, Kamp O, de Cock CC, Voci P, Visser CA, Hanrath P. Impact of flow level on coronary flow velocity pattern. A doppler flow study in patients with first acute myocardial infarction. Int J Cardiovasc Imaging 2004; 20:27-35. [PMID: 15055818 DOI: 10.1023/b:caim.0000013157.14656.9e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Analysis of coronary flow velocity pattern has been used to assess microvascular function post acute myocardial infarction (AMI). This study sought to analyze whether the flow level has an impact on parameters of coronary flow velocity pattern. Parameters of coronary flow velocity pattern were determined at baseline and during increased flow due to maximal hyperemia induced by adenosine in 25 patients after PTCA for first AMI using Doppler flow wires. Patients were divided into those with depressed (global wall motion index (GWMI) > or = 1.5; n = 14) and those with preserved (GWMI < 1.5; n = 11) left ventricular (LV) function at 4 weeks. Coronary flow velocity pattern at rest was different between patients with depressed and patients with preserved LV function at follow-up. A difference in flow pattern between the groups remained at increased flow level. However, increase of flow altered parameters of flow pattern. Diastolic deceleration rate (DSR) increased for patients with preserved LV function (53.7+/-25.6 at baseline vs. 67.0+/-29.8 cm/s2 with adenosine) and depressed LV function (95.3+/-58.6 vs. 110.7+/-61.4 cm/s2, respectively, p = 0.0012). Induction of hyperemia resulted also in increased systolic and diastolic peak flow velocity and diastolic deceleration time (DDT). Higher flow had no impact on early systolic retrograde flow, systolic flow duration and diastolic-systolic velocity ratio (DSVR). The coronary flow velocity pattern allows prediction of LV function at 4 weeks after AMI. However, it should be considered that some parameters of the flow velocity pattern are affected by the coronary flow level.
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Bax M, de Winter RJ, Schotborgh CE, Koch KT, Meuwissen M, Voskuil M, Adams R, Mulder KJJ, Tijssen JGP, Piek JJ. Short- and Long-Term recovery of left ventricular function predicted at the time of primary percutaneous coronary intervention in anterior myocardial infarction. J Am Coll Cardiol 2004; 43:534-41. [PMID: 14975460 DOI: 10.1016/j.jacc.2003.08.055] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2003] [Revised: 07/23/2003] [Accepted: 08/05/2003] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to determine predictors of left ventricular (LV) function recovery at the time of primary percutaneous coronary intervention (PCI). BACKGROUND Angiographic, intracoronary Doppler flow, and electrocardiographic variables have been reported to be predictors of recovery of LV function after acute myocardial infarction (MI). We directly compared the predictive value of Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTfc), myocardial blush grade, coronary Doppler flow velocity analysis, and resolution of ST-segment elevation for recovery of LV function in patients undergoing primary PCI for acute MI. METHODS We prospectively studied 73 patients who underwent PCI for an acute anterior MI. Recovery of global and regional LV function was measured using an echocardiographic 16-segment wall motion index (WMI) before PCI, at 24 h, at one week, and at six months. Directly after successful PCI, coronary flow velocity reserve (CFR), cTfc, TIMI flow grade, and myocardial blush grade were assessed. RESULTS Mean global and regional WMI improved gradually over time from 1.86 +/- 0.23 before PCI to 1.54 +/- 0.34 at six-month follow-up (p < 0.0001) and from 2.39 +/- 0.30 before PCI to 1.87 +/- 0.48 at six-month follow-up (p < 0.0001), respectively. Multivariate analysis revealed CFR as the only independent predictor for global and regional recovery of LV function at six months. CONCLUSIONS Doppler-derived CFR is a better prognostic marker for LV function recovery after anterior MI than other currently used parameters of myocardial reperfusion.
