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Pizzo E, Cervantes DO, Ketkar H, Ripa V, Nassal DM, Buck B, Parambath SP, Di Stefano V, Singh K, Thompson CI, Mohler PJ, Hund TJ, Jacobson JT, Jain S, Rota M. Phosphorylation of cardiac sodium channel at Ser571 anticipates manifestations of the aging myopathy. Am J Physiol Heart Circ Physiol 2024; 326:H1424-H1445. [PMID: 38639742 DOI: 10.1152/ajpheart.00325.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
Diastolic dysfunction and delayed ventricular repolarization are typically observed in the elderly, but whether these defects are intimately associated with the progressive manifestation of the aging myopathy remains to be determined. In this regard, aging in experimental animals is coupled with increased late Na+ current (INa,L) in cardiomyocytes, raising the possibility that INa,L conditions the modality of electrical recovery and myocardial relaxation of the aged heart. For this purpose, aging male and female wild-type (WT) C57Bl/6 mice were studied together with genetically engineered mice with phosphomimetic (gain of function, GoF) or ablated (loss of function, LoF) mutations of the sodium channel Nav1.5 at Ser571 associated with, respectively, increased and stabilized INa,L. At ∼18 mo of age, WT mice developed prolonged duration of the QT interval of the electrocardiogram and impaired diastolic left ventricular (LV) filling, defects that were reversed by INa,L inhibition. Prolonged repolarization and impaired LV filling occurred prematurely in adult (∼5 mo) GoF mutant mice, whereas these alterations were largely attenuated in aging LoF mutant animals. Ca2+ transient decay and kinetics of myocyte shortening/relengthening were delayed in aged (∼24 mo) WT myocytes, with respect to adult cells. In contrast, delayed Ca2+ transients and contractile dynamics occurred at adult stage in GoF myocytes and further deteriorated in old age. Conversely, myocyte mechanics were minimally affected in aging LoF cells. Collectively, these results document that Nav1.5 phosphorylation at Ser571 and the late Na+ current modulate the modality of myocyte relaxation, constituting the mechanism linking delayed ventricular repolarization and diastolic dysfunction.NEW & NOTEWORTHY We have investigated the impact of the late Na current (INa,L) on cardiac and myocyte function with aging by using genetically engineered animals with enhanced or stabilized INa,L, due to phosphomimetic or phosphoablated mutations of Nav1.5. Our findings support the notion that phosphorylation of Nav1.5 at Ser571 prolongs myocardial repolarization and impairs diastolic function, contributing to the manifestations of the aging myopathy.
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Affiliation(s)
- Emanuele Pizzo
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Daniel O Cervantes
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Harshada Ketkar
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York, United States
| | - Valentina Ripa
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Drew M Nassal
- The Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, Ohio, United States
| | - Benjamin Buck
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, United States
| | - Sreema P Parambath
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York, United States
| | - Valeria Di Stefano
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Kanwardeep Singh
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Carl I Thompson
- Department of Physiology, New York Medical College, Valhalla, New York, United States
| | - Peter J Mohler
- The Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, United States
- Department of Physiology and Cell Biology, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Thomas J Hund
- The Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
- Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, Ohio, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, United States
| | - Jason T Jacobson
- Department of Physiology, New York Medical College, Valhalla, New York, United States
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, United States
| | - Sudhir Jain
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York, United States
| | - Marcello Rota
- Department of Physiology, New York Medical College, Valhalla, New York, United States
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Ling H, Fu S, Xu M, Wang B, Li B, Li Y, Liu X, Zhang X, Wang Q, Li A, Liu M. Ranolazine for improving coronary microvascular function in patients with nonobstructive coronary artery disease: a systematic review and meta-analysis with a trial sequential analysis of randomized controlled trials. Quant Imaging Med Surg 2024; 14:1451-1465. [PMID: 38415135 PMCID: PMC10895086 DOI: 10.21037/qims-23-1029] [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: 07/20/2023] [Accepted: 11/23/2023] [Indexed: 02/29/2024]
Abstract
Background Microvascular dysfunction in patients with nonobstructive coronary artery disease is increasingly being recognized as an important health issue. This systematic review and meta-analysis evaluated the effectiveness of ranolazine, an antianginal agent, in improving coronary microvascular function. Methods We conducted a comprehensive literature search of the Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, the Chinese BioMedical Literature Database, and gray literature databases until September 30, 2023. The included studies were randomized controlled trials (RCTs) published in the English or Chinese languages that screened for eligibility using two independent investigators. Risk of bias was evaluated with the Cochrane Collaboration tool. Subgroup and sensitivity analyses were used to identify sources of heterogeneity. Meta-analysis was performed using RevMan version 5.4 (Cochrane) and Stata version 16.0 (StataCorp). Results From 1,470 citations, 8 RCTs involving 379 participants were included in this analysis. Our findings showed that ranolazine increased coronary flow reserve (CFR) over an 8 to 12-week follow-up period [standardized mean difference =1.16; 95% confidence interval (CI): 0.4-1.89; P=0.002]. Ranolazine increased the global myocardial perfusion reserve index (MPRI) [weighted mean difference (WMD) =0.18; 95% CI: 0.07-0.29; P=0.002] and the midsubendocardial MPRI (WMD =0.10; 95% CI: 0.02-0.19; P=0.02). Moreover, ranolazine improved 3 of the 5 Seattle Angina Questionnaire scores, namely, physical functioning (WMD =4.89; 95% CI: 0.14 to 9.64; P=0.04), angina stability (WMD =17.31; 95% CI: 7.13-27.49; P=0.0009), and quality of life (WMD =10.11; 95% CI: 3.57-16.65; P=0.0003). Trial sequential analysis showed that the meta-analysis of angina stability and quality of life scores had a sufficient sample size and statistical power. Conclusions Our analysis suggests that ranolazine is associated with improvements in CFR, myocardial perfusion, and the Seattle Angina Questionnaire scores in patients with nonobstructive coronary artery disease. However, further large-scale RCTs with long-term follow-up are recommended to validate these findings and provide a more comprehensive understanding of the effects of ranolazine on coronary microvascular function.
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Affiliation(s)
- Hao Ling
- Department of Radiology, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
| | - Sunjing Fu
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengting Xu
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Bing Wang
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingwei Li
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan Li
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xueting Liu
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyan Zhang
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qin Wang
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ailing Li
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Mingming Liu
- Institute of Microcirculation, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- International Center of Microvascular Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Diabetes Research Center, Chinese Academy of Medical Sciences, Beijing, China
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Yang Z, Liu Y, Li Z, Feng S, Lin S, Ge Z, Fan Y, Wang Y, Wang X, Mao J. Coronary microvascular dysfunction and cardiovascular disease: Pathogenesis, associations and treatment strategies. Biomed Pharmacother 2023; 164:115011. [PMID: 37321056 DOI: 10.1016/j.biopha.2023.115011] [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: 04/21/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023] Open
Abstract
Coronary microvascular dysfunction (CMD) is a high-risk factor for a variety of cardiovascular events. Due to its complex aetiology and concealability, knowledge of the pathophysiological mechanism of CMD is still limited at present, which greatly restricts its clinical diagnosis and treatment. Studies have shown that CMD is closely related to a variety of cardiovascular diseases, can aggravate the occurrence and development of cardiovascular diseases, and is closely related to a poor prognosis in patients with cardiovascular diseases. Improving coronary microvascular remodelling and increasing myocardial perfusion might be promising strategies for the treatment of cardiovascular diseases. In this paper, the pathogenesis and functional assessment of CMD are reviewed first, along with the relationship of CMD with cardiovascular diseases. Then, the latest strategies for the treatment of CMD and cardiovascular diseases are summarized. Finally, urgent scientific problems in CMD and cardiovascular diseases are highlighted and future research directions are proposed to provide prospective insights for the prevention and treatment of CMD and cardiovascular diseases in the future.
