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AlShaikh S, Rohm CL, Sutton NR, Burgess SN, Alasnag M. INOCA: Ischemia in non-obstructive coronary arteries. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100391. [PMID: 38680648 PMCID: PMC11043816 DOI: 10.1016/j.ahjo.2024.100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
This article provides a summary of the clinical spectrum of no obstructive coronary arteries. We describe the pathologies, invasive and noninvasive assessment, and management strategies.
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Affiliation(s)
- Shereen AlShaikh
- Adult Cardiology Department, Mohammed bin Khalifa Cardiac Centre, Riffa, Bahrain
| | - Charlene L. Rohm
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nadia R. Sutton
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
| | - Sonya N. Burgess
- Cardiology Department, University of Sydney and Nepean Hospital, Sydney, Australia
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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2
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Lopez-Candales A, Sawalha K, Asif T. Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance. Postgrad Med 2024:1-11. [PMID: 38818874 DOI: 10.1080/00325481.2024.2360888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/23/2024] [Indexed: 06/01/2024]
Abstract
For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.
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Affiliation(s)
- Angel Lopez-Candales
- Cardiovascular Medicine Division University Health Truman Medical Center, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Khalid Sawalha
- Cardiometabolic Fellowship, University Health Truman Medical Center and the University of Missouri-Kansas City, Kansas City, USA
| | - Talal Asif
- Division of Cardiovascular Diseases, University Health Truman Medical Center and the University of Missouri-Kansas City Kansas City, Kansas City, MO, USA
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3
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Woudstra J, Feenstra RGT, Vink CEM, Marques KMJ, Boerhout CKM, de Jong EAM, de Waard GA, van de Hoef TP, Chamuleau SAJ, Eringa EC, Piek JJ, Appelman Y, Beijk MAM. Comparison of the Diagnostic Yield of Intracoronary Acetylcholine Infusion and Acetylcholine Bolus Injection Protocols During Invasive Coronary Function Testing. Am J Cardiol 2024; 217:49-58. [PMID: 38417650 DOI: 10.1016/j.amjcard.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
Coronary endothelial dysfunction (CED) and coronary artery spasm (CAS) are causes of angina with no obstructive coronary arteries in patients. Both can be diagnosed by invasive coronary function testing (ICFT) using acetylcholine (ACh). This study aimed to evaluate the diagnostic yield of a 3-minute ACh infusion as compared with a 1-minute ACh bolus injection protocol in testing CED and CAS. We evaluated 220 consecutive patients with angina and no obstructive coronary arteries who underwent ICFT using continuous Doppler flow measurements. Per protocol, 110 patients were tested using 3-minute infusion, and thereafter 110 patients using 1-minute bolus injections, because of a protocol change. CED was defined as a <50% increase in coronary blood flow or any epicardial vasoconstriction in reaction to low-dose ACh and CAS according to the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria, both with and without T-wave abnormalities, in reaction to high dose ACh. The prevalence of CED was equal in both protocols (78% vs 79%, p = 0.869). Regarding the endotypes of CAS according to COVADIS, the equivocal endotype was diagnosed less often in the 3 vs 1-minute protocol (24% vs 44%, p = 0.004). Including T-wave abnormalities in the COVADIS criteria resulted in a similar diagnostic yield of both protocols. Hemodynamic changes from baseline to the low or high ACh doses were comparable between the protocols for each endotype. In conclusion, ICFT using 3-minute infusion or 1-minute bolus injections of ACh showed a similar diagnostic yield of CED. When using the COVADIS criteria, a difference in the equivocal diagnosis was observed. Including T-wave abnormalities as a diagnostic criterion reclassified equivocal test results into CAS and decreased this difference. For clinical practice, we recommend the inclusion of T-wave abnormalities as a diagnostic criterion for CAS and the 1-minute bolus protocol for practicality.
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Affiliation(s)
- Janneke Woudstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands.
| | - Rutger G T Feenstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Koen M J Marques
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Elize A M de Jong
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands; Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
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Karakayali M, Altunova M, Yakisan T, Aslan S, Omar T, Artac I, Ilis D, Arslan A, Cagin Z, Karabag Y, Rencuzogullari I. The Relationship between the Systemic Immune-Inflammation Index and Ischemia with Non-Obstructive Coronary Arteries in Patients Undergoing Coronary Angiography. Arq Bras Cardiol 2024; 121:e20230540. [PMID: 38597536 DOI: 10.36660/abc.20230540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/13/2023] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Ischemia with the non-obstructive coronary artery (INOCA) is an ischemic heart disease that mostly includes coronary microvascular dysfunction and/or epicardial coronary vasospasm due to underlying coronary vascular dysfunction and can be seen more commonly in female patients. The systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery disease (CAD). OBJECTIVE This study aims to investigate the relationship between INOCA and SII, a new marker associated with inflammation. METHODS A total of 424 patients (212 patients with INOCA and 212 normal controls) were included in the study. Peripheral venous blood samples were received from the entire study population prior to coronary angiography to measure SII and other hematological parameters. In our study, the value of p<0.05' was considered statistically significant. RESULTS The optimal cut-off value of SII for predicting INOCA was 153.8 with a sensitivity of 44.8% and a specificity of 78.77% (Area under the curve [AUC]: 0.651 [95% CI: 0.603-0.696, p=0.0265]). Their ROC curves were compared to assess whether SII had an additional predictive value over components. The AUC value of SII was found to be significantly higher than that of lymphocyte (AUC: 0.607 [95% CI: 0.559-0.654, p = 0.0273]), neutrophil (AUC: 0.559 [95%CI: 0.511-0.607, p=0.028]) and platelet (AUC: 0.590 [95% CI: 0.541-0.637, p = 0.0276]) in INOCA patients. CONCLUSIONS A high SII level was found to be independently associated with the existence of INOCA. The SII value can be used as an indicator to add to the traditional expensive methods commonly used in INOCA prediction.
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Affiliation(s)
- Muammer Karakayali
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Mehmet Altunova
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training Research Hospital, Istanbul - Turquia
| | | | - Serkan Aslan
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training Research Hospital, Istanbul - Turquia
| | - Timor Omar
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Inanc Artac
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Doğan Ilis
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Ayca Arslan
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Zihni Cagin
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
| | - Yavuz Karabag
- Kafkas University School of Medicine, Department of Cardiology, Kars - Turquia
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Zhou Y, Lu D, Hu Y, Dai C, Yin M, Lu H, Li C, Chen Z, Qian J, Ge J. Coronary slow flow and angiography-derived index of microcirculatory resistance as prognostic predictors in patients with angina and normal coronary arteries: a retrospective cohort study. Acta Cardiol 2024; 79:149-158. [PMID: 38628089 DOI: 10.1080/00015385.2023.2281115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/03/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND This study aims to investigate prognostic implications of coronary slow flow (CSF) and angiography-derived index of microcirculatory resistance (caIMR) in patients with angina and normal coronary arteries. METHODS A total of 582 patients were enrolled with angiographically normal coronary arteries. caIMR was calculated using a commercial software. Patients were followed up for a median of 45 months. The primary endpoint was defined as major adverse cardiovascular events (MACEs) comprising death, myocardial infarction and readmission for angina or heart failure. RESULTS CSF was diagnosed when TIMI grade 2 flow presented in at least one coronary artery. Multivariate analysis indicated TIMI-flow-based determination of CSF was not significantly associated with MACEs [hazard ratio (HR): 2.14; 95% confidence interval (CI): 0.87-5.31; p = 0.099), while caIMR >42 (HR: 2.53; 95% CI: 1.02-6.32; p = 0.047) were independent predictors of MACEs. Incorporation of caIMR improved the area under the curve from 0.587 to 0.642. CONCLUSIONS caIMR was an independent prognostic factor of long-term cardiovascular events in patients with CSF. Evaluation of caIMR improved the risk stratification of patients with angiographically-normal coronary arteries.
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Affiliation(s)
- You Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Danbo Lu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Yiqing Hu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Chunfeng Dai
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Ming Yin
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Hao Lu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - ChenGuang Li
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Zhangwei Chen
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University; National Clinical Research Center for Interventional Medicine; Shanghai Clinical Research Center for Interventional Medicine, Shanghai, PR China
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Januszek R, Kołtowski Ł, Tomaniak M, Wańha W, Wojakowski W, Grygier M, Siłka W, Jan Horszczaruk G, Czarniak B, Kręcki R, Guzik B, Legutko J, Pawłowski T, Wnęk P, Roik M, Sławek-Szmyt S, Jaguszewski M, Roleder T, Dziarmaga M, Bartuś S. Implementation of Microcirculation Examination in Clinical Practice-Insights from the Nationwide POL-MKW Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:277. [PMID: 38399564 PMCID: PMC10890290 DOI: 10.3390/medicina60020277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/10/2023] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: The assessment of coronary microcirculation may facilitate risk stratification and treatment adjustment. The aim of this study was to evaluate patients' clinical presentation and treatment following coronary microcirculation assessment, as well as factors associated with an abnormal coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) values. Materials and Results: This retrospective analysis included 223 patients gathered from the national registry of invasive coronary microvascular testing collected between 2018 and 2023. Results: The frequency of coronary microcirculatory assessments in Poland has steadily increased since 2018. Patients with impaired IMR (≥25) were less burdened with comorbidities. Patients with normal IMR underwent revascularisation attempts more frequently (11.9% vs. 29.8%, p = 0.003). After microcirculation testing, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors were added more often for patients with IMR and CFR abnormalities, respectively, as compared to control groups. Moreover, patients with coronary microvascular dysfunction (CMD, defined as CFR and/or IMR abnormality), regardless of treatment choice following microcirculation assessment, were provided with trimetazidine (23.2%) and dihydropyridine CCBs (26.4%) more frequently than those without CMD who were treated conservatively (6.8%) and by revascularisation (4.2% with p = 0.002 and 0% with p < 0.001, respectively). Multivariable analysis revealed no association between angina symptoms and IMR or CFR impairment. Conclusions: The frequency of coronary microcirculatory assessments in Poland has steadily increased. Angina symptoms were not associated with either IMR or CFR impairment. After microcirculation assessment, patients with impaired microcirculation, expressed as either low CFR, high IMR or both, received additional pharmacotherapy treatment more often.