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Affiliation(s)
- Matthijs Bax
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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35
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Haager PK, Christott P, Heussen N, Lepper W, Hanrath P, Hoffmann R. Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion. J Am Coll Cardiol 2003; 41:532-8. [PMID: 12598061 DOI: 10.1016/s0735-1097(02)02870-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES We sought to evaluate and compare recently suggested parameters of reperfusion after angioplasty in acute myocardial infarction (AMI) for risk stratification during long-term follow-up. BACKGROUND Abnormal myocardial perfusion has a detrimental impact on survival. Several parameters of reperfusion have been evaluated in controlled study populations for risk stratification. METHODS In 253 consecutive patients undergoing intervention in AMI on a native coronary vessel, angiographic myocardial blush grade (MBG), corrected TIMI (thrombolysis in myocardial infarction) frame count (CTFC) and persistent ST-segment elevation (STE) were determined to evaluate reperfusion. This was a high-risk population, including referral for treatment failure at a primary center in 29.2%, failed thrombolysis in 22.1% and cardiogenic shock in 13.4% of cases. RESULTS In addition to age, patient referral, LBBB and heart rate on admission, MBG 0 to 1 (odds ratio [OR] = 3.23, p < 0.001), CTFC (OR = 1.01, p = 0.015) and persistent STE >2 leads (OR = 3.46, p = 0.010) were univariate predictors of mortality during a 22.1 +/- 15.6 months follow-up. Myocardial blush grade 0 to 1 (OR = 2.17, p = 0.033) and persistent STE (OR = 3.61, p = 0.017) persisted as independent predictors of mortality, whereas CTFC failed. Differences in mortality between reperfusion groups at 30 days remained throughout the complete follow-up. In sequential Cox models, the predictive power of clinical data alone for mortality (model chi-squared 55.8) was strengthened by adding MBG (model chi-squared 64.2) and ECG postintervention (model chi-squared 69.2). CONCLUSIONS Myocardial blush grade 0 to 1 and persistent STE are independent predictors for long-term mortality after angioplasty in AMI. Corrected TIMI frame count is a less powerful predictor. Combining both parameters to consider quality of reperfusion in the myocardium at risk and extent of the infarct zone increases the predictive power.
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Affiliation(s)
- Philipp K Haager
- Medical Clinic I, University Hospital RWTH, Pauwelsstrasse 30, 52057 Aachen, Germany
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Beygui F, Le Feuvre C, Helft G, Maunoury C, Metzger JP. Myocardial viability, coronary flow reserve, and in-hospital predictors of late recovery of contractility following successful primary stenting for acute myocardial infarction. Heart 2003; 89:179-83. [PMID: 12527673 PMCID: PMC1767565 DOI: 10.1136/heart.89.2.179] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the relation between myocardial viability, coronary flow reserve, and recovery of myocardial contractility after stenting for acute myocardial infarction. DESIGN Consecutive sample prospective study. SETTING University hospital. PATIENTS 41 patients with single vessel disease and successful primary stenting for a first acute myocardial infarction. INTERVENTIONS (201)Tl single photon emission computed tomography, contrast ventriculography, and intracoronary Doppler performed 7 (1) days after primary stenting. MAIN OUTCOME MEASURES Regional contractility recovery assessed by contrast ventriculography at 6 (1) months' follow up. RESULTS On univariate analysis, contractility recovery was correlated to prereperfusion anterograde and collateral flow grades (r = 0.41, p = 0.03 and r = 0.55, p = 0.0004), viability index (r = 0.55, p = 0.04), peak creatine kinase concentrations (r = -0.55, p = 0.0005), left ventricular ejection fraction (r = 0.45, p = 0.005), end diastolic pressure (r = -0.62, p < 0.0001), end systolic volume index (r = -0.47, p = 0.01), and the extent of hypokinetic area (r = -0.48, p = 0.003), but not the coronary flow reserve. On multivariate analysis, independent predictors of late contractility recovery were prereperfusion anterograde and collateral flow grades and viability index. Relative coronary flow reserve, reflecting the culprit vessel's microvascular function, was correlated only to the extent of the infarct risk area (r = -0.45, p = 0.003). CONCLUSIONS Independent predictors of contractility recovery between the seventh day and the sixth month after successful stenting for acute myocardial infarction are prereperfusion anterograde and collateral flows and myocardial viability. The culprit vessel's microvascular dysfunction is independent of myocardial viability and contractility and correlated to the extent of "jeopardised microvasculature".
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Affiliation(s)
- F Beygui
- Adult Cardiology Department, Necker University Hospital, 149, Rue de Sévres, 75015, Paris, France.