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Affiliation(s)
- Zhihua Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China; Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Yangxi Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhenzhen Li
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Shaoling Feng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Shanshan Lin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Zhao Ge
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yujian Fan
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Yi Wang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Xianliang Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
| | - Jingyuan Mao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China.
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Cempaka Putri DKS, Andrianto A, Al-Farabi MJ, Saputra PBT, Nugraha RA. Efficacy of Ranolazine to Improve Diastolic Performance in Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-analysis. Eur Cardiol 2023; 18:e02. [PMID: 36844933 PMCID: PMC9947928 DOI: 10.15420/ecr.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/01/2022] [Indexed: 01/24/2023] Open
Abstract
This article evaluates the efficacy of using ranolazine to improve diastolic performance and exercise capacity in heart failure with preserved ejection fraction. A comprehensive literature review found eight trials where there are no significant difference in peak O2 (p=0.09) and exercise duration (p=0.18) between ranolazine and placebo. The ranolazine group had significantly higher and better diastolic parameters compared to placebo, with a mean difference of 0.45 (95% CI [27.18-39.50]). There were no significant differences for haemodynamic parameters (blood pressure and heart rate) and electrocardiography (QT interval) between ranolazine and placebo. The review found that ranolazine has good wefficacy to improve diastolic performance among heart failure with preserved ejection fraction patients and it does not affect blood pressure, heart rate and rate of ventricular repolarisation (shortening of the QT interval).
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Affiliation(s)
- Desak Ketut Sekar Cempaka Putri
- Department of Cardiology and Vascular Medicine, Soetomo General Hospital, Faculty of Medicine, Universitas AirlanggaSurabaya, Indonesia
| | - Andrianto Andrianto
- Department of Cardiology and Vascular Medicine, Soetomo General Hospital, Faculty of Medicine, Universitas AirlanggaSurabaya, Indonesia
| | - Makhyan Jibril Al-Farabi
- Department of Cardiology and Vascular Medicine, Soetomo General Hospital, Faculty of Medicine, Universitas AirlanggaSurabaya, Indonesia
| | | | - Ricardo Adrian Nugraha
- Department of Cardiology and Vascular Medicine, Soetomo General Hospital, Faculty of Medicine, Universitas AirlanggaSurabaya, Indonesia
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Effects of ranolazine on various outcomes in patients with stable angina: an updated meta-analysis. Hellenic J Cardiol 2022; 71:26-32. [PMID: 36481415 DOI: 10.1016/j.hjc.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/24/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We determined the effect of ranolazine vs. placebo in angina patients on 1) selective measures of the ischemic burden, 2) cardiovascular outcomes, including atrial fibrillation incidence, 3) the in-treatment glycohemoglobin levels and the permanent discontinuations because of side effects, and 4) the achieved between-arms blood pressure and heart rate difference. METHODS PubMed and Cochrane Collaboration Library databases were searched for eligible trials until end of September 2020. Trial quality was assessed by the Rob2 tool. Risk ratios or achieved mean differences during follow-up and 95% confidence interval (CI) of categorical or continuous outcomes, respectively, were calculated (random-effects model). The relationship between discontinuation rates and ranolazine's mean dose was investigated by meta-regression analysis. RESULTS We selected 18 trials (n = 12,995 patients in patients with macro or microvascular coronary heart disease. Achieved blood pressure and heart rate at rest were not different between randomized arms. Ranolazine administration compared to placebo was associated with an increase of 1) total exercise duration by 30 seconds (95% CI, 18-42), 2) time to 1 mm ST-segment depression by 44 seconds (95% CI, 30-54), and 3) time to angina onset by 40 seconds (95% CI, 30-54). On average, the incidence of atrial fibrillation was reduced by 25% following ranolazine treatment compared to placebo, while glycohemoglobin showed a mean decrease of 0.4% (95% CI, 0.3-0.5%). DISCUSSION Ranolazine remains an effective anti-ischemic drug, increases the angina-free exercise duration, delays the onset of ST-segment depression. The beneficial effects of ranolazine are extended to atrial fibrillation reduction rates and better glycemic control.
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Divakaran S, Caron JP, Zhou W, Hainer J, Bibbo CF, Skali H, Taqueti VR, Dorbala S, Blankstein R, Groarke JD, Nohria A, Di Carli MF. Coronary vasomotor dysfunction portends worse outcomes in patients with breast cancer. J Nucl Cardiol 2022; 29:3072-3081. [PMID: 34820770 PMCID: PMC9126993 DOI: 10.1007/s12350-021-02825-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/17/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Impaired MFR in the absence of flow-limiting CAD is associated with adverse events. Cardiovascular disease is an important cause of morbidity and mortality in patients with breast cancer. We sought to test the utility of MFR to predict outcomes in a cohort of patients with breast cancer. METHODS We retrospectively studied consecutive patients with breast cancer or breast cancer survivors who underwent cardiac stress PET imaging from 2006 to 2017 at Brigham and Women's Hospital. Patients with a history of clinically overt CAD, LVEF < 45%, or abnormal myocardial perfusion were excluded. Subjects were followed from time of PET to the occurrence of a first major adverse cardiovascular event (MACE) and all-cause death. RESULTS The final cohort included 87 patients (median age 69.0 years, 98.9% female, mean MFR 2.05). Over a median follow-up of 7.6 years after PET, the lowest MFR tertile was associated with higher cumulative incidence of MACE (adjusted subdistribution hazard ratio 4.91; 95% CI 1.68-14.38; p = 0.004) when compared with the highest MFR tertile. CONCLUSIONS In patients with breast cancer, coronary vasomotor dysfunction was associated with incident cardiovascular events. MFR may have potential as a risk stratification biomarker among patients with/survivors of breast cancer.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jesse P Caron
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA.