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Affiliation(s)
- Rafał Januszek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, 30-705 Kraków, Poland
| | - Łukasz Kołtowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Mariusz Tomaniak
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (Ł.K.); (M.T.)
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland; (W.W.); (W.W.)
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Wojciech Siłka
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
| | - Grzegorz Jan Horszczaruk
- Faculty of Medical Science, Collegium Medicum. Cardinal Stefan Wyszyński University in Warsaw, 01-938 Warsaw, Poland;
- Department of Cardiology, Voivodeship Hospital in Łomża, 18-404 Łomża, Poland
| | - Bartosz Czarniak
- Provincial Specialist Hospital in Wloclawek, 87-800 Włocławek, Poland;
| | | | - Bartłomiej Guzik
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland; (B.G.); (J.L.)
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Tomasz Pawłowski
- Department of Cardiology, National Institute of Medicine of the Ministry of Internal Affairs and Administration, 02-507 Warsaw, Poland;
- Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Paweł Wnęk
- Provincial Specialist Hospital in Wroclaw, 51-124 Wrocław, Poland;
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Sylwia Sławek-Szmyt
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland; (M.G.); (S.S.-S.)
| | - Miłosz Jaguszewski
- 1st Department of Cardiology, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Tomasz Roleder
- Department of Cardiology, Wroclaw Medical University, 50-556 Wrocław, Poland;
| | - Miłosz Dziarmaga
- Department of Cardiology-Intensive Therapy and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
| | - Stanisław Bartuś
- Faculty of Medicine, Jagiellonian University Medical College, 31-008 Kraków, Poland; (W.S.); (S.B.)
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Cardiol Clin 2024; 42:125-135. [PMID: 37949533 PMCID: PMC11090694 DOI: 10.1016/j.ccl.2023.07.003] [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] [Indexed: 11/12/2023]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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8
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Sakai A, Nagao M, Yamamoto A, Nakao R, Arashi H, Momose M, Sato K, Yamaguchi J. 13N-ammonia positron emission tomography for diagnosis and monitoring of ischemia without obstructive coronary artery disease. Int J Cardiol 2024; 395:131392. [PMID: 37748522 DOI: 10.1016/j.ijcard.2023.131392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Ischemia with no obstructive coronary arteries (INOCA), a chronic disorder with a poor prognosis, remains challenging to diagnose. 13N-ammonia positron emission tomography (13NH3 PET), which can quantify microcirculation, is its most reliable detection method. We aimed to investigate the differences in 13NH3 PET findings between INOCA and coronary artery disease (CAD). METHODS Overall, consecutive 433 patients with known or suspected CAD underwent adenosine-stress 13NH3 PET. Based on the European Society of Cardiology guidelines, INOCA was defined as typical angina without coronary stenosis (INOCA n = 45, CAD n = 293, no CAD n = 95). Papillary muscle ischemia (PMI) and global myocardial flow reserve (MFR) were examined as microvascular injuries using 13NH3 PET. RESULTS PMI was observed significantly more frequently in patients with INOCA than in those with CAD (40.0% vs. 11.6%, respectively; p = 0.02). Global MFR (1.84 ± 0.54 vs. 2.08 ± 0.66, respectively; p < 0.0001) and reactive hyperemia index were significantly lower in patients with INOCA than in those with CAD. Forty-five major adverse cardiac events (MACE) were recorded in a median follow-up time of 827 days. Kaplan-Meier analysis revealed that the survival rate worsened in patients with INOCA and PMI (log-rank test, p = 0.001). In the Cox proportional hazards model, PMI was an independent predictive factor for MACE (odds ratio, 4.16; 95% confidence interval, 2.13-8.15; p < 0.0001). CONCLUSIONS PMI presence and decreased MFR were 13NH3 PET findings characteristic of INOCA. 13NH3 PET can be used to monitor the treatment course.
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Affiliation(s)
- Akiko Sakai
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan.
| | - Michinobu Nagao
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Atsushi Yamamoto
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Risako Nakao
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Hiroyuki Arashi
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Mitsuru Momose
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Kayoko Sato
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo 162-8666, Japan
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9
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Polyak A, Wei J, Gulati M, Merz NB. Clinical aspects of ischemia with no obstructive coronary artery disease (INOCA). AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 37:100352. [PMID: 38222977 PMCID: PMC10785769 DOI: 10.1016/j.ahjo.2023.100352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 01/16/2024]
Abstract
Ischemia with no obstructive coronary arteries (INOCA) is defined as patients with evidence of myocardial ischemia without obstructive coronary artery disease. About 3-4 million people in the United States have INOCA, more commonly affecting women, and carries adverse morbidity, mortality, and relatively high healthcare costs. The pathophysiology of INOCA appears to be multi-factorial with a variety of contributing mechanisms. Diagnosis of INOCA is suggested by non-invasive or invasive testing consistent with myocardial ischemia. Due to the high prevalence of coronary risk factors and atherosclerosis in the INOCA population, current treatment strategies target angina, coronary atherosclerosis, and atherosclerotic risk factors, as well as burgeoning treatment of coronary microvascular dysfunction (CMD). Ongoing clinical trials are assessing different options.
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Affiliation(s)
- Alexander Polyak
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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10
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Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis 2024; 18:17539447241230400. [PMID: 38343041 PMCID: PMC10860484 DOI: 10.1177/17539447241230400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
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Affiliation(s)
- Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Brown
- Cardiovascular Care Partnership, British Cardiovascular Society, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Medical School, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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11
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Kest M, Ágoston A, Szabó GT, Kiss A, Üveges Á, Czuriga D, Komócsi A, Hizoh I, Kőszegi Z. Angiography-based coronary microvascular assessment with and without intracoronary pressure measurements: a systematic review. Clin Res Cardiol 2023:10.1007/s00392-023-02338-6. [PMID: 37987840 DOI: 10.1007/s00392-023-02338-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND In recent years, several indices have been proposed for quantifying coronary microvascular resistance. We intended to conduct a comprehensive review that systematically evaluates indices of microvascular resistance derived from angiography. OBJECTIVE The objective of this study was to identify and analyze angiography-derived indices of microvascular resistance that have been validated against an invasive reference method. We aimed to compare their limits of agreement with their reference methods and explore their advantages and inherent limitations. METHODS AND RESULTS We searched PubMed from inception until 2022 for studies on different techniques for quantifying microvascular resistance. Seven studies met the inclusion criteria. Five studies included techniques that applied calculations based solely on invasive angiography, and were validated against invasively measured thermodilution-derived index of microvascular resistance. The remaining two studies combined angiography with invasively measured intracoronary pressure data, and were validated against invasive Doppler measurements. We converted the ± 1.96 standard deviation limits of agreement with the reference method from the seven studies into percentages relative to the cut-off value of the reference method. The lower limits of agreement for angiography-based methods ranged from - 122 to - 60%, while the upper limits ranged from 74 to 135%. The range of the limits of agreement was considerably lower for the two combined angiography- and pressure-based methods, standing at - 52 to 60% and - 25 to 27%. CONCLUSION Our findings suggest that combined angiography- and pressure-based methods provide a more reliable assessment of microvascular resistance compared to methods relying solely on angiography. Central illustration. Comparative assessment of image-based methods quantifying microvascular resistance with and without intracoronary pressure measurements. Angiography-based methods rely on angiography alone to calculate the microvascular resistance by utilizing angiographic frame counting to extrapolate coronary flow (Q) and subsequently deriving distal coronary pressure using fluid dynamic equations. Combined angiography- and pressure-based methods utilize invasive intracoronary pressure gradients measured during rest and maximal vasodilation to determine coronary flow in their calculation of microvascular resistance. The combined methods showed more acceptable levels of agreement with their reference methods compared to angiography-based methods alone.
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Affiliation(s)
- Michael Kest
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
| | - András Ágoston
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Gábor Tamás Szabó
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Attila Kiss
- Center for Biomedical Research and Translational Surgery, Medical University Vienna, Vienna, Austria
| | - Áron Üveges
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - Dániel Czuriga
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Hizoh
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Kőszegi
- Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital, Nyíregyháza, Hungary.
- Division of Cardiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, Debrecen, Hungary.