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Shimada K, Sakanoue Y, Kobayashi Y, Ehara S, Hirose M, Nakamura Y, Fukuda D, Yamagishi H, Yoshiyama M, Takeuchi K, Yoshikawa J. Assessment of myocardial viability using coronary zero flow pressure after successful angioplasty in patients with acute anterior myocardial infarction. Heart 2003; 89:71-6. [PMID: 12482796 PMCID: PMC1767508 DOI: 10.1136/heart.89.1.71] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the relation between coronary flow reserve (CFR), coronary zero flow pressure (Pzf), and residual myocardial viability in patients with acute myocardial infarction. DESIGNS Prospective study. SETTING Primary care hospital. PATIENTS 27 consecutive patients with acute anterior myocardial infarction. MAIN OUTCOME MEASURES F-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 27 patients who underwent successful intervention within 12 hours of onset of a first acute anterior myocardial infarction. Within three days before discharge they had < 25% stenosis in the culprit lesion as determined by angiography 24 (3) days after acute myocardial infarction. Pzf and the slope index of the flow-pressure relation (SIFP) were calculated from the simultaneously recorded aortic pressure and coronary flow velocity signals at peak hyperaemia.%FDG was quantified by comparing FDG uptake in the infarct myocardium with FDG uptake in the normal myocardium. RESULTS There was a correlation between %FDG and CFR, where y = -1.477x + 62.517, r = -0.072 (NS). There was also a correlation between %FDG and SIFP, where y = -0.975x + 60.542, r = -0.045 (NS), and a significant correlation between %FDG and Pzf, where y = -0.98x + 85.108, r = -0.696 (p < 0.001). CONCLUSIONS CFR does not correlate with FDG-PET at the time of postreperfusion evaluation of residual myocardial viability. The parameter that correlates best with residual myocardial viability is Pzf and this may be a useful index for predicting patient prognosis.
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Affiliation(s)
- K Shimada
- Department of Internal Medicine and Cardiology Graduate School of Medicine, Osaka City University Medical School, Osaka, Japan.
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Beygui F, Le Feuvre C, Maunoury C, Helft G, Metzger J. Coronary vasodilator reserve: a clue to the explanation of (201)Tl redistribution patterns early after successful primary stenting for acute myocardial infarction. J Am Coll Cardiol 2002; 40:877-81. [PMID: 12225710 DOI: 10.1016/s0735-1097(02)02041-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We sought to assess the mechanism and significance of different (201)Tl redistribution patterns after successful primary stenting following acute myocardial infarction (AMI). BACKGROUND The mechanism of (201)Tl reverse redistribution and the impact of different redistribution patterns on the recovery of contractility after successful reperfusion therapy for AMI remain unclear. METHODS We studied 41 consecutive patients with successful primary stenting for a first AMI. Patients underwent predischarge and six-month follow-up dipyridamole stress-reinjection single photon emission tomography (SPECT), coronary and left ventricular angiography. Intracoronary Doppler assessment of coronary flow reserve (CFR) was performed before discharge. RESULTS Four patient groups were identified according to predischarge SPECT: patients with I: nonreversible defects (n = 8), II: redistribution (n = 7), III: reverse redistribution (n = 21), IV: no defect (n = 5). At follow-up contractility recovery increased in a stepwise fashion from groups I to IV (19 +/- 41%, 40 +/- 53%, 70 +/- 28%, 78 +/- 33%, p = 0.01). Compared with patients with redistribution, those with reverse redistribution had lower infarct-related artery (IRA) CFR (2.2 +/- 0.5 vs. 2.8 +/- 0.9, p = 0.03) but higher contractility recovery. CONCLUSIONS Variable (201)Tl redistribution patterns, early after successful stenting for AMI, may predict different degrees of late contractility recovery. The lower IRA CFR and the higher contractility recovery in areas with reverse redistribution suggest more severe microvascular dysfunction and less severe myocardial injury in such areas compared with those with redistribution.
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Affiliation(s)
- Farzin Beygui
- Adult Cardiology Department, Necker University Hospital, Paris, France.