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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8
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Coronary Microvascular Dysfunction in Diabetes Mellitus: Pathogenetic Mechanisms and Potential Therapeutic Options. Biomedicines 2022; 10:biomedicines10092274. [PMID: 36140374 PMCID: PMC9496134 DOI: 10.3390/biomedicines10092274] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/04/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Diabetic patients are frequently affected by coronary microvascular dysfunction (CMD), a condition consisting of a combination of altered vasomotion and long-term structural change to coronary arterioles leading to impaired regulation of blood flow in response to changing cardiomyocyte oxygen requirements. The pathogenesis of this microvascular complication is complex and not completely known, involving several alterations among which hyperglycemia and insulin resistance play particularly central roles leading to oxidative stress, inflammatory activation and altered barrier function of endothelium. CMD significantly contributes to cardiac events such as angina or infarction without obstructive coronary artery disease, as well as heart failure, especially the phenotype associated with preserved ejection fraction, which greatly impact cardiovascular (CV) prognosis. To date, no treatments specifically target this vascular damage, but recent experimental studies and some clinical investigations have produced data in favor of potential beneficial effects on coronary micro vessels caused by two classes of glucose-lowering drugs: glucagon-like peptide 1 (GLP-1)-based therapy and inhibitors of sodium-glucose cotransporter-2 (SGLT2). The purpose of this review is to describe pathophysiological mechanisms, clinical manifestations of CMD with particular reference to diabetes, and to summarize the protective effects of antidiabetic drugs on the myocardial microvascular compartment.
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Fernández-Torras A, Duran-Frigola M, Bertoni M, Locatelli M, Aloy P. Integrating and formatting biomedical data as pre-calculated knowledge graph embeddings in the Bioteque. Nat Commun 2022; 13:5304. [PMID: 36085310 PMCID: PMC9463154 DOI: 10.1038/s41467-022-33026-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/30/2022] [Indexed: 12/25/2022] Open
Abstract
Biomedical data is accumulating at a fast pace and integrating it into a unified framework is a major challenge, so that multiple views of a given biological event can be considered simultaneously. Here we present the Bioteque, a resource of unprecedented size and scope that contains pre-calculated biomedical descriptors derived from a gigantic knowledge graph, displaying more than 450 thousand biological entities and 30 million relationships between them. The Bioteque integrates, harmonizes, and formats data collected from over 150 data sources, including 12 biological entities (e.g., genes, diseases, drugs) linked by 67 types of associations (e.g., ‘drug treats disease’, ‘gene interacts with gene’). We show how Bioteque descriptors facilitate the assessment of high-throughput protein-protein interactome data, the prediction of drug response and new repurposing opportunities, and demonstrate that they can be used off-the-shelf in downstream machine learning tasks without loss of performance with respect to using original data. The Bioteque thus offers a thoroughly processed, tractable, and highly optimized assembly of the biomedical knowledge available in the public domain. Biomedical data is accumulating at a fast pace and integrating it into a unified framework is a major challenge. Here, the authors present a resource that contains pre-calculated biomedical descriptors derived from a very large knowledge graph.
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Affiliation(s)
- Adrià Fernández-Torras
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Catalonia, Spain
| | - Miquel Duran-Frigola
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Catalonia, Spain.,Ersilia Open Source Initiative, Cambridge, UK
| | - Martino Bertoni
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Catalonia, Spain
| | - Martina Locatelli
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Catalonia, Spain
| | - Patrick Aloy
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Catalonia, Spain. .,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain.
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10
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Yang Z, Lin S, Liu Y, Ren Q, Ge Z, Wang C, Bi Y, Wang X, Mao J. Traditional chinese medicine in coronary microvascular disease. Front Pharmacol 2022; 13:929159. [PMID: 36003524 PMCID: PMC9393228 DOI: 10.3389/fphar.2022.929159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary microvascular disease (CMVD) is common in patients with cardiovascular risk factors and is associated with an increased risk of adverse cardiovascular events. Although the study of CMVD in modern medicine is ongoing, there is still no effective treatment for it. Traditional Chinese medicine (TCM) has some clinical advantages based on syndrome differentiation and individualized treatment. In this review, we review the clinical significance, pathogenesis, and current treatments of CMVD and systematically summarize the clinical efficacy and potential action mechanisms of TCM for CMVD. In addition, the scientific problems that need to be solved urgently and the research strategy of TCM for CMVD are described. CMVD has great clinical significance, but there are still many gaps in the related research. This review aims to attract the attention of clinicians to CMVD and promote research on CMVD in TCM.
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Affiliation(s)
- Zhihua Yang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shanshan Lin
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangxi Liu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qiuan Ren
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhao Ge
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ci Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingfei Bi
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xianliang Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingyuan Mao
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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11
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Zhan J, Zhong L, Wu J. Assessment and Treatment for Coronary Microvascular Dysfunction by Contrast Enhanced Ultrasound. Front Cardiovasc Med 2022; 9:899099. [PMID: 35795368 PMCID: PMC9251174 DOI: 10.3389/fcvm.2022.899099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
With growing evidence in clinical practice, the understanding of coronary syndromes has gradually evolved out of focusing on the well-established link between stenosis of epicardial coronary artery and myocardial ischemia to the structural and functional abnormalities at the level of coronary microcirculation, known as coronary microvascular dysfunction (CMD). CMD encompasses several pathophysiological mechanisms of coronary microcirculation and is considered as an important cause of myocardial ischemia in patients with angina symptoms without obstructive coronary artery disease (CAD). As a result of growing knowledge of the understanding of CMD assessed by multiple non-invasive modalities, CMD has also been found to be involved in other cardiovascular diseases, including primary cardiomyopathies as well as heart failure with preserved ejection fraction (HFpEF). In the past 2 decades, almost all the imaging modalities have been used to non-invasively quantify myocardial blood flow (MBF) and promote a better understanding of CMD. Myocardial contrast echocardiography (MCE) is a breakthrough as a non-invasive technique, which enables assessment of myocardial perfusion and quantification of MBF, exhibiting promising diagnostic performances that were comparable to other non-invasive techniques. With unique advantages over other non-invasive techniques, MCE has gradually developed into a novel modality for assessment of the coronary microvasculature, which may provide novel insights into the pathophysiological role of CMD in different clinical conditions. Moreover, the sonothrombolysis and the application of artificial intelligence (AI) will offer the opportunity to extend the use of contrast ultrasound theragnostics.
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12
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Cervantes DO, Pizzo E, Ketkar H, Parambath SP, Tang S, Cianflone E, Cannata A, Vinukonda G, Jain S, Jacobson JT, Rota M. Scn1b expression in the adult mouse heart modulates Na + influx in myocytes and reveals a mechanistic link between Na + entry and diastolic function. Am J Physiol Heart Circ Physiol 2022; 322:H975-H993. [PMID: 35394857 PMCID: PMC9076421 DOI: 10.1152/ajpheart.00465.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
Voltage-gated sodium channels (VGSCs) are macromolecular assemblies composed of a number of proteins regulating channel conductance and properties. VGSCs generate Na+ current (INa) in myocytes and play fundamental roles in excitability and impulse conduction in the heart. Moreover, VGSCs condition mechanical properties of the myocardium, a process that appears to involve the late component of INa. Variants in the gene SCN1B, encoding the VGSC β1- and β1B-subunits, result in inherited neurological disorders and cardiac arrhythmias. But the precise contributions of β1/β1B-subunits and VGSC integrity to the overall function of the adult heart remain to be clarified. For this purpose, adult mice with cardiac-restricted, inducible deletion of Scn1b (conditional knockout, cKO) were studied. Myocytes from cKO mice had increased densities of fast (+20%)- and slow (+140%)-inactivating components of INa, with respect to control cells. By echocardiography and invasive hemodynamics, systolic function was preserved in cKO mice, but diastolic properties and ventricular compliance were compromised, with respect to control animals. Importantly, inhibition of late INa with GS967 normalized left ventricular filling pattern and isovolumic relaxation time in cKO mice. At the cellular level, cKO myocytes presented delayed kinetics of Ca2+ transients and cell mechanics, defects that were corrected by inhibition of INa. Collectively, these results document that VGSC β1/β1B-subunits modulate electrical and mechanical function of the heart by regulating, at least in part, Na+ influx in cardiomyocytes.NEW & NOTEWORTHY We have investigated the consequences of deletion of Scn1b, the gene encoding voltage-gated sodium channel β1-subunits, on myocyte and cardiac function. Our findings support the notion that Scn1b expression controls properties of Na+ influx and Ca2+ cycling in cardiomyocytes affecting the modality of cell contraction and relaxation. These effects at the cellular level condition electrical recovery and diastolic function in vivo, substantiating the multifunctional role of β1-subunits in the physiology of the heart.