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12
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La S, Tavella R, Wu J, Pasupathy S, Zeitz C, Worthley M, Sinhal A, Arstall M, Spertus JA, Beltrame JF. Angina and Non-Obstructive Coronary Artery (ANOCA) Patients with Coronary Vasomotor Disorders. Life (Basel) 2023; 13:2190. [PMID: 38004330 PMCID: PMC10672683 DOI: 10.3390/life13112190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Angina and Non-Obstructive Coronary Artery (ANOCA) patients often lack a clear explanation for their symptoms, and are frequently discharged with the label of "unspecified chest pain", despite the availability of functional coronary angiography (provocative spasm and microvascular function testing) to identify potential underlying coronary vasomotor disorders. This study compared the outcomes of ANOCA patients with a coronary vasomotor disorder diagnosis post elective coronary angiography to patients discharged with unspecified chest pain. Using the CADOSA (Coronary Angiogram Database of South Australia) registry, consecutive symptomatic patients (n = 7555) from 2012 to 2018 underwent elective angiography; 30% had ANOCA (stenosis <50%). Of this cohort, 9% had documented coronary vasomotor disorders diagnosed, and 91% had unspecified chest pain. Patients with coronary vasomotor disorders were younger and had a similar female prevalence compared with those with unspecified chest pain. New prescriptions of calcium channel blockers and long-acting nitrates were more common for the coronary vasomotor cohort at discharge. In the 3 years following angiography, both groups had similar all-cause mortality rates. However, those with coronary vasomotor disorders had higher rates of emergency department visits for chest pain (39% vs. 15%, p < 0.001) and readmissions for chest pain (30% vs. 10%, p < 0.001) compared with those with unspecified chest pain. This real-world study emphasizes the importance of identifying high-risk ANOCA patients for personalized management to effectively address their symptoms.
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Affiliation(s)
- Sarena La
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Rosanna Tavella
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Jing Wu
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
| | - Sivabaskari Pasupathy
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Christopher Zeitz
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Matthew Worthley
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Ajay Sinhal
- Southern Adelaide Local Health Network, Adelaide, SA 5042, Australia;
- School of Medicine, Faculty of Health Sciences, Flinders University, Adelaide, SA 5042, Australia
| | - Margaret Arstall
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Northern Adelaide Local Health Network, Adelaide, SA 5112, Australia
| | - John A. Spertus
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Saint Luke’s Mid America Heart Institute, Kansas City, MO 64111, USA
- School of Medicine, Healthcare Institute for Innovations in Quality, The University of Missouri-Kansas City, Kansas City, MO 64110, USA
| | - John F. Beltrame
- School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; (S.L.); (R.T.); (J.W.); (S.P.); (C.Z.); (M.A.); (J.A.S.)
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
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13
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Mohammed AQ, Abdu FA, Liu L, Yin G, Mareai RM, Mohammed AA, Xu Y, Che W. Coronary microvascular dysfunction and myocardial infarction with non-obstructive coronary arteries: Where do we stand? Eur J Intern Med 2023; 117:8-20. [PMID: 37482469 DOI: 10.1016/j.ejim.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/15/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
In the past decade, scientific and clinical research has provided a translational perspective on myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). MINOCA is characterized by clinical documentation of an acute MI but angiography shows no significant coronary artery obstruction (stenosis <50%). The prevalence of MINOCA is estimated to range from approximately 6 to 10% among MI patients, and those with this condition have a poor prognosis, experiencing high rates of mortality, rehospitalization, and socioeconomic burden. MINOCA represents a major unmet need in cardiovascular medicine, with uncertain clinical management. It is a complex condition that can be caused by various factors, including atherosclerosis, plaque rupture, coronary vasospasm, and microvascular dysfunction. Effective management of MINOCA depends on identifying the underlying mechanism of the infarction, thus a systematic diagnostic approach is recommended. Contemporary data shows that a significant number of patients exhibit structural and functional abnormalities in coronary microcirculation, which is referred to as coronary microvascular dysfunction (CMD). CMD plays a crucial role in patients with signs and symptoms of myocardial ischemia and non-obstructive coronary artery stenosis, including MINOCA. Furthermore, conducting a thorough evaluation of coronary function can have significant prognostic and therapeutic implications, since personalized patient management strategies based on this assessment have been shown to improve symptoms and prognosis. Therefore, an accurate and timely diagnosis of CMD is essential for effective patient management, which can be achieved through various invasive and non-invasive methods. This review will discuss the pathophysiological understanding, current diagnostic techniques, and management strategies of patients with MINOCA and CMD.
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Affiliation(s)
- Abdul-Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fuad A Abdu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Redhwan M Mareai
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ayman A Mohammed
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China.
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14
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Hokimoto S, Kaikita K, Yasuda S, Tsujita K, Ishihara M, Matoba T, Matsuzawa Y, Mitsutake Y, Mitani Y, Murohara T, Noda T, Node K, Noguchi T, Suzuki H, Takahashi J, Tanabe Y, Tanaka A, Tanaka N, Teragawa H, Yasu T, Yoshimura M, Asaumi Y, Godo S, Ikenaga H, Imanaka T, Ishibashi K, Ishii M, Ishihara T, Matsuura Y, Miura H, Nakano Y, Ogawa T, Shiroto T, Soejima H, Takagi R, Tanaka A, Tanaka A, Taruya A, Tsuda E, Wakabayashi K, Yokoi K, Minamino T, Nakagawa Y, Sueda S, Shimokawa H, Ogawa H. JCS/CVIT/JCC 2023 guideline focused update on diagnosis and treatment of vasospastic angina (coronary spastic angina) and coronary microvascular dysfunction. J Cardiol 2023; 82:293-341. [PMID: 37597878 DOI: 10.1016/j.jjcc.2023.06.009] [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: 08/21/2023]
Affiliation(s)
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroki Ikenaga
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan
| | - Takahiro Imanaka
- Department of Cardiovascular and Renal Medicine, School of Medicine, Hyogo Medical University, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroyuki Miura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Japan
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | | | - Ryu Takagi
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Japan
| | - Etsuko Tsuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan
| | - Kohei Wakabayashi
- Division of Cardiology, Cardiovascular Center, Showa University Koto-Toyosu Hospital, Japan
| | - Kensuke Yokoi
- Department of Cardiovascular Medicine, Saga University, Japan
| | - Toru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Japan
| | - Shozo Sueda
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | - Hiroaki Shimokawa
- Graduate School, International University of Health and Welfare, Japan
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15
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Takahashi T, Gupta A, Samuels BA, Wei J. Invasive Coronary Assessment in Myocardial Ischemia with No Obstructive Coronary Arteries. Curr Atheroscler Rep 2023; 25:729-740. [PMID: 37682498 PMCID: PMC10564835 DOI: 10.1007/s11883-023-01144-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is threefold: (i) to give an overview of well-established invasive methods for assessing patients with ischemia with no obstructive coronary arteries (INOCA) in the cardiac catheterization laboratory; (ii) to describe the prognostic and treatment implications based on these findings, and (iii) to discuss current knowledge gaps and future perspectives. RECENT FINDINGS Recent studies have demonstrated that invasive coronary function testing not only allows for risk stratification of patients with INOCA but also guides medical therapy with improvement in symptoms and quality of life. Based on these findings, invasive coronary function assessment is now a class 2a recommendation in the 2021 ACC/AHA chest pain guideline to improve the diagnosis of coronary microvascular dysfunction and to enhance risk stratification. Invasive functional testing for patients with INOCA is well established and easily performed in the catheterization laboratory. Comprehensive invasive assessment is a key to differentiating INOCA endotypes and optimizing both medical therapy and preventive strategies including lifestyle modification.
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Affiliation(s)
| | - Aakriti Gupta
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd A3212, Los Angeles, CA, 90048, USA.
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16
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Boerhout C, Feenstra R, van de Hoef T, Piek J, Beijk M. Pharmacotherapy in patients with vasomotor disorders. IJC HEART & VASCULATURE 2023; 48:101267. [PMID: 37727753 PMCID: PMC10505589 DOI: 10.1016/j.ijcha.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Abstract
Background Anginal symptoms in patients with non-obstructive coronary artery disease are frequently related to vasomotor disorders of the coronary circulation. Although frequently overlooked, a distinct diagnosis of different vasomotor disorders can be made by intracoronary function testing. Early detection and treatment seems beneficial, but little evidence is available for the medical treatment of these disorders. Nevertheless, there are several pharmacotherapeutic options available to treat these patients and improve quality of life. Methods & findings We performed an extensive yet non-systematic literature search to explore available pharmacotherapeutic strategies for addressing vasomotor disorders in individuals experiencing angina and non-obstructive coronary artery disease. This article presents a comprehensive overview of therapeutic possibilities for patients exhibiting abnormal vasoconstriction (such as spasm) and abnormal vasodilation (like coronary microvascular dysfunction). Conclusion Treatment of vasomotor disorders can be very challenging, but a general treatment algorithm based on the existing evidence and the best available current practice is feasible.