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Ueno Y, Nakamura Y, Kinoshita M, Fujita T, Sakamoto T, Okamura H. Can coronary flow velocity reserve determined by transthoracic Doppler echocardiography predict the recovery of regional left ventricular function in patients with acute myocardial infarction? Heart 2002; 88:137-41. [PMID: 12117834 PMCID: PMC1767231 DOI: 10.1136/heart.88.2.137] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine whether the early assessment of coronary flow velocity reserve (CFVR) by transthoracic Doppler echocardiography (TTDE) can predict myocardial viability after revascularisation in patients with acute myocardial infarction. METHODS 29 patients with anterior acute myocardial infarction who were successfully treated by coronary angioplasty were studied. TTDE was used to record coronary flow velocities in the distal left anterior descending artery at rest and during hyperaemia induced by intravenous infusion of adenosine triphosphate. CFVR was calculated immediately and 24 hours after revascularisation and at discharge. Regional wall motion was analysed to calculate the anterior wall motion score index (A-WMSI) by two dimensional echocardiography before revascularisation and at discharge. RESULTS CFVR immediately and 24 hours after revascularisation correlated significantly with A-WMSI at discharge (r = -0.58, p < 0.001 and r = -0.80, p < 0.0001, respectively). CFVR 24 hours after revascularisation was a better predictor of recovery of regional left ventricular function than CFVR immediately after revascularisation. The optimal cut off ratio for predicting viable myocardium was 1.5 for CFVR 24 hours after revascularisation (sensitivity = 94%, specificity = 91%). CONCLUSIONS CFVR by TTDE was useful for predicting the recovery of left ventricular function after revascularisation in patients with acute myocardial infarction
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Affiliation(s)
- Y Ueno
- The First Department of Internal Medicine, Shiga University of Medical Science, Otsu, Japan.
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40
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Affiliation(s)
- S R Dixon
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, USA
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41
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Steg PG, Grollier G, Gallay P, Morice M, Karrillon GJ, Benamer H, Kempf C, Laperche T, Arnaud P, Sellier P, Bourguignon C, Harpey C. A randomized double-blind trial of intravenous trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction. Int J Cardiol 2001; 77:263-73. [PMID: 11182191 DOI: 10.1016/s0167-5273(00)00443-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite high patency rates, primary angioplasty for myocardial infarction does not necessarily result in optimal myocardial reperfusion and limitation of infarct size. Experimentally, trimetazidine limits infarct size, decreases platelet aggregation, and reduces leukocyte influx into the infarct zone. To assess trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction a prospective, double-blind, placebo-controlled pilot trial was performed. METHODS 94 patients with acute myocardial infarction were randomized to receive trimetazidine (40 mg bolus followed by 60 mg/day intravenously for 48 h) (n=44) or placebo (n=50), starting before recanalization of the infarct vessel by primary angioplasty. Patients underwent continuous ST-segment monitoring to assess return of ST-segment deviation to baseline and presence of ST-segment exacerbation at the time of vessel recanalization. Infarct size was measured enzymatically from serial myoglobin measurements. Left ventricular angiography was performed before treatment and repeated at day 14. RESULTS Blinded ST segment analysis showed that despite higher initial ST deviation from baseline in the trimetazidine group (355 (32) vs. 278 (29) microV, P=0.07), there was an earlier and more marked return towards baseline within the first 6 h than in the placebo group (P=0.014) (change: 245 (30) vs. 156 (31) microV respectively, P=0.044). There was a trend towards less frequent exacerbation of ST deviation at the time of recanalization in the trimetazidine group (23.3 vs. 42.2%, P=0.11). There was no difference in left ventricular wall motion at day 14, or in enzymatic infarct size. There was no side effect from treatment. Clinical outcomes were similar between groups. CONCLUSION Trimetazidine was safe and led to earlier resolution of ST-segment elevation in patients treated by primary angioplasty for acute myocardial infarction.
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Affiliation(s)
- P G Steg
- Cardiologie, Hôpital Bichat, 46 rue Henri Huchard, 75877 Cedex 18, Paris, France.