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Affiliation(s)
| | - Emanuele Pizzo
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Harshada Ketkar
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York
| | - Sreema P Parambath
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York
| | - Samantha Tang
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York
| | - Eleonora Cianflone
- Department of Physiology, New York Medical College, Valhalla, New York
- Molecular and Cellular Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Antonio Cannata
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, United Kingdom
| | | | - Sudhir Jain
- Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, New York
| | - Jason T Jacobson
- Department of Physiology, New York Medical College, Valhalla, New York
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Marcello Rota
- Department of Physiology, New York Medical College, Valhalla, New York
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13
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Manolis AJ, Boden WE, Collins P, Dechend R, Kallistratos MS, Lopez Sendon J, Poulimenos LE, Ambrosio G, Rosano G. State of the art approach to managing angina and ischemia: tailoring treatment to the evidence. Eur J Intern Med 2021; 92:40-47. [PMID: 34419311 DOI: 10.1016/j.ejim.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/24/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
Stable angina represents a chronic and often debilitating condition that affects daily activities and quality of life in patients with chronic coronary syndromes (CCS). Current European Society of Cardiology guidelines recommend a four-step approach for the medical treatment of patients taking into consideration hemodynamic variables (heart rate and blood pressure) and the presence or absence of left ventricular dysfunction. However, CCS patients often have several comorbidities and risk factors. Thus, a tailored approach that takes into consideration patient risk factors and comorbidities may have additional benefits beyond angina relief. This is a state of the art review of stable angina treatment based on the currently available evidence.
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Affiliation(s)
- A J Manolis
- Asklepeion General Hospital, Cardiology Department, Athens, Greece; Metropolitan General Hospital, Cardiology Department, Athens, Greece.
| | - W E Boden
- Department of Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA; Boston University School of Medicine, Boston, Massachusetts, USA
| | - P Collins
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, United Kingdom
| | - R Dechend
- Experimental and Clinical Research Center, a joint cooperation between Max-Delbruck Center for Molecular Medicine and Charité - Universitatsmedizin Berlin and HELIOS Clinic Department of Cardiology and Nephrology, Germany
| | - M S Kallistratos
- Asklepeion General Hospital, Cardiology Department, Athens, Greece
| | - J Lopez Sendon
- Servicio de Cardiología, Hospital Universitario La Paz, Instituto de Investigación La Paz (IdiPAZ), Madrid, Spain
| | - L E Poulimenos
- Asklepeion General Hospital, Cardiology Department, Athens, Greece
| | - G Ambrosio
- Division of Cardiology University of Perugia School of Medicine, Italy
| | - G Rosano
- St George's Hospitals NHS Trust University of London - IRCCS San Raffaele Roma, Italy
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14
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Sharp RP, Patatanian E, Sirajuddin R. Use of Ranolazine for the Treatment of Coronary Microvascular Dysfunction. Am J Cardiovasc Drugs 2021; 21:513-521. [PMID: 33438139 DOI: 10.1007/s40256-020-00462-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/24/2022]
Abstract
Coronary microvascular dysfunction (CMD) is defined as a mismatch of myocardial blood supply and oxygen consumption due to a dysfunction of the coronary microvessels. Up to 20-30% of patients with CMD have progressive worsening of symptoms with significant impairment of quality of life. Large-scale randomized studies of the pharmacologic treatment of CMD are lacking. Classic anti-ischemic drugs are the initial form of treatment, but efficacy is often limited. Ranolazine has a unique mechanism of action that does not affect blood pressure or heart rate. When added to existing anti-anginal agents, ranolazine improved at least one domain in eight of ten studies in which a questionnaire was used to assess patient health status. Five studies evaluated coronary arterial flow reserve (CFR), reporting that patients with low values had significant improvement in CFR and suggesting that those with more severe CMD respond more favorably to ranolazine. In two studies, exercise duration and time to myocardial ischemia were significantly increased after treatment with ranolazine. Data are lacking for ranolazine use as the sole agent for CMD treatment. Some questions remain to be answered regarding ranolazine use for CMD. Larger studies of longer duration are needed to verify the effectiveness of ranolazine in the treatment of CMD.
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Affiliation(s)
- Randall P Sharp
- Department of Pharmacy Practice c/o Heart Solutions of Oklahoma, College of Pharmacy, Southwestern Oklahoma State University, 10413 Greenbriar Parkway, Oklahoma City, OK, 73159, USA.
| | - Edna Patatanian
- College of Pharmacy, Southwestern Oklahoma State University, 100 Campus Drive, Weatherford, OK, 73096, USA
| | - Riaz Sirajuddin
- Heart Solutions of Oklahoma, 10413 Greenbriar Parkway, Oklahoma City, OK, 73159, USA
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15
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Reynolds HR, Picard MH, Spertus JA, Peteiro J, Lopez-Sendon JL, Senior R, El-Hajjar MC, Celutkiene J, Shapiro MD, Pellikka PA, Kunichoff DF, Anthopolos R, Alfakih K, Abdul-Nour K, Khouri M, Bershtein L, De Belder M, Poh KK, Beltrame JF, Min JK, Fleg JL, Li Y, Maron DJ, Hochman JS. Natural History of Patients with Ischemia and No Obstructive Coronary Artery Disease: The CIAO-ISCHEMIA Study. Circulation 2021; 144:1008-1023. [PMID: 34058845 DOI: 10.1161/circulationaha.120.046791] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Ischemia with no obstructive coronary artery disease (INOCA) is common and has an adverse prognosis. We set out to describe the natural history of symptoms and ischemia in INOCA. Methods: CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in ISCHEMIA trial screen failures with INOCA) was an international cohort study conducted from 2014-2019 involving angina assessments (Seattle Angina Questionnaire [SAQ]) and stress echocardiograms 1-year apart. This was an ancillary study that included patients with history of angina who were not randomized in the ISCHEMIA trial. Stress-induced wall motion abnormalities were determined by an echocardiographic core laboratory blinded to symptoms, coronary artery disease (CAD) status and test timing. Medical therapy was at the discretion of treating physicians. The primary outcome was the correlation between changes in SAQ Angina Frequency score and change in echocardiographic ischemia. We also analyzed predictors of 1-year changes in both angina and ischemia, and compared CIAO participants with ISCHEMIA participants with obstructive CAD who had stress echocardiography before enrollment, as CIAO participants did. Results: INOCA participants in CIAO were more often female (66% of 208 vs. 26% of 865 ISCHEMIA participants with obstructive CAD, p<0.001), but the magnitude of ischemia was similar (median 4 ischemic segments [IQR 3-5] both groups). Ischemia and angina were not significantly correlated at enrollment in CIAO (p=0.46) or ISCHEMIA stress echocardiography participants (p=0.35). At 1 year, the stress echocardiogram was normal in half of CIAO participants and 23% had moderate or severe ischemia (≥3 ischemic segments). Angina improved in 43% and worsened in 14%. Change in ischemia over one year was not significantly correlated with change in angina (rho=0.029). Conclusions:Improvement in ischemia and improvement in angina were common in INOCA, but not correlated. Our INOCA cohort had a similar degree of inducible wall motion abnormalities to concurrently enrolled ISCHEMIA participants with obstructive CAD. Our results highlight the complex nature of INOCA pathophysiology and the multifactorial nature of angina. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02347215.