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Affiliation(s)
| | | | - T.P. van de Hoef
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J.J. Piek
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - M.A.M. Beijk
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
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17
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Samuels BA, Shah SM, Widmer RJ, Kobayashi Y, Miner SES, Taqueti VR, Jeremias A, Albadri A, Blair JA, Kearney KE, Wei J, Park K, Barseghian El-Farra A, Holoshitz N, Janaszek KB, Kesarwani M, Lerman A, Prasad M, Quesada O, Reynolds HR, Savage MP, Smilowitz NR, Sutton NR, Sweeny JM, Toleva O, Henry TD, Moses JW, Fearon WF, Tremmel JA. Comprehensive Management of ANOCA, Part 1-Definition, Patient Population, and Diagnosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1245-1263. [PMID: 37704315 DOI: 10.1016/j.jacc.2023.06.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/15/2023] [Indexed: 09/15/2023]
Abstract
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
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Affiliation(s)
- Bruce A Samuels
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samit M Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Jay Widmer
- Baylor Scott and White Health, Temple, Texas, USA
| | - Yuhei Kobayashi
- New York Presbyterian Brooklyn Methodist Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Steven E S Miner
- Southlake Regional Medical Centre, Newmarket, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen Jeremias
- St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Ahmed Albadri
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John A Blair
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Kathleen E Kearney
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Janet Wei
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Noa Holoshitz
- Ascension Columbia St Mary's, Milwaukee, Wisconsin, USA
| | | | - Manoj Kesarwani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA; The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael P Savage
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Nadia R Sutton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joseph M Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olga Toleva
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Jeffery W Moses
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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18
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Ha ET, Qu YS, Takahashi T, Parikh MA, Kobayashi Y. Challenge in Diagnosis and Management of a Patient With Myocardial Bridge and Coronary Artery Spasm. JACC Case Rep 2023; 20:101950. [PMID: 37614330 PMCID: PMC10442663 DOI: 10.1016/j.jaccas.2023.101950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 08/25/2023]
Abstract
Positive ischemia by noninvasive imaging studies often results in nonobstructive disease in cardiac catheterization. In this case, we observed ischemia by nuclear stress test in only the anteroseptal area, and the apex is free of ischemia. Coronary angiogram findings were unremarkable, but intravascular ultrasound confirmed the long length of the myocardial bridge. Further testing with spasm provocation and microvascular testing showed diffuse epicardial spasm in this area of myocardial bridge without microvascular dysfunction. We observed the myocardial bridge but no microvascular dysfunction. This case illustrates the coexistence of spasm in the area of a myocardial bridge and the challenges in the medical management of these patients. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Edward T. Ha
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Yongxia S. Qu
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | | | - Manish A. Parikh
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Yuhei Kobayashi
- Division of Cardiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
- Weill Cornell Medical College, New York, New York, USA
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19
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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20
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Marano P, Wei J, Merz CNB. Coronary Microvascular Dysfunction: What Clinicians and Investigators Should Know. Curr Atheroscler Rep 2023; 25:435-446. [PMID: 37338666 PMCID: PMC10412671 DOI: 10.1007/s11883-023-01116-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW Abnormal structure and function of the coronary microvasculature have been implicated in the pathophysiology of multiple cardiovascular disease processes. This article reviews recent research progress related to coronary microvascular dysfunction (CMD) and salient clinical takeaways. RECENT FINDINGS CMD is prevalent in patients with signs and symptoms of ischemia and no obstructive epicardial coronary artery disease (INOCA), particularly in women. CMD is associated with adverse outcomes, including most frequently the development of heart failure with preserved ejection fraction. It is also associated with adverse outcomes in patient populations including hypertrophic cardiomyopathy, dilated cardiomyopathy, and acute coronary syndromes. In patients with INOCA, stratified medical therapy guided by invasive coronary function testing to define the subtype of CMD leads to improved symptoms. There are invasive and non-invasive methodologies to diagnose CMD that provide prognostic information and mechanistic information to direct treatment. Available treatments improve symptoms and myocardial blood flow; ongoing investigations aim to develop therapy to improve adverse outcomes related to CMD.
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Affiliation(s)
- Paul Marano
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA.
- Cedars-Sinai Medical Center, Barbra Streisand Women's Heart Center, Smidt Heart Institute, 127 S. San Vicente Blvd, Los Angeles, CA, 90048, USA.
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21
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Tomdio AN, McFalls EO, Jovin IS. Editorial commentary: Best imaging modalities to decipher coronary microvascular angina. Trends Cardiovasc Med 2023; 33:384-385. [PMID: 35337960 DOI: 10.1016/j.tcm.2022.03.006] [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] [Received: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Anna N Tomdio
- Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Edward O McFalls
- McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, 111J, Richmond, VA 23249, United States
| | - Ion S Jovin
- Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, VA, United States; McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, 111J, Richmond, VA 23249, United States.
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22
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Wang XH, Li MD, Xie FX, Liang H, Yang L, Wei XF, Pang H, Wang ZJ, Jing XG. Prognostic utility of 99mTc-MIBI single photon emission computerized tomography myocardial perfusion imaging in patients with ischemia and non-obstructive coronary artery disease. Front Cardiovasc Med 2023; 10:1115135. [PMID: 37469480 PMCID: PMC10352836 DOI: 10.3389/fcvm.2023.1115135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Objective The aim of our study was to evaluate the prognostic value of gated SPECT MPI in non-obstructed coronary arteries (INOCA) patients, sought to stratify patients more accurately and thus derive more reliable prognostic information. Materials and methods In total, 167 patients with INOCA were enrolled. The patients were divided into two groups according to their SSS. Patients were followed-up regularly in terms of major adverse cardiovascular event (MACE), including cardiac death, nonfatal myocardial infarction, stroke, re-hospitalization with angina pectoris, and recurrent angina pectoris. Kaplan-Meier curves and Cox's proportional hazards models were used to analyze survival and identify predictive factors. Results Adverse cardiac events occurred in 33 cases (19.8%). The rate of MACE was higher in the summed stress score (SSS) ≥4 group than in the SSS 0-3 group (30.1% vs. 9.5%, respectively, P = 0.001) and MACE-free survival was lower (annual MACE-free rates of 87.5% vs. 96.2%, respectively, P = 0.003). Event-free survival was consistently higher in patients with normal arteries than in those with non-obstructive coronary artery disease (annual MACE-free rates of 96.1% and 88.4%, P = 0.035). When the SSS and the CAG results were combined, patients with normal coronary arteries (SSS 0-3) had the best prognosis and those with non-obstructive coronary artery stenosis (SSS ≥ 4) had the worst. However, the early prognosis of patients with non-obstructive coronary artery disease and SSS of 0-3 was comparable to that of patients with normal coronary arteries and SSS ≥ 4 (annual MACE-free rates of 100%, 94.6%, 93.1%, and 78.2%, respectively). Multivariate Cox's regression indicated that the SSS [hazard ratio (HR) = 1.126, 95% confidence interval (CI) 1.042-1.217, P = 0.003] and non-obstructive coronary artery disease (HR = 2.559, 95% CI 1.249-5.246, P = 0.01) were predictors of adverse cardiac events. Conclusion SPECT MPI data were prognostic for INOCA patients, thus identifying groups at high risk. The long-term predictive efficacy of such data exceeded that of CAG data. A combination of the two measures more accurately stratified INOCA patients in terms of risk.
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23
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Zhang H, Caobelli F, Che W, Huang Y, Zhang Y, Fan X, Hu X, Xu C, Fei M, Zhang J, Lv Z, Shi K, Yu F. The prognostic value of CZT SPECT myocardial blood flow (MBF) quantification in patients with ischemia and no obstructive coronary artery disease (INOCA): a pilot study. Eur J Nucl Med Mol Imaging 2023; 50:1940-1953. [PMID: 36786817 PMCID: PMC10199834 DOI: 10.1007/s00259-023-06125-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Despite the demonstrated adverse outcome, it is difficult to early identify the risks for patients with ischemia and no obstructive coronary artery disease (INOCA). We aimed to explore the prognostic potential of CZT SPECT in INOCA patients. METHODS The study population consisted of a retrospective cohort of 118 INOCA patients, all of whom underwent CZT SPECT imaging and invasive coronary angiography (ICA). Dynamic data were reconstructed, and MBF was quantified using net retention model. Major adverse cardiovascular events (MACEs) were defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, heart failure, late coronary revascularization, or hospitalization for unstable angina. RESULTS During a median follow-up of 15 months (interquartile range (IQR) 11-20), 19 (16.1%) MACEs occurred; both stress myocardial blood flow (sMBF) ([Formula: see text]) and coronary flow reserve (CFR) ([Formula: see text]) were significantly lower in the MACE group. Optimal thresholds of sMBF<3.16 and CFR<2.52 were extracted from the ROC curves, and both impaired sMBF (HR: 15.08; 95% CI 2.95-77.07; [Formula: see text]) and CFR (HR: 6.51; 95% CI 1.43-29.65; [Formula: see text]) were identified as prognostic factors for MACEs. Only sMBF<3.16 (HR: 11.20; 95% CI 2.04-61.41; [Formula: see text]) remained a robust predictor when sMBF and CFR were integrated considered. Compared with CFR, sMBF provides better prognostic model discrimination and reclassification ability (C-index improvement = 0.06, [Formula: see text]; net reclassification improvement (NRI) = 0.19; integrated discrimination improvement (IDI) = 0.10). CONCLUSION The preliminary results demonstrated that quantitative analysis on CZT SPECT provides prognostic value for INOCA patients, which may allow the stratification for early prevention and intervention.
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Affiliation(s)
- Han Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Federico Caobelli
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yan Huang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Yu Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xin Fan
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xueping Hu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Chong Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Mengyu Fei
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Jiajia Zhang
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Zhongwei Lv
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Computer Aided Medical Procedures and Augmented Reality, Institute of Informatics I16, Technical University of Munich, Munich, Germany.
| | - Fei Yu
- Department of Nuclear Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200072, China.
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24
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Smilowitz NR, Toleva O, Chieffo A, Perera D, Berry C. Coronary Microvascular Disease in Contemporary Clinical Practice. Circ Cardiovasc Interv 2023; 16:e012568. [PMID: 37259860 PMCID: PMC10330260 DOI: 10.1161/circinterventions.122.012568] [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] [Indexed: 06/02/2023]
Abstract
Coronary microvascular disease (CMD) causes myocardial ischemia in a variety of clinical scenarios. Clinical practice guidelines support routine testing for CMD in patients with ischemia with nonobstructive coronary artery disease. Invasive testing to identify CMD requires Doppler or thermodilution measures of flow to determine the coronary flow reserve and measures of microvascular resistance. Acetylcholine coronary reactivity testing identifies concomitant endothelial dysfunction, microvascular spasm, or epicardial coronary spasm. Comprehensive testing may improve symptoms, quality of life, and patient satisfaction by establishing a diagnosis and guiding-targeted medical therapy and lifestyle measures. Beyond ischemia with nonobstructive coronary artery disease, testing for CMD may play a role in patients with acute myocardial infarction, angina following coronary revascularization, heart failure with preserved ejection fraction, Takotsubo syndrome, and after heart transplantation. Additional education and provider awareness of CMD and its role in cardiovascular disease is needed to improve patient-centered outcomes of ischemic heart disease.