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Roe MT, Ohman EM, Maas AC, Christenson RH, Mahaffey KW, Granger CB, Harrington RA, Califf RM, Krucoff MW. Shifting the open-artery hypothesis downstream: the quest for optimal reperfusion. J Am Coll Cardiol 2001; 37:9-18. [PMID: 11153779 DOI: 10.1016/s0735-1097(00)01101-3] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Successful reperfusion after acute myocardial infarction (MI) has traditionally been considered to be restoration of epicardial patency, but increasing evidence suggests that disordered microvascular function and inadequate myocardial tissue perfusion are often present despite infarct vessel patency. Thus, optimal reperfusion is being redefined to include intact microvascular flow and restored myocardial perfusion, as well as sustained epicardial patency. Coronary angiography has been used as the gold standard to define failed reperfusion, according to the Thrombolysis In Myocardial Infarction (TIMI) flow grades. However, new angiographic techniques, including the corrected TIMI frame count and myocardial blush grade, have been used to show that epicardial TIMI flow grade 3 may be an incomplete measure of reperfusion success. Furthermore, evolving noninvasive diagnostic techniques, including measurement of infarct size with cardiac marker release patterns or technetium-99m-sestamibi single-photon emission computed tomographic imaging and analysis of ST segment resolution appear to be useful complements to angiography for the assessment of myocardial tissue reperfusion. Promising adjunctive therapies that target microvascular dysfunction, including platelet glycoprotein IIb/IIIa inhibitors, and agents designed to improve tissue perfusion and attenuate reperfusion injury are being evaluated to further improve clinical outcomes after acute MI. To accelerate development of these new reperfusion regimens, an integrated approach to phase II clinical trials that incorporates multiple efficacy variables, including angiography and noninvasive biomarkers of microvascular dysfunction, should be considered. Thus, as the reperfusion era moves into the next millennium, the open-artery hypothesis is expected to shift downstream and guide efforts to further improve myocardial salvage and clinical outcomes after acute MI.
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Affiliation(s)
- M T Roe
- Duke Clinical Research Institute, Durham, North Carolina 27715, USA.
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Lim DS, Kim YH, Lee HS, Park CG, Seo HS, Shim WJ, Oh DJ, Ro YM. Coronary flow reserve is reflective of myocardial perfusion status in acute anterior myocardial infarction. Catheter Cardiovasc Interv 2000; 51:281-6. [PMID: 11066106 DOI: 10.1002/1522-726x(200011)51:3<281::aid-ccd7>3.0.co;2-o] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our objective was to determine whether coronary vasodilatory reserve (CVR) correlates with the perfusion state of infarct zone in early recovery phase of acute anterior myocardial infarction (AMI). We studied 14 patients (11 males; mean age, 46 years) who had AMI and 6 control subjects who had chest pain but normal coronary angiograms. All patients underwent successful percutaneous revascularization of left anterior descending (LAD) coronary artery. Coronary flow velocity was measured using intracoronary (IC) Doppler at baseline and following IC injection of 18 microg of adenosine. Myocardial perfusion was evaluated by myocardial contrast echocardiography (MCE). CVR was higher in patients without a perfusion defect on MCE than in those with (2.48 +/- 0.21 vs. 1.66 +/- 0.13, P = 0.001). Subjects with a perfusion defect had a lower CVR than controls (1.66 +/- 0.13 vs.2.40 +/- 0.18, P < 0.05). CVR was > 2.0 in all subjects without a perfusion defect. There was a strong correlation between the magnitude of myocardial opacification in the LAD territory and CVR (r = 0.80, P < 0.01). Increase in peak diastolic flow velocity after adenosine infusion, but not systolic flow velocity, correlated with myocardial opacification index (r = 0.63, P = 0.016). CVR of infarct-related artery correlated closely with the perfusion status of the myocardium in infarct zone and those with a CVR > 2.0 had normal myocardial perfusion. These data suggest that CVR may be used to determine the perfusion state of the myocardium in the infarct zone, which is a known predictor of myocardial viability. Cathet. Cardiovasc. Intervent. 51:281-286, 2000.
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Affiliation(s)
- D S Lim
- Department of Cardiology, Korea University Hospital, Seoul, Korea
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Abstract
Successful reperfusion following acute myocardial infarction is considered to be restoration of epicardial infarct vessel patency, but recent studies suggest that disrupted microvascular function and inadequate myocardial tissue perfusion are often present despite epicardial patency. New angiographic techniques, including the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count and myocardial blush grade, have been used to demonstrate that restoration of downstream coronary flow and tissue perfusion may be the key links to improved clinical outcomes. Additionally, other diagnostic techniques, including infarct size measurement with cardiac marker release patterns, or (99m) Tc-sestamibi single photon emission computed tomography imaging, and analysis of ST-segment resolution have also been used to assess microvascular function and tissue perfusion. Promising adjunctive therapies that target microvascular dysfunction, including platelet glycoprotein IIb/IIIa inhibitors, anti-inflammatory agents, vasodilators, glucose-insulin-potassium, and embolization protection devices, may ameliorate microvascular dysfunction following epicardial reperfusion. However, these therapies have not yet been shown to improve clinical outcomes and are thus currently being studied together with fibrinolytics and primary angioplasty in clinical trials. Therefore, shifting the focus of reperfusion therapy to the microcirculation offers the potential to further improve myocardial salvage and clinical outcomes following acute myocardial infarction.