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Affiliation(s)
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña,/CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Royal Brompton Hospital, London, UK; Northwick Park Hospital, Harrow, UK
| | | | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine/ State Research Institute Centre For Innovative Medicine, Vilnius, Lithuania
| | | | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, UNITED STATES
| | | | | | | | | | | | - Leonid Bershtein
- Internal Medicine & Cardiology, North-Western State Medical University n.a. I.I Mechnikov, Saint Petersburg, Russia, RUSSIAN FEDERATION
| | | | - Kian Keong Poh
- National University Heart Centre, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - John F Beltrame
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - James K Min
- University of Adelaide /Central Adelaide Local Health Network, South Australia, Adelaide, Australia
| | | | - Yi Li
- New York University Grossman School of Medicine, New York, NY
| | - David J Maron
- National Heart, Lung, and Blood Institute, Bethesda, MD
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16
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Elevated serum endothelin-1 is an independent predictor of coronary microvascular dysfunction in non-obstructive territories in patients with coronary artery disease. Heart Vessels 2021; 36:917-923. [PMID: 33484293 DOI: 10.1007/s00380-020-01767-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
Endothelin-1 contributes to the constrictor response of the coronary arteries in patients with ischemia with normal coronary arteries. There is thus increasing evidence that endothelin-1 plays a role in coronary microvascular dysfunction (CMD). We investigated whether elevated endothelin-1 is associated with CMD in patients with coronary artery disease (CAD). We prospectively studied 49 consecutive CAD patients with 1- or 2-vessel disease (age 71 ± 10 years, 43 males). Myocardial blood flow (MBF) was measured by 15O-water PET/CT at rest and during stress, and the coronary flow reserve (CFR) was calculated by dividing the stress MBF by the rest MBF. A CFR of less than 2.0 in non-obstructive regions was defined as a marker of CMD. Eighteen out of 49 (37%) CAD patients had CMD. Endothelin-1 in patients with CMD was significantly higher than in those without CMD (2.27 ± 0.81 vs. 1.64 ± 0.48 pg/mL, P = 0.001). Accordingly, univariate ROC analysis showed that the continuous endothelin-1 levels significantly discriminated between the presence and absence of CMD (area under the curve = 0.746 [95%CI 0.592-0.899]). The dichotomous treatment of elevated endothelin-1 as 1.961 pg/mL or more yielded the optimal discriminatory capacity, with a sensitivity of 72.2% and a specificity of 71.0%. High endothelin-1 was still a significant predictor of CMD after adjusting for diabetes mellitus (odds ratio = 6.64 [1.75-25.22], P = 0.005). Endothelin-1 is associated with CMD in non-obstructive territories in patients with CAD, suggesting that endothelin-1 is a potential target for treating CMD in CAD patients.
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17
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Kofler T, Hess S, Moccetti F, Pepine CJ, Attinger A, Wolfrum M, Toggweiler S, Kobza R, Cuculi F, Bossard M. Efficacy of Ranolazine for Treatment of Coronary Microvascular Dysfunction-A Systematic Review and Meta-analysis of Randomized Trials. CJC Open 2021; 3:101-108. [PMID: 33458636 PMCID: PMC7801206 DOI: 10.1016/j.cjco.2020.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is a common cause of angina and exercise intolerance in patients without obstructive coronary artery disease. The efficacy of ranolazine, a late sodium channel blocker, in patients with symptomatic obstructive coronary artery disease is well established. To evaluate the efficacy of ranolazine in CMD, we performed a systematic review and meta-analysis of randomized studies. Methods MEDLINE, EMBASE, Cochrane CENTRAL, and conference abstracts were searched from January 1975 to March 2020. Randomized trials evaluating ranolazine in patients with CMD were screened. Two reviewers independently extracted data and assessed study quality. End points of interest included a change in angina measured by the Seattle Angina Questionnaire (SAQ), coronary flow reserve (CFR), and clinical outcomes. Data were combined using random-effects models. Results Of 836 citations, 6 randomized studies (318 patients) were included. Median follow-up was 4 weeks. When pooling the 6 trials analyzing ranolazine, we found that patients treated with ranolazine had a higher SAQ value regarding physical functioning (mean difference, 6.42; 95% confidence interval [CI], 2.41; 10.42) quality of life (10.07; 95% CI, 3.4; 16.74), and angina stability (20.14; 95% CI, 10.12; 30.17), as well as improved CFR (0.27; 95% CI, 0.09; 0.45) compared with placebo/control therapy. A high heterogeneity was observed (range I2, 30%-84%). Conclusions In CMD, ranolazine may be associated with improvements in CFR and some of the SAQ domains, including angina stability, physical functioning, and quality of life. However, it does not seem to beneficially impact angina frequency and treatment satisfaction. It is also unknown if it improves prognosis of afflicted patients.