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Affiliation(s)
- Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, NY (N.R.S.)
- Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, NY (N.R.S.)
| | | | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy (A.C.)
| | - Divaka Perera
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, UK (D.P.)
- Guy's and St Thomas' Hospital, London, UK (D.P.)
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Scotland, UK (C.B.)
- The West of Scotland Heart and Lung Centre, NHS Golden Jubilee, Glasgow, Scotland, UK (C.B.)
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25
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Hung MJ, Yeh CT, Kounis NG, Koniari I, Hu P, Hung MY. Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review. Int J Mol Sci 2023; 24:ijms24087530. [PMID: 37108691 PMCID: PMC10145866 DOI: 10.3390/ijms24087530] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.
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Affiliation(s)
- Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Keelung, Chang Gung University College of Medicine, Keelung City 24201, Taiwan
| | - Chi-Tai Yeh
- Department of Medical Research and Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Continuing Education Program of Food Biotechnology Applications, College of Science and Engineering, National Taitung University, Taitung 95092, Taiwan
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, 26221 Patras, Greece
| | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Patrick Hu
- Department of Internal Medicine, School of Medicine, University of California, Riverside, Riverside, CA 92521, USA
- Department of Cardiology, Riverside Medical Clinic, Riverside, CA 92506, USA
| | - Ming-Yow Hung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, No.291, Zhongzheng Rd., Zhonghe District, New Taipei City 23561, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei City 110301, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 23561, Taiwan
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26
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Hashikata T, Kameda R, Ako J. Clinical Implication and Optimal Management of Myocardial Bridging: Role of Cardiovascular Imaging. Interv Cardiol Clin 2023; 12:281-288. [PMID: 36922068 DOI: 10.1016/j.iccl.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Myocardial bridging (MB) was historically considered a benign structure as most people with MB are clinically asymptomatic. Recently, however, mounting evidence indicates that MB can cause adverse cardiac events owing to arterial systolic compression/diastolic restriction, atherosclerotic plaque progression upstream from MB, and/or vasospastic angina. In MB patients with refractory angina, the optimal treatment strategy should be determined individually based on versatile anatomic and hemodynamical assessments that often require multidisciplinary diagnostic approaches. The present review summarizes the clinical implication and management of MB, highlighting the role of imaging modalities currently available in this arena.
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Affiliation(s)
- Takehiro Hashikata
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan.
| | - Ryo Kameda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
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27
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Hwang D, Park SH, Koo BK. Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management. JACC. ASIA 2023; 3:169-184. [PMID: 37181394 PMCID: PMC10167523 DOI: 10.1016/j.jacasi.2023.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 05/16/2023]
Abstract
In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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28
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Godo S, Takahashi J, Shiroto T, Yasuda S, Shimokawa H. Coronary Microvascular Spasm: Clinical Presentation and Diagnosis. Eur Cardiol 2023; 18:e07. [PMID: 37377449 PMCID: PMC10291603 DOI: 10.15420/ecr.2022.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/13/2022] [Indexed: 06/29/2023] Open
Abstract
Professor Maseri pioneered the research and treatment of coronary vasomotion abnormalities represented by coronary vasospasm and coronary microvascular dysfunction (CMD). These mechanisms can cause myocardial ischaemia even in the absence of obstructive coronary artery disease, and have been appreciated as an important aetiology and therapeutic target with major clinical implications in patients with ischaemia with non-obstructive coronary artery disease (INOCA). Coronary microvascular spasm is one of the key mechanisms responsible for myocardial ischaemia in patients with INOCA. Comprehensive assessment of coronary vasomotor reactivity by invasive functional coronary angiography or interventional diagnostic procedure is recommended to identify the underlying mechanisms of myocardial ischaemia and to tailor the best treatment and management based on the endotype of INOCA. This review highlights the pioneering works of Professor Maseri and contemporary research on coronary vasospasm and CMD with reference to endothelial dysfunction, Rho-kinase activation and inflammation.
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Affiliation(s)
- Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of MedicineSendai, Japan
- Graduate School, International University of Health and WelfareNarita, Japan
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29
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Madeira S. Unrevealing what is beyond our glance. Rev Port Cardiol 2023; 42:467-469. [PMID: 36828178 DOI: 10.1016/j.repc.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- Sérgio Madeira
- Unidade de Intervenção Cardiovascular do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal.
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30
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Di Carli MF. Clinical Value of Positron Emission Tomography Myocardial Perfusion Imaging and Blood Flow Quantification. Cardiol Clin 2023; 41:185-195. [PMID: 37003676 DOI: 10.1016/j.ccl.2023.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Myocardial blood flow (MBF) and flow reserve (MFR) measurements by PET/computed tomography provide incremental diagnostic and prognostic information over traditional quantification of ischemia and scar by myocardial perfusion imaging. A normal stress MBF and MFR (>2.0) have a very high negative predictive value for excluding high-risk obstructive coronary artery disease (CAD). These flow measurements are also used for surveillance of coronary allograft vasculopathy after heart transplantation. A global normal MFR (>2.0) identifies patients at lower clinical risk, whereas a severely reduced MFR (<1.5) identifies patients at high risk for adverse events, even among patients without regional perfusion abnormalities.
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Chen L, Yu WY, Liu R, Gao MX, Wang BL, Ding XH, Yu Y. A bibliometric analysis on the progress of myocardial bridge from 1980 to 2022. Front Cardiovasc Med 2023; 9:1051383. [PMID: 36684604 PMCID: PMC9853984 DOI: 10.3389/fcvm.2022.1051383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Although the vast majority of patients with a myocardial bridge (MB) are asymptomatic, the anomaly was found to be associated with stable or unstable angina, vasospastic angina, acute coronary syndrome, and even malignant arrhythmias and sudden cardiac death in some cases. Methods By retrieving the relevant literature on MB from 1 January 1980 to 31 July 2022 from the Web of Science Core Collection (WoSCC) database, we used the bibliometric tools, including CiteSpace, VOS viewer, and alluvial generator, to visualize the scientific achievements on MB. Results A total of 630 articles were included. The number of published articles was in a fluctuating growth trend. These publications came from 37 contries, led by the USA and China. The leading country on MB was the United States, the leading position among institutions was Stanford University, and the most productive researcher on MB was Jennifer A. Tremmel. After analysis, the most common keywords were myocardial bridge, mortality, coronary angiography, descending coronary artery, and sudden death. Conclusion Our findings can aid researchers in understanding the current state of MB research and in choosing fresh lines of inquiry for forthcoming investigations. Prevalence and prognosis, mechanism atherosclerosis, hemodynamic significance, and molecular autops will likely become the focus of future research. In addition, more studies and cooperations are still needed worldwide.
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Caiati C, Stanca A, Lepera ME. Case report: Diagnosis of apical hypertrophic cardiomyopathy that escaped clinical and echocardiographic investigations for twenty years: Reasons and clinical implications. Front Cardiovasc Med 2023; 10:1157599. [PMID: 37168654 PMCID: PMC10165117 DOI: 10.3389/fcvm.2023.1157599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/03/2023] [Indexed: 05/13/2023] Open
Abstract
Background Apical hypertrophic cardiomyopathy (ApHCM) is a rare form of hypertrophic cardiomyopathy which predominantly affects the apex of the left ventricle. The diagnosis can be challenging due to several factors, ranging from no typical clinical and electrocardiogram (EKG) findings to potential difficulties in executing and interpreting the echocardiographic examination. Case presentation We report the case of an 84-year-old woman who came to our echo-lab to undergo a routine echocardiogram. She had a history of permanent atrial fibrillation, paced rhythm and previous episodes of heart failure (HF), allegedly explained by a diagnosis of hypertensive heart disease that had been confirmed many times over the previous 20 years. The clinical examination and the EKG were unremarkable. The echocardiographic images were poor quality. But a senior cardiologist, expert in imaging and echocardiography, noted the lack of delineation of the endocardial border of the left ventricular (LV) apex region. Contrast echocardiography was performed and severe apical hypertrophy discovered. Conclusion ApHCM can be a challenging diagnosis. Contrast echocardiography must always be applied in cases of poor delineation of the LV apical endocardial border at baseline echocardiography. Timely detection and appropriate lifestyle intervention might slow the development of LV hypertrophy, and possibly minimize and delay heart failure (HF) related symptoms and arrhythmias. The prognosis remains relatively benign during long term follow-up.
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Pruthi S, Siddiqui E, Smilowitz NR. Beyond Coronary Artery Disease: Assessing the Microcirculation. Interv Cardiol Clin 2023; 12:119-129. [PMID: 36372455 PMCID: PMC10019932 DOI: 10.1016/j.iccl.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Ischemic heart disease (IHD) affects more than 20 million adults in the United States. Although classically attributed to atherosclerosis of the epicardial coronary arteries, nearly half of patients with stable angina and IHD who undergo invasive coronary angiography do not have obstructive epicardial coronary artery disease. Ischemia with nonobstructive coronary arteries is frequently caused by microvascular angina with underlying coronary microvascular dysfunction (CMD). Greater understanding the pathophysiology, diagnosis, and treatment of CMD holds promise to improve clinical outcomes of patients with ischemic heart disease.
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Affiliation(s)
- Sonal Pruthi
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Emaad Siddiqui
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA; The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, 12-West, New York, NY 10010, USA.