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Affiliation(s)
- M T Roe
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA.
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Feldman LJ, Himbert D, Juliard JM, Karrillon GJ, Benamer H, Aubry P, Boudvillain O, Seknadji P, Faraggi M, Steg G. Reperfusion syndrome: relationship of coronary blood flow reserve to left ventricular function and infarct size. J Am Coll Cardiol 2000; 35:1162-9. [PMID: 10758956 DOI: 10.1016/s0735-1097(00)00523-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We tested the hypothesis that the reperfusion syndrome (RS), defined as an additional elevation of the ST segment upon reperfusion, may be a marker of microcirculatory reperfusion injury during acute myocardial infarction (AMI). BACKGROUND The pathophysiology of the RS is unknown, and its prognostic implications are controversial. METHODS Twenty-one patients with an anterior AMI treated < or =12 h after onset by primary coronary angioplasty (PTCA) were studied. Coronary velocity reserve (CVR), an index of microcirculatory function, was measured using a Doppler guidewire. Left ventricular (LV) ejection fraction, infarct size (percent defect) and LV end-systolic volume index (LVESVi) were evaluated by radionuclide ventriculography, 201T1 single-photon emission computed tomography and contrast ventriculography, respectively. RESULTS Baseline ST elevation and pain-to-TIMI 3 time were similar in patients with and without RS. Patients with RS (10/21) had a lower post-PTCA CVR than patients without RS (median [95% confidence interval]: 1.2 [1-1.3] vs. 1.6 [1.5-1.7], p < 0.005). Even though predischarge CVR was similar in the two groups, infarct size at six weeks (26 [21 to 37] vs. 14 [10-17]% 201T1 defect, p = 0.001) and predischarge LVESVi (45% [40 to 52] vs. 30% [29 to 38] mL/m2, p = 0.001) were larger, and LV ejection fraction at six weeks (40% [37 to 46] vs. 55% [50 to 60], p = 0.004) was lower in patients with RS than in patients without RS. CONCLUSIONS Patients with RS during primary PTCA for an anterior AMI have a transiently lower CVR than patients without RS, but sustained LV dysfunction and larger infarct size, suggesting that RS is a marker of microcirculatory reperfusion injury.
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Affiliation(s)
- L J Feldman
- Department of Cardiology, Bichat Hospital, Paris, France.
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Williams MJ, McCormick MP, Kay IP, Restieaux NJ. Improved coronary artery flow after coronary angioplasty in patients with unstable angina. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 2000; 30:226-30. [PMID: 10833115 DOI: 10.1111/j.1445-5994.2000.tb00812.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coronary artery flow is impaired after myocardial infarction but there is limited information regarding coronary flow in unstable angina. AIM To assess baseline coronary artery flow and the effects of coronary angioplasty on coronary flow in patients with unstable angina. METHODS Twenty-one patients with unstable angina with a culprit lesion suitable for coronary angioplasty were enrolled in the study. Coronary flow was assessed with the Thrombolysis In Myocardial Infarction (TIMI) grade and the Corrected TIMI Frame Count (CTFC) pre and post angioplasty. RESULTS Baseline flow was impaired in the culprit artery compared to the non culprit artery (42.0+/-28.1 vs 25.3+/-7.0 frames, p<0.02). Pre angioplasty coronary flow was TIMI grade 2 in 52% and TIMI grade 3 in 48% of patients. Post angioplasty flow improved with TIMI grade 2 flow in 5% and TIMI grade 3 in 95%. After angioplasty coronary flow improved from 42.0+/-28.1 frames to 21.6+/-16.3 (p=0.0001). The culprit coronary stenosis decreased from 74+/-9% pre angioplasty to 28+/-12% after intervention (p=0.0001). CONCLUSIONS Angioplasty and stenting of the culprit vessel restores normal coronary flow in most patients with unstable angina. This suggests that impaired flow in unstable angina is predominantly related to the culprit lesion residual stenosis.