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Affiliation(s)
- Thomas Kofler
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefanie Hess
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Federico Moccetti
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Adrian Attinger
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Mathias Wolfrum
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefan Toggweiler
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
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18
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Koh JS, Hung OY, Eshtehardi P, Kumar A, Rabah R, Raad M, Kumar S, Chaudhry S, Gupta S, Hosseini H, Brilakis E, Corban M, Sabbak N, Burnett GM, Liu C, Mehta PK, Quyyumi AA, Samady H. Microvascular Assessment of Ranolazine in Non-Obstructive Atherosclerosis: The MARINA Randomized, Double-Blinded, Controlled Pilot Trial. Circ Cardiovasc Interv 2020; 13:e008204. [PMID: 33272036 DOI: 10.1161/circinterventions.119.008204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Microvascular dysfunction is known to play a key role in patients with angina and nonobstructive coronary artery disease. We investigated the impact of ranolazine among patients with angina and nonobstructive coronary artery disease. METHODS In this randomized, double-blinded, placebo-controlled pilot trial, 26 patients with angina once weekly or more, abnormal stress test, and nonobstructive coronary artery disease (<50% stenosis by angiography and fractional flow reserve >0.80) were randomized 1:1 to ranolazine or placebo for 12 weeks. Primary end point was ΔSeattle Angina Questionnaire (SAQ) angina frequency score. Baseline and 3 months follow-up SAQ, Duke Activity Status Index scores along with invasive fractional flow reserve, coronary flow reserve (CFR), hyperemic myocardial resistance, and cardiopulmonary exercise testing measurements were performed. RESULTS No significant differences in ΔSAQ angina frequency scores (P=0.53) or Duke Activity Status Index (P=0.76) were observed between ranolazine versus placebo, although patients on ranolazine had lesser improvement in SAQ physical limitation scores (P=0.02) compared with placebo at 3 months. There were no significant differences in ΔCFR or Δhyperemic myocardial resistance between ranolazine and placebo groups. Patients treated with ranolazine, compared with placebo, had no significant improvement in maximum rate of oxygen consumption measured during incremental exercise (VO2 max) and peak metabolic equivalents of task. Interestingly, in the ranolazine group, patients with baseline CFR<2.0 demonstrated greater gain in CFR compared with those with baseline CFR≥2.0 (P=0.02). CONCLUSIONS Ranolazine did not demonstrate improvement in SAQ angina frequency score, invasive microvascular function, or peak metabolic equivalent compared with placebo at 3 months. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02147067.
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Affiliation(s)
- Jin-Sin Koh
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea (J.-S.K.).,Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Olivia Y Hung
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Parham Eshtehardi
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Arnav Kumar
- Interventional Cardiology, Emory University School of Medicine, Atlanta, GA (A.K.)
| | | | - Mohamad Raad
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Sonali Kumar
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | | | - Sonu Gupta
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Hossein Hosseini
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | | | - Michel Corban
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.C.)
| | - Nabil Sabbak
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Grady Murphy Burnett
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Chang Liu
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Puja K Mehta
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Arshed A Quyyumi
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.-S.K., O.Y.H., P.E., R.R., M.R., S.K., S.G., H.H., N.S., G.M.B., C.L., P.K.M., A.A.Q., H.S.)
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Lu Y, Chu X, Zhang J, Zhao Y, Jin C, Zhu J, Fu G, Qiu F. Effect of Shexiang Tongxin dropping pill on stable coronary artery disease patients with normal fractional flow reserve and coronary microvascular disease: A study protocol. Medicine (Baltimore) 2020; 99:e22126. [PMID: 32957332 PMCID: PMC7505333 DOI: 10.1097/md.0000000000022126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Coronary microvascular disease (CMVD) can affect the structure, function, and metabolism of the heart, and has an important impact on the occurrence, development and prognosis of coronary artery disease (CAD). Shexiang Tongxin dropping pill (STDP) can dilate blood vessels, alleviate inflammation, reduce endothelial damage, and improve coronary microvascular function in mice with myocardial infarction. This study aims to assess the impact of STDP on stable coronary artery disease (SCAD) patients with normal FFR and CMVD. METHODS AND ANALYSIS This is a single-center, prospective randomized trial that will enroll 64 SCAD patients, CAD with normal FFR and CMVD. Patients will be randomly divided into study group and control group in a 1:1 fashion. On the basis of conventional drug treatment, the former will receive STDP while the latter will not. The follow-up period of the subjects is 12 months, and clinical follow-up will be conducted before discharge, 30 days, 3 months, 6 months, and 12 months after procedure to complete the detection of relevant indicators. The primary endpoint is the change of index of microcirculatory resistance (ΔIMR) at 12-month follow-up. DISCUSSION The present study will be the first randomized control study to evaluate the efficacy and safety of STDP on SCAD patients, CAD with normal FFR and CMVD, which will provide a broader idea and more experimental basis for improving the treatment of CMVD. TRIAL REGISTRATION This is a protocol for the randomized clinical trial which has been registered in the Chinese clinical Trial Registry with an identifier: ChiCTR2000032429.
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20
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Coronary Microvascular Dysfunction and the Role of Noninvasive Cardiovascular Imaging. Diagnostics (Basel) 2020; 10:diagnostics10090679. [PMID: 32916881 PMCID: PMC7555249 DOI: 10.3390/diagnostics10090679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023] Open
Abstract
Patients with coronary microvascular dysfunction (CMD) have significantly higher rates of cardiovascular events, including hospitalization for heart failure, sudden cardiac death, and myocardial infarction (MI). In CMD, several pathophysiological changes lead to functional and structural abnormalities in the coronary microvasculature, which disrupt the ability of the vessels to vasodilate and augment myocardial blood flow in response to increased myocardial oxygen demand, causing ischemia and angina. With the advent of more advanced non-invasive cardiac imaging techniques, the coronary microvasculature has been subjected to more intense study in the past two decades-this has led to further insights into the diagnosis, pathophysiology, treatment, prognosis and follow-up of CMD. This review will highlight and compare the salient features of the currently available non-invasive imaging modalities used in these patients, and discuss the clinical utility of these techniques in the workup and management of these patients.
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21
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Mavrogeni SI, Markousis-Mavrogenis G, Karapanagiotou O, Toutouzas K, Argyriou P, Velitsista S, Kanoupakis G, Apostolou D, Hautemann D, Sfikakis PP, Tektonidou MG. Silent Myocardial Perfusion Abnormalities Detected by Stress Cardiovascular Magnetic Resonance in Antiphospholipid Syndrome: A Case-Control Study. J Clin Med 2019; 8:jcm8071084. [PMID: 31340567 PMCID: PMC6678220 DOI: 10.3390/jcm8071084] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/12/2019] [Accepted: 07/20/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: To examine the prevalence of silent myocardial ischemia and fibrosis in antiphospholipid syndrome (APS), using stress cardiovascular magnetic resonance (CMR). Methods: Forty-four consecutive APS patients without prior cardiac disease (22 primary APS, 22 systemic lupus erythematosus (SLE)/APS, mean age 44 (12.9) years, 64% women) and 44 age/gender-matched controls were evaluated using CMR at 1.5 T. Steady-state free precession imaging for function assessment and adenosine stress-CMR for perfusion-fibrosis evaluation were employed. The myocardial perfusion reserve index (MPRI), and myocardial fibrosis expressed as late gadolinium enhancement (LGE), were evaluated. Coronary angiography was indicated in patients with LGE. Associations with APS characteristics, classic cardiovascular disease (CVD) risk factors, high-sensitivity CRP (hs-CRP) and high-sensitivity Troponin (hs-TnT) levels were tested. All patients were followed up for 12 months. Results: Median MPRI was significantly lower in APS patients versus controls [1.5 (0.9–1.9) vs. 2.7 (2.2–3.2), p < 0.001], independently of any LGE presence. LGE was detected in 16 (36.3%) patients versus none of controls (p < 0.001); 12/16 were subsequently examined with coronary angiography and only two of them had coronary artery lesions. In multivariable analysis, none of the APS-related and classic CVD risk factors, or hs-CRP and hs-TnT covariates, were significant predictors of abnormal MPRI or LGE. At the twelve month follow-up, three (6.8%) patients experienced coronary artery disease, notably those with the lowest MPRI values. Conclusions: Abnormal MPRI and LGE are common in asymptomatic APS patients, independently so of any APS-related and classic CVD risk factors, or coronary angiography findings in cases with LGE. Stress-CMR is a valuable tool to detect silent myocardial ischemia and fibrosis in APS.