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Dutta U, Sinha A, Demir OM, Ellis H, Rahman H, Perera D. Coronary Slow Flow Is Not Diagnostic of Microvascular Dysfunction in Patients With Angina and Unobstructed Coronary Arteries. J Am Heart Assoc 2022; 12:e027664. [PMID: 36565193 PMCID: PMC9973578 DOI: 10.1161/jaha.122.027664] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Guidelines recommend that coronary slow flow phenomenon (CSFP), defined as corrected thrombolysis in myocardial infarction frame count (CTFC) >$$ > $$27, can diagnose coronary microvascular dysfunction (CMD) in patients with angina and nonobstructed coronary arteries. CSFP has also historically been regarded as a sign of coronary endothelial dysfunction (CED). We sought to validate the utility of CTFC, as a binary classifier of CSFP and as a continuous variable, to diagnose CMD and CED. Methods and Results Patients with angina and nonobstructed coronary arteries had simultaneous coronary pressure and flow velocity measured using a dual sensor-tipped guidewire during rest, adenosine-mediated hyperemia, and intracoronary acetylcholine infusion. CMD was defined as the inability to augment coronary blood flow in response to adenosine (coronary flow reserve <2.5) and CED in response to acetylcholine (acetylcholine flow reserve ≤1.5); 152 patients underwent assessment using adenosine, of whom 82 underwent further acetylcholine testing. Forty-six patients (30%) had CSFP, associated with lower flow velocity and higher microvascular resistance as compared with controls (16.5±$$ \pm $$6.9 versus 20.2±$$ \pm $$6.9 cm/s; P=0.001 and 6.26±$$ \pm $$1.83 versus 5.36±$$ \pm $$1.83 mm Hg/cm/s; P=0.009, respectively). However, as a diagnostic test, CSFP had poor sensitivity and specificity for both CMD (26.7% and 65.2%) and CED (21.1% and 56.0%). Furthermore, on receiver operating characteristics analyses, CTFC could not predict CMD or CED (area under the curve, 0.41 [95% CI, 0.32%-0.50%] and 0.36 [95% CI, 0.23%-0.49%], respectively). Conclusions In patients with angina and nonobstructed coronary arteries, CSFP and CTFC are not diagnostic of CMD or CED. Guidelines supporting the use of CTFC in the diagnosis of CMD should be revisited.
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Affiliation(s)
- Utkarsh Dutta
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Aish Sinha
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Ozan M. Demir
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Howard Ellis
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Haseeb Rahman
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
| | - Divaka Perera
- School of Cardiovascular Medicine and SciencesBritish Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King’s College LondonLondonUK
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Avtaar Singh SS, Nappi F. Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study. Biomedicines 2022; 10:biomedicines10123010. [PMID: 36551766 PMCID: PMC9775403 DOI: 10.3390/biomedicines10123010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies. METHODS A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework. RESULTS The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon. CONCLUSION The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.
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Affiliation(s)
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord of Saint-Denis, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-(14)-9334104; Fax: +33-149334119
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Impairment in quantitative microvascular function in non-ischemic cardiomyopathy as demonstrated using cardiovascular magnetic resonance. PLoS One 2022; 17:e0264454. [DOI: 10.1371/journal.pone.0264454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Microvascular dysfunction (MVD) is present in various cardiovascular diseases and portends worse outcomes. We assessed the prevalence of MVD in patients with non-ischemic cardiomyopathy (NICM) as compared to subjects with preserved ejection fraction (EF) using stress cardiovascular magnetic resonance (CMR).
Methods
We retrospectively studied consecutive patients with NICM and 58 subjects with preserved left ventricular (LV) EF who underwent stress CMR between 2011–2016. MVD was defined visually as presence of a subendocardial perfusion defect and semiquantitatively by myocardial perfusion reserve index (MPRI<1.51). MPRI was compared between groups using univariate analysis and multivariable linear regression.
Results
In total, 41 patients with NICM (mean age 51 ± 14, 59% male) and 58 subjects with preserved LVEF (mean age 51 ± 13, 31% male) were identified. In the NICM group, MVD was present in 23 (56%) and 11 (27%) by semiquantitative and visual evaluation respectively. Compared to those with preserved LVEF, NICM patients had lower rest slope (3.9 vs 4.9, p = 0.05) and stress perfusion slope (8.8 vs 11.7, p<0.001), and MPRI (1.41 vs 1.74, p = 0.02). MPRI remained associated with NICM after controlling for age, gender, hypertension, ethnicity, diabetes, and late gadolinium enhancement (log MPR, β coefficient = -0.19, p = 0.007).
Conclusions
MVD—as assessed using CMR—is highly prevalent in NICM as compared to subjects with preserved LVEF even after controlling for covariates. Semiquantitative is able to detect a greater number of incidences of MVD compared to visual methods alone. Further studies are needed to determine whether treatment of MVD is beneficial in NICM.
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Park S, Lee SH, Shin D, Hong D, Joh HS, Choi KH, Kim HK, Ha SJ, Park TK, Yang JH, Song YB, Hahn JY, Choi SH, Gwon HC, Lee JM. Prognostic Impact of Coronary Flow Reserve in Patients With CKD. Kidney Int Rep 2022; 8:64-74. [PMID: 36644355 PMCID: PMC9832048 DOI: 10.1016/j.ekir.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/24/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Both coronary flow reserve (CFR) and chronic kidney disease (CKD) are known to be associated with adverse cardiac events. However, it is unclear how these prognostic factors are interrelated. This study evaluated the association between intracoronary physiologic indexes and CKD and their prognostic implications. Methods A total of 351 patients without left ventricular systolic dysfunction (ejection fraction ≥ 40%) and not on dialysis whose revascularization was deferred based on fractional flow reserve (FFR) > 0.80 were analyzed. Depressed CFR was defined as CFR ≤ 2.0. The primary outcome was a composite of cardiac death or hospitalization for heart failure at 3 years. Results Patients with CKD showed lower CFR than the non-CKD population (3.28 ± 1.77 vs. 2.60 ± 1.09, P < 0.001), mainly driven by increased resting coronary flow. There was no significant difference in hyperemic coronary flow, FFR, and index of microvascular resistance between the 2 groups. CFR was significantly associated with estimated glomerular filtration rate (eGFR) (P = 0.045), and the proportion of depressed CFR was significantly increased with higher CKD stages (P = 0.011). The risk of cardiac death or hospitalization for heart failure was the lowest in the non-CKD and preserved CFR group (11.9%) and the highest in the CKD and depressed CFR group (60.0%, overall log rank P < 0.001). Both CKD (adjusted hazard ratio [HRadj] 2.614, 95% confidence interval [CI] 1.505-4.539, P < 0.001) and depressed CFR (HRadj 3.237, 95% CI 2.015-5.199, P < 0.001) were independently associated with the risk of the primary outcome. Conclusion There was a significant association between severity of CKD and CFR. Both CKD and depressed CFR showed independent association with higher risk of cardiac death or hospitalization for heart failure.
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Affiliation(s)
- Sugeon Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Sung Joh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Republic of Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,Correspondence: Joo Myung Lee, Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea.
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Travieso A, Jeronimo-Baza A, Faria D, Shabbir A, Mejia-Rentería H, Escaned J. Invasive evaluation of coronary microvascular dysfunction. J Nucl Cardiol 2022; 29:2474-2486. [PMID: 35618991 PMCID: PMC9553758 DOI: 10.1007/s12350-022-02997-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 12/02/2022]
Abstract
Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.
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Affiliation(s)
- Alejandro Travieso
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Adrian Jeronimo-Baza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Daniel Faria
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Asad Shabbir
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Hernan Mejia-Rentería
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, c/ Profesor Martin Lagos, s/n, 28040, Madrid, Spain.
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Acute Coronary Syndrome in Women. Emerg Med Clin North Am 2022; 40:629-636. [DOI: 10.1016/j.emc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Nye JA, Piccinelli M, Hwang D, Cooke CD, Paeng JC, Lee JM, Cho SG, Folks R, Haber M, Bom HS, Koo BK, Garcia EV. Determination of [N-13]-ammonia extraction fraction in patients with coronary artery disease by calibration to invasive coronary and fractional flow reserve. J Nucl Cardiol 2022; 29:2210-2219. [PMID: 34036523 PMCID: PMC10630982 DOI: 10.1007/s12350-021-02628-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study presents a new extraction fraction (EF) model based on physiological measures of invasive coronary flow reserve (CFR) and fractional flow reserve (FFR) in patients with suspected coronary artery disease (CAD) and normal index microcirculatory resistance (IMR). To ascertain the clinical relevance of the new EFs, flow measurements using the newly patient-determined EFs were compared to flow measurements using traditional animal-determined EFs. METHODS 39 patients were retrospectively selected that included a total of 91 vascular territories with invasive coronary angiography physiological measures. [N-13]-ammonia dynamic rest/adenosine-stress PET imaging was conducted in all patients and absolute myocardial flow was estimated using four published compartmental models. The extraction fraction during hyperemic flow was iteratively estimated by maximizing the agreement between invasive CFR and FFR with the non-invasive analogs myocardial flow reserve (MFR) and relative flow reserve (RFR) at similar physiological states, respectively. RESULTS Using the new patient-determined EFs, agreement between CFR vs MFR for Model 1 and 2 was moderate and poor for Model 3 and 4. All models showed moderate agreement for FFR vs RFR. When using published models of animal-determined EFs, agreement between CFR vs MFR remained moderate for Model 1 and 2, and poor for Model 3 and 4. Similarly, all models showed moderate agreement for FFR vs RFR using animal-determined EF values. None of the observed differences were statistically significant. CONCLUSIONS Flow measurements using extraction fraction correction for [N-13]-ammonia based on calibration to invasive intracoronary angiography physiological measures in patients with CAD were not discordant from those reported in the literature. Either patient-determined or traditional animal-determined EF correction, when used with the appropriate flow model, yields moderate agreement with invasive measurements of coronary flow reserve and fractional flow reserve.