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Affiliation(s)
- M J Williams
- Department of Medicine, University of Otago, Dunedin, New Zealand.
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Furber AP, Lethimonnier F, Le Jeune JJ, Balzer P, Jallet P, Tadéi A, Geslin P. Noninvasive assessment of the infarct-related coronary artery blood flow velocity using phase-contrast magnetic resonance imaging after coronary angioplasty. Am J Cardiol 1999; 84:24-30. [PMID: 10404846 DOI: 10.1016/s0002-9149(99)00186-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This study assesses infarct-related coronary artery blood flow velocity using phase-contrast magnetic resonance imaging (MRI) in patients with reperfused acute myocardial infarction (AMI) and compares these results with flow measurements obtained nonsimultaneously by intracoronary Doppler ultrasound. MRI examination was performed in 17 patients with AMI within 1 to 4 days (mean 2.5 days) after direct or rescue coronary angioplasty using a 0.014-in Doppler guidewire. MRI was performed on a 1.5-T clinical imager. The fast gradient echo segmented k-space phase-contrast pulse sequence was employed during breath-hold. The MRI and Doppler parameters of average peak velocity and maximum peak velocity were measured. Mean phase contrast MRI average peak velocity was 13.3+/-10.7 cm/s, and mean phase-contrast MRI maximum peak velocity was 27+/-16.6 cm/s. Mean Doppler average peak velocity was 17.1+/-5.1 cm/s, and mean Doppler maximum peak velocity was 35.5+/-10.1 cm/s. At the same anatomic levels, phase-contrast MRI average peak velocity correlated significantly to Doppler average peak velocity (r = 0.52; p<0.006) and Doppler maximum peak velocity (r = 0.42; p<0.03). Phase-contrast MRI velocity measurements were correlated with the same heterogeneity of Thrombolysis In Myocardial Infarction 3 flow velocity observed during Doppler examination. Thus, by comparing phase-contrast MRI with invasive intracoronary Doppler flow measurements, the measured MRI values showed significant correlation with Doppler data. Phase-contrast MRI has the potential to noninvasively quantify coronary flow velocity and to evaluate quality of reperfusion in patients with AMI after reperfused therapy.
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Affiliation(s)
- A P Furber
- Department of Cardiology, The University Hospital of Angers, France
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48
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Williams MJ, Stewart RA. Coronary artery flow ten weeks after myocardial infarction or unstable angina: effects of combined warfarin and aspirin therapy. Int J Cardiol 1999; 69:19-25. [PMID: 10362368 DOI: 10.1016/s0167-5273(98)00378-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Forty-three patients presenting with unstable angina or myocardial infarction were randomised double blind to warfarin [target international normalised ratio (INR), 2.0 to 2.5] and aspirin (150 mg) daily or placebo plus aspirin (150 mg) daily. Coronary flow was assessed with the thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count (CTFC). Coronary artery flow was reduced (higher CTFC) at baseline in culprit arteries (mean +/-SD, 37.1+/-15.4 frames) compared to nonculprit arteries (22.5+/-6.7 frames, P<0.0001). In patients with a patent artery at follow-up, coronary flow was unchanged after ten weeks of warfarin and aspirin (-2.0+/-19.9 frames) or aspirin alone (3.8+/-10.4 frames, P = 0.20). Patients randomised to aspirin alone were more likely to progress to total occlusion [aspirin, 7 of 19 (37%) vs. warfarin and aspirin, 1 of 24 (4%); P = 0.01). Higher baseline culprit artery CTFC was also associated with an increased risk of late occlusion [+10 frames; odds ratio (OR), 1.65; 95% CI, 1.01 to 2.33]. Coronary flow remained impaired ten weeks after presentation with myocardial infarction or unstable angina. Combination warfarin and aspirin therapy did not improve flow in vessels that remained patent but did reduce the risk of progression to occlusion.
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Affiliation(s)
- M J Williams
- Department of Medicine, University of Otago, Dunedin, New Zealand.
