1
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Sarafis ZK, Squair JW, Barak OF, Coombs GB, Soriano JE, Larkin-Kaiser KA, Lee AHX, Hansen A, Vodopic M, Romac R, Grant C, Charbonneau R, Mijacika T, Krassioukov AV, Ainslie PN, Dujic Z, Phillips AA. Common carotid artery responses to the cold-pressor test are impaired in individuals with cervical spinal cord injury. Am J Physiol Heart Circ Physiol 2022; 323:H1311-H1322. [PMID: 36367686 DOI: 10.1152/ajpheart.00261.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cervical spinal cord injury (SCI) leads to autonomic cardiovascular dysfunction that underlies the three- to fourfold elevated risk of cardiovascular disease in this population. Reduced common carotid artery (CCA) dilatory responsiveness during the cold-pressor test (CPT) is associated with greater cardiovascular disease risk and progression. The cardiovascular and CCA responses to the CPT may provide insight into cardiovascular autonomic dysfunction and cardiovascular disease risk in individuals with cervical SCI. Here, we used CPT to perturb the autonomic nervous system in 14 individuals with cervical SCI and 12 uninjured controls, while measuring cardiovascular responses and CCA diameter. The CCA diameter responses were 55% impaired in those with SCI compared with uninjured controls (P = 0.019). The CCA flow, velocity, and shear response to CPT were reduced in SCI by 100% (P < 0.001), 113% (P = 0.001), and 125% (P = 0.002), respectively. The association between mean arterial pressure and CCA dilation observed in uninjured individuals (r = 0.54, P = 0.004) was absent in the SCI group (r = 0.22, P = 0.217). Steady-state systolic blood pressure (P = 0.020), heart rate (P = 0.003), and cardiac contractility (P < 0.001) were reduced in those with cervical SCI, whereas total peripheral resistance was increased compared with uninjured controls (P = 0.042). Relative cerebral blood velocity responses to CPT were increased in the SCI group and reduced in controls (middle cerebral artery, P = 0.010; posterior cerebral artery, P = 0.026). The CCA and cardiovascular responsiveness to CPT are impaired in those with cervical SCI.NEW & NOTEWORTHY This is the first study demonstrating that CCA responses during CPT are suppressed in SCI. Specifically, CCA diameter, flow, velocity, and shear rate were reduced. The relationship between changes in MAP and CCA dilatation in response to CPT was absent in individuals with SCI, despite similar cardiovascular activation between SCI and uninjured controls. These findings support the notion of elevated cardiovascular disease risk in SCI and that the cardiovascular responses to environmental stimuli are impaired.
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Affiliation(s)
- Zoe K Sarafis
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan W Squair
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,RESTORE.network, Departments of Physiology and Pharmacology, Cardiac Sciences and Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,MD/PhD Training Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Experimental Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Otto F Barak
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Geoff B Coombs
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Jan Elaine Soriano
- RESTORE.network, Departments of Physiology and Pharmacology, Cardiac Sciences and Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kelly A Larkin-Kaiser
- RESTORE.network, Departments of Physiology and Pharmacology, Cardiac Sciences and Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Amanda H X Lee
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Experimental Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Hansen
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Maro Vodopic
- Department of Neurology, General Hospital, Dubrovnik, Croatia
| | - Rinaldo Romac
- Department of Neurology, Clinical Hospital Center, Split, Croatia
| | - Christopher Grant
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rebecca Charbonneau
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanja Mijacika
- Department of Integrative Physiology, University of Split School of Medicine, Split, Croatia
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada.,GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Zeljko Dujic
- Department of Integrative Physiology, University of Split School of Medicine, Split, Croatia
| | - Aaron A Phillips
- RESTORE.network, Departments of Physiology and Pharmacology, Cardiac Sciences and Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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2
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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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3
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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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4
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Cosson E, Nguyen MT, Rezgani I, Berkane N, Pinto S, Bihan H, Tatulashvili S, Taher M, Sal M, Soussan M, Brillet PY, Valensi P. Epicardial adipose tissue volume and myocardial ischemia in asymptomatic people living with diabetes: a cross-sectional study. Cardiovasc Diabetol 2021; 20:224. [PMID: 34819079 PMCID: PMC8613918 DOI: 10.1186/s12933-021-01420-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/14/2021] [Indexed: 12/18/2022] Open
Abstract
Background Epicardial adipose tissue (EAT) is considered a novel diagnostic marker for cardiometabolic disease. This study aimed to evaluate whether EAT volume was associated with stress-induced myocardial ischemia in asymptomatic people living with diabetes—independently of confounding factors—and whether it could predict this condition. Methods We included asymptomatic patients with diabetes and no coronary history, who had undergone both a stress a myocardial scintigraphy to diagnose myocardial ischemia, and a computed tomography to measure their coronary artery calcium (CAC) score. EAT volume was retrospectively measured from computed tomography imaging. Determinants of EAT volume and asymptomatic myocardial ischemia were evaluated. Results The study population comprised 274 individuals, including 153 men. Mean (± standard deviation) age was 62 ± 9 years, and 243, 23 and 8 had type 2, type 1, or another type of diabetes, respectively. Mean body mass index was 30 ± 6 kg/m2, and mean EAT volume 96 ± 36 cm3. Myocardial ischemia was detected in 32 patients (11.7%). EAT volume was positively correlated with age, body mass index and triglyceridemia, but negatively correlated with HbA1c, HDL- and LDL-cholesterol levels. Furthermore, EAT volume was lower in people with retinopathy, but higher in men, in current smokers, in patients with nephropathy, those with a CAC score > 100 Agatston units, and finally in individuals with myocardial ischemia (110 ± 37 cm3 vs 94 ± 37 cm3 in those without myocardial ischemia, p < 0.05). The association between EAT volume and myocardial ischemia remained significant after adjustment for gender, diabetes duration, peripheral macrovascular disease and CAC score. We also found that area under the ROC curve analysis showed that EAT volume (AROC: 0.771 [95% confidence interval 0.683–0.858]) did not provide improved discrimination of myocardial ischemia over the following classic factors: gender, diabetes duration, peripheral macrovascular disease, retinopathy, nephropathy, smoking, atherogenic dyslipidemia, and CAC score (AROC 0.773 [0.683–0.862]). Conclusions EAT may play a role in coronary atherosclerosis and coronary circulation in patients with diabetes. However, considering EAT volume is not a better marker for discriminating the risk of asymptomatic myocardial ischemia than classic clinical data.