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Affiliation(s)
| | | | | | - Konstantinos Toutouzas
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | | | | | | | - David Hautemann
- Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece.
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Ford TJ, Berry C. How to Diagnose and Manage Angina Without Obstructive Coronary Artery Disease: Lessons from the British Heart Foundation CorMicA Trial. Interv Cardiol 2019; 14:76-82. [PMID: 31178933 PMCID: PMC6545998 DOI: 10.15420/icr.2019.04.r1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/17/2019] [Indexed: 01/15/2023] Open
Abstract
Patients with symptoms and/or signs of ischaemia but no obstructive coronary artery disease (INOCA) present a diagnostic and therapeutic challenge. Microvascular and/or vasospastic angina are the two most common causes of INOCA; however, invasive coronary angiography lacks the sensitivity to diagnose these functional coronary disorders. In this article, the authors summarise the rationale for invasive testing in the absence of obstructive coronary disease, namely that correct treatment for angina patients starts with the correct diagnosis. They provide insights from the CORonary MICrovascular Angina (CorMicA) study, where an interventional diagnostic procedure was performed with linked medical therapy to improve patient health. Identification of these distinct disorders (microvascular angina, vasospastic angina or non-cardiac chest pain) is key for stratifying INOCA patients, allowing prognostic insights and better patient care with linked therapy based on contemporary guidelines. Finally, they propose a framework to diagnose and manage patients in this common clinical scenario.
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Affiliation(s)
- Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow UK
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Mehta PK, Sharma S, Minissian M, Harsch MR, Martinson M, Nyman JA, Shaw LJ, Bairey Merz CN, Wenger NK. Ranolazine Reduces Angina in Women with Ischemic Heart Disease: Results of an Open-Label, Multicenter Trial. J Womens Health (Larchmt) 2019; 28:573-582. [PMID: 30888919 DOI: 10.1089/jwh.2018.7019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Persistent angina is prevalent in women, who more often present with atypical angina, and experience less relief from antianginal therapies. The impact of ranolazine on female-specific angina is unclear. A single-arm, open-label trial was conducted to quantify the impact of ranolazine on angina in women with ischemic heart disease (IHD). Materials and Methods: Women with IHD and ≥2 angina episodes/week were recruited from 30 U.S. sites. Angina and nitroglycerin (NTG) consumption were assessed using patient-reported diaries, Seattle Angina Questionnaire (SAQ), Duke Activity Score Index (DASI), and Women's Ischemia Symptom Questionnaire (WISQ) at baseline and at 4 weeks of treatment with ranolazine 500 mg twice/day. A modified intent-to-treat analysis and parametric or nonparametric methods were used as appropriate to analyze changes. Results: Of 171 women enrolled, mean age was 65 ± 12 years. Of the 159 women included in the analysis, at week 4 compared to baseline, median angina frequency decreased with ranolazine treatment from 5.0 to 1.5 attacks/week and median change from baseline was -3.3 (95% confidence interval [CI]: -4.0 to -2.5; p ≤ 0.0001). Median NTG consumption decreased from 2.0 to 0.0 per week over the 4 weeks and median change was -1.0 (95% CI: -2.0 to -0.5; p < 0.0001). All five SAQ subscales showed mean improvements: physical limitation 9.2 (standard error [SE] 1.5; p < 0.0001), angina stability 31.8 (SE 2.7; p < 0.0001), angina frequency 17.7 (SE 1.6; p < 0.0001), treatment satisfaction 9.3 (SE 1.6; p < 0.0001), and disease perception 2.9 (SE 0.8; p < 0.0001). DASI score also improved 2.9 (SE 0.8; p = 0.0014). WISQ subscales also showed significant improvements (all p < 0.0001). Thirty-one women reported drug-related adverse events (AEs), predominantly mild to moderate gastrointestinal symptoms. Conclusions: Women with IHD treated with ranolazine for 4 weeks experienced less angina measured by SAQ and WISQ. NTG use decreased, physical activity improved, and treatment satisfaction improved. AEs were consistent with prior reports.
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Affiliation(s)
- Puja K Mehta
- 1 Division of Cardiology and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Shilpa Sharma
- 2 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Margo Minissian
- 2 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - John A Nyman
- 4 Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Leslee J Shaw
- 5 Department of Radiology, Weil Cornell Medicine, New York, New York
| | - C Noel Bairey Merz
- 2 Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Nanette K Wenger
- 1 Division of Cardiology and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia
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Taqueti VR, Di Carli MF. Coronary Microvascular Disease Pathogenic Mechanisms and Therapeutic Options: JACC State-of-the-Art Review. J Am Coll Cardiol 2018; 72:2625-2641. [PMID: 30466521 PMCID: PMC6296779 DOI: 10.1016/j.jacc.2018.09.042] [Citation(s) in RCA: 355] [Impact Index Per Article: 59.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/06/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
Coronary microvascular disease (CMD) refers to the subset of disorders affecting the structure and function of the coronary microcirculation, is prevalent in patients across a broad spectrum of cardiovascular risk factors, and is associated with an increased risk of adverse events. Contemporary evidence supports that most patients with CMD also have macrovessel atherosclerosis, which has important implications for their prognosis and management. In this state-of-the-art review, the authors summarize the pathophysiology of CMD, provide an update of diagnostic testing strategies, and classify CMD into phenotypes according to severity and coexistence with atherosclerosis. They examine emerging data highlighting the significance of CMD in specific populations, including obesity and insulin resistance, myocardial injury and heart failure with preserved ejection fraction, and nonobstructive and obstructive coronary artery disease. Finally, they discuss the role of CMD as a potential target for novel interventions beyond conventional approaches, representing a new frontier in cardiovascular disease reduction.