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Affiliation(s)
- Jonathon A Nye
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA.
| | - Marina Piccinelli
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - C David Cooke
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA
| | - Jin Chul Paeng
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Samsung Medical Center, Heart Vascular Stroke Institute, Seoul, Korea
| | - Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Russell Folks
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA
| | - Michael Haber
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA
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Khan MO, Nishi T, Imura S, Seo J, Wang H, Honda Y, Nieman K, Rogers IS, Tremmel JA, Boyd J, Schnittger I, Marsden A. Colocalization of Coronary Plaque with Wall Shear Stress in Myocardial Bridge Patients. Cardiovasc Eng Technol 2022; 13:797-807. [PMID: 35296987 DOI: 10.1007/s13239-022-00616-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/25/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE Patients with myocardial bridges (MBs) have a higher prevalence of atherosclerosis. Wall shear stress (WSS) has previously been correlated with plaque in coronary artery disease patients, but such correlations have not been investigated in symptomatic MB patients. The aim of this paper was to use a multi-scale computational fluid dynamics (CFD) framework to simulate hemodynamics in MB patient, and investigate the co-localization of WSS and plaque. METHODS We identified N = 10 patients from a previously reported cohort of 50 symptomatic MB patients, all of whom had plaque in the proximal vessel. Dynamic 3D models were reconstructed from coronary computed tomography angiography (CCTA), intravascular ultrasound (IVUS) and catheter angiograms. CFD simulations were performed to compute WSS proximal to, within and distal to the MB. Plaque was quantified from IVUS images in 2 mm segments and registered to CFD model. Plaque area was compared to absolute and patient-normalized WSS. RESULTS WSS was lower in the proximal segment compared to the bridge segment (6.1 ± 2.9 vs. 16.0 ± 7.1 dynes/cm2, p value < 0.01). Plaque area and plaque burden measured from IVUS peaked at 1-3 cm proximal to the MB entrance, coinciding with the first diagonal branch. Normalized WSS showed a statistically significant moderate correlation with plaque area (r = 0.41, p < 0.01). CONCLUSION WSS may be obtained non-invasively in MB patients and provides a surrogate marker of plaque area. Using CFD, it may be possible to non-invasively assess the extent of plaque area, and identify patients who could benefit from frequent monitoring or medical management.
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Affiliation(s)
- Muhammad Owais Khan
- Department of Pediatrics, Stanford University School of Medicine, 318 Campus Drive, Clark Center E100b, Stanford, CA, 94305-5428, USA.,Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Takeshi Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Shinji Imura
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Jongmin Seo
- Department of Pediatrics, Stanford University School of Medicine, 318 Campus Drive, Clark Center E100b, Stanford, CA, 94305-5428, USA.,Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Koen Nieman
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ian S Rogers
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine and Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Alison Marsden
- Department of Pediatrics, Stanford University School of Medicine, 318 Campus Drive, Clark Center E100b, Stanford, CA, 94305-5428, USA. .,Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA. .,Department of Bioengineering, Stanford University, Stanford, CA, USA.
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Luu JM, Wei J, Shufelt CL, Asif A, Tjoe B, Theriot P, Bairey Merz CN. Clinical Practice Variations in the Management of Ischemia With No Obstructive Coronary Artery Disease. J Am Heart Assoc 2022; 11:e022573. [PMID: 36172938 DOI: 10.1161/jaha.121.022573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Ischemia with no obstructive coronary artery disease is a condition associated with major adverse cardiovascular outcomes. To date, there are no specific American Heart Association or American College of Cardiology guidelines. The objective of this survey is to better understand the clinical practice and knowledge gaps that exist nationally. Methods and Results Participant-specific links for a survey with 11 questions and 3 reminders were sent between September and October 2020 to the American College of Cardiology CardioSurve Panel. The panel consist of randomly selected cardiologists (n=437) who represent the current profile of the American College of Cardiology US membership. The survey received a 30% response rate. Of the 172 respondents, 130 (76%) indicated that they have treated patients with ischemia with no obstructive coronary artery disease. Although the majority (69%) are generally confident in their ability to manage this condition, 1 of 3 report lack of confidence or are neutral. The American College of Cardiology/American Heart Association Chronic Stable Angina Guidelines are the most commonly used reference for treating ischemia with no obstructive coronary artery disease (81%), with most cardiologists wanting additional clinical guidance, such as randomized controlled trials (61%). More than 4 of 5 cardiologists rarely or never order advanced imaging modalities to assess coronary flow reserve. Approximately 2 of 3 of respondents frequently prescribe statins (68%), aspirin (66%), calcium channel blockers (63%), and β blockers or α/β blockers (55%). However, nearly 70% never prescribe angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Conclusions This survey demonstrates heterogeneity in the management of ischemia with no obstructive coronary artery disease among US cardiologists, identifies support for guideline development, and outlines knowledge gaps for research and education in the therapeutic management of this condition.
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Affiliation(s)
- Judy M Luu
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Anum Asif
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Benita Tjoe
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | | | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
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Caiati C, Iacovelli F, Mancini G, Lepera ME. Hidden Coronary Atherosclerosis Assessment but Not Coronary Flow Reserve Helps to Explain the Slow Coronary Flow Phenomenon in Patients with Angiographically Normal Coronary Arteries. Diagnostics (Basel) 2022; 12:diagnostics12092173. [PMID: 36140575 PMCID: PMC9497914 DOI: 10.3390/diagnostics12092173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/27/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
The significance of the slow coronary flow phenomenon (SCFph), as visualized in patients (pts) with angiographically normal coronary arteries, is controversial. Absolute coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD), non-invasively assessed by a transthoracic color-guided pulsed-wave Doppler (E-Doppler TTE), is a reliable parameter to assess coronary microcirculatory dysfunction (CMD). Mild and angiographically hidden epicardial atherosclerosis (Hath), as visualized by intracoronary ultrasound (IVUS), which could be the clue to atherosclerotic coronary microvascular involvement, has never been investigated together with CFR in patients. This study was aimed at assessing the value of CFR and HA in explaining the SCFph. Methods. Both non-invasive assessment of CFR in the LAD and corrected TIMI frame count assessment of the coronary contrast runoff were performed in 124 pts with angiographically normal coronary arteries. Among the whole group, 32 patients also underwent intracoronary ultrasounds in the LMCA and LAD, and the maximal plaque burden was assessed (Lesion external elastic (EEM) cross sectional area (CSA)—Lesion Lumen CSA/Lesion EEM CSA * 100). We found that 24 of the 124 pts (group 1) had the SCFph and the remaining 100 had a normal runoff (group 2). CFR, evaluated in both groups, was not significantly different, being 2.79 ± 0.79 (Mean ± SD) in group 1 and 2.90 ± 0.8 in group 2 (p = ns); in the pts also examined by IVUS (32 pts), the SCFph was always associated with hidden atherosclerosis, and a plaque burden of ≥33%. On the contrary, in the normal runoff group, any grade of PB was observed (from no athero to a PB > 70%) and remarkably, 10 pts had no signs of athero or just a minimal plaque burden. This resulted in a ROC curve analysis in which PB < 33% had a high negative predictive value (100%) in ruling out the SCFph. In addition, considering a CFR value < 2.21 as an index of coronary microcirculatory dysfunction, we found CMD in 15 pts (15%) in group 1 and in 7 pts (29%) in group 2 (p = ns). In conclusion, the SCFph is strongly connected to epicardial athero to the extent that the absence of hidden coronary athero has a very high negative predictive power in ruling out SCFph. CFR that is based on an endothelium-independent mechanism remains fairly normal in this condition. An endothelium-dependent microcirculatory constriction at rest due to atherosclerotic involvement of the coronary microvascular network is a possible explanation of the SCFph.
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Affiliation(s)
- Carlo Caiati
- Correspondence: ; Tel.: +39-080-5592117; Fax: +39-080-5478796
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Aguiar Rosa S, Mota Carmo M, Rocha Lopes L, Oliveira E, Thomas B, Baquero L, Cruz Ferreira R, Fiarresga A. Index of microcirculatory resistance in the assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy. Rev Port Cardiol 2022; 41:761-767. [DOI: 10.1016/j.repc.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/27/2021] [Indexed: 10/17/2022] Open
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45
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Feenstra RGT, Boerhout CKM, Woudstra J, Vink CEM, Wittekoek ME, de Waard GA, Appelman Y, Eringa EC, Marques KMJ, de Winter RJ, Beijk MAM, van de Hoef TP, Piek JJ. Presence of Coronary Endothelial Dysfunction, Coronary Vasospasm, and Adenosine-Mediated Vasodilatory Disorders in Patients With Ischemia and Nonobstructive Coronary Arteries. Circ Cardiovasc Interv 2022; 15:e012017. [PMID: 35904014 DOI: 10.1161/circinterventions.122.012017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary function testing in patients with ischemia and nonobstructive coronary arteries (INOCA) commonly includes assessment of adenosine-mediated vasodilation and acetylcholine spasm provocation. The purpose of this study was to evaluate the diagnostic value of additional endothelial function testing for the diagnosis of vasomotor dysfunction in patients with INOCA. METHODS In this retrospective cohort study, we included patients with INOCA who underwent clinically indicated comprehensive coronary function testing. Endothelial dysfunction was defined as a <50% increase in coronary blood flow, determined by Doppler flow, and/or epicardial vasoconstriction compared to baseline, in response to low-dose acetylcholine. Coronary artery spasm (CAS) was defined as vasospastic angina or microvascular angina in response to coronary high-dose acetylcholine. An impaired adenosine-mediated vasodilation was defined as a coronary flow reserve <2.5 and/or hyperemic microvascular resistance ≥2.5. RESULTS Among all 110 patients, 79% had endothelial dysfunction, 62% had CAS, and 29% had an impaired adenosine-mediated vasodilation. Endothelial dysfunction was present in 80% of patients who tested positively for CAS and/or an impaired adenosine-mediated vasodilation. Endothelial function testing increases the diagnostic yield of coronary function testing that only incorporates adenosine testing and spasm provocation by 17% to 92%. Of patients with normal adenosine-mediated vasodilation and no inducible CAS, 68% had endothelial dysfunction. CONCLUSIONS Concomitant endothelial dysfunction was prevalent in the vast majority of patients with INOCA with inducible CAS and/or an impaired adenosine-mediated vasodilation. In patients with INOCA without inducible CAS and normal adenosine-mediated vasodilation, two-thirds had endothelial dysfunction. These results indicate the relevance to perform endothelial function testing in patients with INOCA in view of its therapeutic implication.