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Hattori R, Matsui H, Kitano M, Ichihara Y, Ogawa S, Hirai M, Hayashi H, Saito H. Staged reperfusion preserves the coronary flow reserve, especially in the regions not severely damaged by ischemic injury in the canine heart. Angiology 1998; 49:991-1004. [PMID: 9855374 DOI: 10.1177/000331979804901205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to determine the effects of staged reperfusion on the progressive reduction in coronary blood flow (CBF) and coronary flow reserve during reperfusion and on the infarct size in the canine heart. Fifteen dogs underwent 90 min of left circumflex coronary artery occlusion and 3 hr of reperfusion. In the abrupt reperfusion group, the occluder was released completely at the initiation of reperfusion. In the staged reperfusion group, CBF was maintained at 20% of preocclusion values for 10 min after initiation of reperfusion, then gradually released, and completely released 20 min after initiation of reperfusion. There was no significant difference in CBF between the staged (n = seven) and abrupt (n = eight) groups after 3 hr of reperfusion. The repayment of flow debt in the staged reperfusion group was significantly greater than in the abrupt reperfusion group after 3 hr of reperfusion (260+/-120% vs 100+/-60%, staged vs abrupt at 3 hr, p < 0.03). The ratio of peak reactive hyperemic flow to resting flow in the staged reperfusion group was significantly greater than in the abrupt reperfusion group throughout the reperfusion phase (4.4+/-1.0 vs 2.6+/-0.6 at 3 hr, p < 0.001), and had returned to the preocclusion values after 3 hr of reperfusion. This preservation of the coronary flow reserve in the staged reperfusion group was observed in the epicardium (4.1+/-0.6 vs 2.8+/-0.7, staged vs abrupt at 3 hr, p < 0.01), but not in the endocardium or midmyocardium. Infarct size did not differ significantly between the two groups. Staged reperfusion in this study did not appear to attenuate the reduction of CBF, or to reduce infarct size, however preserved the coronary flow reserve, especially in the regions not severely damaged by ischemic injury.
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Affiliation(s)
- R Hattori
- First Department of Internal Medicine, Nagoya University School of Medicine, Japan
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Tsunoda T, Nakamura M, Wakatsuki T, Nishida T, Asahara T, Anzai H, Touma H, Mitsuo K, Soumitsu Y, Sakatani H, Nakamura S, Degawa T, Yamaguchi T. The pattern of alteration in flow velocity in the recanalized artery is related to left ventricular recovery in patients with acute infarction and successful direct balloon angioplasty. J Am Coll Cardiol 1998; 32:338-44. [PMID: 9708458 DOI: 10.1016/s0735-1097(98)00228-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES We evaluated the relationship between alterations in coronary flow velocity during the acute phase of acute myocardial infarction (AMI) and the recovery of left ventricular wall motion in patients who underwent successful primary angioplasty. BACKGROUND The status of the coronary microcirculation is the major determinant of the prognosis of patients who have had successful reperfusion after AMI. Animal studies have shown that dynamic changes in regional flow are associated with the extent of infarction. Evaluation of alterations in coronary flow velocity in infarcted arteries may provide information about microcirculatory damage. METHODS Flow velocity of the distal anterior descending artery was continuously monitored with the use of a Doppler guide wire immediately after recanalization for 18 +/- 4 h in 19 patients who underwent successful primary angioplasty after anterior AMI. Subjects were divided into two groups on the basis of the time course of alterations in average peak velocity (APV). Group D consisted of patients who had progressive decreases in APV through the next day (n = 9), and Group I comprised patients with an increase in APV after a transient decline (n = 10). Ejection fraction (EF) and regional wall motion (RWM) were assessed by left ventriculography performed on admission and at discharge. RESULTS The APV at the end of monitoring was greater in group I than in group D. In group I, EF and RWM were significantly improved at discharge. The change in EF was greater in group I than in group D (17 +/- 9% vs. 4 +/- 9%, p = 0.007), as was the change in RWM (0.96 +/- 0.23 vs. 0.13 +/- 0.36 SD/chord, p < 0.0001). CONCLUSIONS The alteration in flow velocity in recanalized infarcted arteries is related to left ventricular recovery. A progressive decrease in velocity after angioplasty implies no reflow, which is associated with a poor recovery of left ventricular function. Reperfusion injury may account in part for this phenomenon.
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Affiliation(s)
- T Tsunoda
- Third Department of Internal Medicine, Ohashi Hospital, Toho University Faculty of Medicine, Tokyo, Japan.
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