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Affiliation(s)
- Viviany R Taqueti
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/VTaqMD
| | - Marcelo F Di Carli
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Rambarat CA, Elgendy IY, Handberg EM, Bairey Merz CN, Wei J, Minissian MB, Nelson MD, Thomson LEJ, Berman DS, Shaw LJ, Cook-Wiens G, Pepine CJ. Late sodium channel blockade improves angina and myocardial perfusion in patients with severe coronary microvascular dysfunction: Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction ancillary study. Int J Cardiol 2018; 276:8-13. [PMID: 30293664 DOI: 10.1016/j.ijcard.2018.09.081] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND In a prior trial of late sodium channel inhibition (ranolazine) among symptomatic subjects without obstructive coronary artery disease (CAD) and limited myocardial perfusion reserve index (MPRI), we observed no improvement in angina or MPRI, overall. Here we describe the clinical characteristics and myocardial perfusion responses of a pre-defined subgroup who had coronary flow reserve (CFR) assessed invasively. METHODS Symptomatic patients without obstructive CAD and limited MPRI in a randomized, double-blind, crossover trial of ranolazine vs. placebo were subjects of this prespecified substudy. Because we had previously observed that adverse outcomes and beneficial treatment responses occurred in those with lower CFR, patients were subgrouped by CFR <2.5 vs ≥2.5. Symptoms were assessed using the Seattle Angina Questionnaire and the SAQ-7, and left-ventricular volume and MPRI were assessed by magnetic resonance imaging (MRI). Coronary angiograms, CFR, and MRI data were analyzed by core labs masked to treatment and patient characteristics. RESULTS During qualifying coronary angiography, 81 patients (mean age 55 years, 98% women) had invasively determined CFR 2.69 ± 0.65 (mean ± SD; range 1.4-5.5); 43% (n = 35) had CFR <2.5. Demographic and symptomatic findings did not differ comparing CFR subgroups. Those with low CFR had improved angina (p = 0.04) and midventricular MPRI (p = 0.03) with ranolazine vs placebo. Among patients with low CFR, reduced left-ventricular end-diastolic volume predicted a beneficial angina response. CONCLUSIONS Symptomatic patients with CFR <2.5 and no obstructive CAD had improved angina and myocardial perfusion with ranolazine, supporting the hypothesis that the late sodium channel is important in management of coronary microvascular dysfunction. TRIAL REGISTRATION clinicaltrials.gov Identifier NCT01342029.
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Affiliation(s)
- Cecil A Rambarat
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Eileen M Handberg
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - C Noel Bairey Merz
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Margo B Minissian
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Michael D Nelson
- Barbara Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Leslee J Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, GA, USA
| | - Galen Cook-Wiens
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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Pathan F, Puntmann VO, Nagel E. Role of Cardiac Magnetic Resonance in Heart Failure with Preserved Ejection Fraction. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9450-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Stocco FG, Evaristo E, Shah NR, Cheezum MK, Hainer J, Foster C, Nearing BD, Gervino E, Verrier RL. Marked exercise-induced T-wave heterogeneity in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis. Ann Noninvasive Electrocardiol 2018; 23:e12503. [PMID: 28949056 PMCID: PMC6495190 DOI: 10.1111/anec.12503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/26/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND T-wave heterogeneity (TWH) independently predicted cardiovascular mortality in Health Survey 2000 based on 12-lead ECGs recorded at rest. We investigated whether TWH is elevated during exercise tolerance testing (ETT) in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis compared to control subjects without diabetes. METHODS Cases were all patients (n = 20) with analyzable ECG recordings during both rest and ETT who were enrolled in the Effects of Ranolazine on Coronary Flow Reserve (CFR) in Symptomatic Patients with Diabetes and Suspected or Known Coronary Artery Disease (RAND-CFR) study (NCT01754259); median CFR was 1.44; 80% of cases had CFR <2. Control subjects (n = 9) were nondiabetic patients who had functional flow reserve (FFR) >0.8, a range not associated with inducible ischemia. TWH was analyzed from precordial leads V4 , V5 , and V6 by second central moment analysis, which assesses the interlead splay of T-waves about a mean waveform. RESULTS During exercise to similar rate-pressure products (p = .31), RAND-CFR patients exhibited a 49% increase in TWH during exercise (rest: 49 ± 5 μV; exercise: 73 ± 8 μV, p = .003). By comparison, in control subjects, TWH was not significantly altered (rest: 52 ± 11 μV; ETT: 38 ± 5 μV, p = .19). ETT-induced ST-segment depression >1 mm (p = .11) and Tpeak -Tend (p = .18) and QTc intervals (p = .80) failed to differentiate cases from controls. CONCLUSIONS TWH is capable of detecting latent repolarization abnormalities, which are present during ETT in diabetic patients with nonflow-limiting stenosis but not in control subjects. The technique developed in this study permits TWH analysis from archived ECGs and thereby enables mining of extensive databases for retrospective studies and hypothesis testing.
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Affiliation(s)
- Fernando G. Stocco
- University of Sao Paulo School of MedicineSao PauloBrazil
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | - Ederson Evaristo
- University of Sao Paulo School of MedicineSao PauloBrazil
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | - Nishant R. Shah
- Brigham & Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
- Brown University Warren Alpert Medical SchoolProvidenceRIUSA
| | | | | | | | - Bruce D. Nearing
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Ernest Gervino
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Richard L. Verrier
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Evaristo E, Stocco FG, Shah NR, Cheezum MK, Hainer J, Foster C, Nearing BD, Di Carli M, Verrier RL. Ranolazine reduces repolarization heterogeneity in symptomatic patients with diabetes and non-flow-limiting coronary artery stenosis. Ann Noninvasive Electrocardiol 2017; 23. [PMID: 28653394 DOI: 10.1111/anec.12480] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Experimental evidence suggests that ranolazine decreases susceptibility to ischemia-induced arrhythmias independent of effects on coronary artery blood flow. OBJECTIVE In symptomatic diabetic patients with non-flow-limiting coronary artery stenosis with diffuse atherosclerosis and/or microvascular dysfunction, we explored whether ranolazine reduces T-wave heterogeneity (TWH), an electrocardiographic (ECG) marker of arrhythmogenic repolarization abnormalities shown to predict sudden cardiac death. METHODS We studied all 16 patients with analyzable ECG recordings during rest and exercise tolerance testing before and after 4 weeks of ranolazine in the double-blind, crossover, placebo-controlled RAND-CFR trial (NCT01754259). TWH was quantified without knowledge of treatment assignment by second central moment analysis, which assesses the interlead splay of T waves in precordial leads about a mean waveform. Myocardial blood flow (MBF) was measured by positron emission tomography. RESULTS At baseline, prior to randomization, TWH during rest was 54 ± 7 μV and was not altered following placebo (47 ± 6 μV, p = .47) but was reduced by 28% (to 39 ± 5 μV, p = .002) after ranolazine. Ranolazine did not increase MBF at rest. Exercise increased TWH after placebo by 49% (to 70 ± 8 μV, p = .03). Ranolazine did not reduce TWH during exercise (to 75 ± 16 μV), and there were no differences among the groups (p = .95, ANOVA). TWH was not correlated with MBF at rest before (r2 = .07, p = .36) or after ranolazine (r2 = .23, p = .06). CONCLUSIONS In symptomatic diabetic patients with non-flow-limiting coronary artery stenosis with diffuse atherosclerosis and/or microvascular dysfunction, ranolazine reduced TWH at rest but not during exercise. Reduction in repolarization abnormalities appears to be independent of alterations in MBF.
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Affiliation(s)
- Ederson Evaristo
- Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Fernando G Stocco
- Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nishant R Shah
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Michael K Cheezum
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Brigham & Women's Hospital, Boston, MA, USA
| | | | - Bruce D Nearing
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Marcelo Di Carli
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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