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Affiliation(s)
- Rutger G T Feenstra
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Janneke Woudstra
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | | | - Guus A de Waard
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Etto C Eringa
- Department of Physiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam UMC, the Netherlands (E.C.E.).,Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (E.C.E.)
| | - Koen M J Marques
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.).,Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands (T.P.v.d.H.)
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, the Netherlands (R.G.T.F., C.K.M.B., J.W., C.E.M.V., G.A.d.W., Y.A., K.M.J.M., R.J.d.W., M.A.M.B., T.P.v.d.H., J.J.P.)
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Morrone D, Gentile F, Aimo A, Cameli M, Barison A, Picoi ME, Guglielmo M, Villano A, DeVita A, Mandoli GE, Pastore MC, Barillà F, Mancone M, Pedrinelli R, Indolfi C, Filardi PP, Muscoli S, Tritto I, Pizzi C, Camici PG, Marzilli M, Crea F, Caterina RD, Pontone G, Neglia D, Lanza G. Perspectives in noninvasive imaging for chronic coronary syndromes. Int J Cardiol 2022; 365:19-29. [PMID: 35901907 DOI: 10.1016/j.ijcard.2022.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022]
Abstract
Both the latest European guidelines on chronic coronary syndromes and the American guidelines on chest pain have underlined the importance of noninvasive imaging to select patients to be referred to invasive angiography. Nevertheless, although coronary stenosis has long been considered the main determinant of inducible ischemia and symptoms, growing evidence has demonstrated the importance of other underlying mechanisms (e.g., vasospasm, microvascular disease, energetic inefficiency). The search for a pathophysiology-driven treatment of these patients has therefore emerged as an important objective of multimodality imaging, integrating "anatomical" and "functional" information. We here provide an up-to-date guide for the choice and the interpretation of the currently available noninvasive anatomical and/or functional tests, focusing on emerging techniques (e.g., coronary flow velocity reserve, stress-cardiac magnetic resonance, hybrid imaging, functional-coronary computed tomography angiography, etc.), which could provide deeper pathophysiological insights to refine diagnostic and therapeutic pathways in the next future.
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Affiliation(s)
- Doralisa Morrone
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy.
| | - Francesco Gentile
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Maria Elena Picoi
- Azienda Tutela Salute Sardegna, Ospedale Giovanni Paolo II, Unità di terapia intensiva Cardiologica, Olbia, Sardegna, Italy
| | - Marco Guglielmo
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Angelo Villano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio DeVita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Barillà
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Massimo Mancone
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Roberto Pedrinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Ciro Indolfi
- Istituto di Cardiologia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi "Magna Graecia", Catanzaro - Mediterranea Cardiocentro, Napoli, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy, Mediterranea Cardiocentro, Naples, Italy
| | - Saverio Muscoli
- U.O.C. Cardiologia, Fondazione Policlinico "Tor Vergata", Roma, Italy
| | - Isabella Tritto
- Università di Perugia, Dipartimento di Medicina, Sezione di Cardiologia e Fisiopatologia Cardiovascolare, Perugia, Italy
| | - Carmine Pizzi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Paolo G Camici
- Vita-Salute University and IRCCS San Raffaele Hospital, Milan, Italy
| | - Mario Marzilli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Filippo Crea
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | | | - Gaetano Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Jiang J, Li C, Hu Y, Li C, He J, Leng X, Xiang J, Ge J, Wang J. A novel CFD-based computed index of microcirculatory resistance (IMR) derived from coronary angiography to assess coronary microcirculation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 221:106897. [PMID: 35636354 DOI: 10.1016/j.cmpb.2022.106897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study sought to present a novel approach for computation of the index of microcirculatory resistance (IMR) and to evaluate its diagnostic performance. BACKGROUND IMR is a quantitative assessment to identify coronary microvascular dysfunction. However, its clinical use remains extremely limited. Calculation of IMR from coronary angiography images may increase the utility of coronary microvasculature assessment. METHODS 203 patients with 203 vessels were included in this study. Physiology measurements were obtained with pressure-wire in the whole cohort. The computational fluid dynamics (CFD)-based AccuIMR was computed and evaluated in a blinded fashion using wire-based IMR as the reference standard. RESULTS The overall diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AccuIMR for detecting coronary microvascular disease were 91.1% (95% CI: 86.4% to 94.7%), 89.4% (95% CI: 80.9% to 95.0%), 92.4% (95% CI: 86.0% to 96.5%), 89.4% (95% CI: 81.8% to 94.1%), and 92.2% (95% CI: 86.7% to 95.8%), respectively. The correlation coefficient equaled to 0.81 (p < 0.001) between AccuIMR and wire-based IMR with the receiver-operating curve had area under the curve of 0.924 (95% CI: 0.878 to 0.956). CONCLUSIONS AccuIMR is a novel pressure-wire free approach to assess coronary microvascular disease with great diagnostic performance, which can be a valid, efficient, and cost-reducing tool to provide an easier routine assessment of coronary microcirculation.
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Affiliation(s)
- Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yumeng Hu
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingsong He
- ArteryFlow Technology Co., Ltd., Hangzhou, China
| | | | | | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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48
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Tar B, Ágoston A, Üveges Á, Szabó GT, Szűk T, Komócsi A, Czuriga D, Csippa B, Paál G, Kőszegi Z. Pressure- and 3D-Derived Coronary Flow Reserve with Hydrostatic Pressure Correction: Comparison with Intracoronary Doppler Measurements. J Pers Med 2022; 12:jpm12050780. [PMID: 35629202 PMCID: PMC9146986 DOI: 10.3390/jpm12050780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose: To develop a method of coronary flow reserve (CFR) calculation derived from three-dimensional (3D) coronary angiographic parameters and intracoronary pressure data during fractional flow reserve (FFR) measurement. Methods: Altogether 19 coronary arteries of 16 native and 3 stented vessels were reconstructed in 3D. The measured distal intracoronary pressures were corrected to the hydrostatic pressure based on the height differences between the levels of the vessel orifice and the sensor position. Classical fluid dynamic equations were applied to calculate the flow during the resting state and vasodilatation based on morphological data and intracoronary pressure values. 3D-derived coronary flow reserve (CFRp-3D) was defined as the ratio between the calculated hyperemic and the resting flow and was compared to the CFR values simultaneously measured by the Doppler sensor (CFRDoppler). Results: Haemodynamic calculations using the distal coronary pressures corrected for hydrostatic pressures showed a strong correlation between the individual CFRp-3D values and the CFRDoppler measurements (r = 0.89, p < 0.0001). Hydrostatic pressure correction increased the specificity of the method from 46.1% to 92.3% for predicting an abnormal CFRDoppler < 2. Conclusions: CFRp-3D calculation with hydrostatic pressure correction during FFR measurement facilitates a comprehensive hemodynamic assessment, supporting the complex evaluation of macro-and microvascular coronary artery disease.
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Affiliation(s)
- Balázs Tar
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - András Ágoston
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - Áron Üveges
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - Gábor Tamás Szabó
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | - Tibor Szűk
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | | | - Dániel Czuriga
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (G.P.)
| | - György Paál
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (G.P.)
| | - Zsolt Kőszegi
- Kálmán Laki Doctoral School of Biomedical and Clinical Sciences, University of Debrecen, 4032 Debrecen, Hungary; (B.T.); (A.Á.); (Á.Ü.); (G.T.S.); (T.S.); (D.C.)
- Szabolcs–Szatmár–Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
- Institute of Cardiology, University of Debrecen, 4032 Debrecen, Hungary
- Correspondence:
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Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SE, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. A Practical Approach to Invasive Testing in Ischemia with No Obstructive Coronary Arteries (INOCA). CJC Open 2022; 4:709-720. [PMID: 36035733 PMCID: PMC9402961 DOI: 10.1016/j.cjco.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
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Affiliation(s)
- Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
- Corresponding author: Dr Alexandra Bastiany, Thunder Bay Regional Health Sciences Centre, Catheterization Laboratory, 980 Oliver Rd, Thunder Bay, Ontario P7B 6V4, Canada. Tel.: +1-807-622-3091; fax: +1-807-333-0903.
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Université de Montréal, Montreal, Quebec, Canada
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Tara Sedlak
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaqueline Saw
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Shuangbo Liu
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Lavoie
- Saskatchewan Health Authority and Regina Mosaic Heart Centre, Regina, Saskatchewan, Canada
| | - Daniel H. Kim
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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