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Affiliation(s)
- Emmanuel Cosson
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France. .,Unité de Recherche Epidémiologique Nutritionnelle, UMR U1153 INSERM/U11125 INRA/CNAM/Université Paris 13, Bobigny, France.
| | - Minh Tuan Nguyen
- Unit of Endocrinology-Diabetology-Nutrition, Jean Verdier Hospital, AP-HP, Université Paris 13, Bondy, France
| | - Imen Rezgani
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France
| | - Narimane Berkane
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France
| | - Sara Pinto
- Unit of Diabetology, Jean Verdier Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, Bondy, France
| | - Hélène Bihan
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France.,Laboratoire Educations et Pratiques de Santé UR 3412, UFR Santé, Médecine, Biologie Humaine, Université Paris Sorbonne Paris Nord, 74, Rue Marcel Cachin, 93017, Bobigny Cedex, France
| | - Sopio Tatulashvili
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France
| | - Malak Taher
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France
| | - Meriem Sal
- Department of Endocrinology-Diabetology-Nutrition, Avicenne Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, 125 Rue de Stalingrad, 93000, Bobigny Cedex, France
| | - Michael Soussan
- Department of Nuclear Medicine, Avicenne Hospital, AP-HP, Bobigny, France
| | | | - Paul Valensi
- Unit of Diabetology, Jean Verdier Hospital, CRNH-IdF, CINFO, AP-HP, Université Paris 13, Sorbonne Paris Cité, Bondy, France
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5
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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6
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Konst RE, Guzik TJ, Kaski JC, Maas AHEM, Elias-Smale SE. The pathogenic role of coronary microvascular dysfunction in the setting of other cardiac or systemic conditions. Cardiovasc Res 2020; 116:817-828. [PMID: 31977015 PMCID: PMC7526753 DOI: 10.1093/cvr/cvaa009] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/09/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022] Open
Abstract
Coronary microvascular dysfunction (CMD) plays a pathogenic role in cardiac and systemic conditions other than microvascular angina. In this review, we provide an overview of the pathogenic role of CMD in the setting of diabetes mellitus, obesity, hypertensive pregnancy disorders, chronic inflammatory and autoimmune rheumatic disorders, chronic kidney disease, hypertrophic cardiomyopathy, and aortic valve stenosis. In these various conditions, CMD results from different structural, functional, and/or dynamic alterations in the coronary microcirculation associated with the primary disease process. CMD is often detectable very early in the course of the primary disease, before clinical symptoms or signs of myocardial ischaemia are present, and it portrays an increased risk for cardiovascular events.
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Affiliation(s)
- Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Juan-Carlos Kaski
- The Queen Elizabeth Hospital Discipline of Medicine, University of Adelaide, Central Adelaide Local Health Network, Coronary Vasomotion Disorders International Study Group (COVADIS), Adelaide, Australia.,Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Suzette E Elias-Smale
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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7
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Kumar S, Mehta PK, Eshtehardi P, Hung OY, Koh J, Kumar A, Al‐Badri A, Rabah R, D'Souza M, Gupta S, McDaniel M, Vaccarino V, Douglas J, Mavromatis K, Lee JM, Quyyumi A, Samady H. Functional coronary angiography in symptomatic patients with no obstructive coronary artery disease. Catheter Cardiovasc Interv 2020; 98:827-835. [DOI: 10.1002/ccd.29237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Sonali Kumar
- Division of Cardiology, Department of Internal Medicine Emory Women's Heart Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Puja K. Mehta
- Division of Cardiology, Department of Internal Medicine Emory Women's Heart Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Parham Eshtehardi
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Olivia Y. Hung
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Jin‐Sin Koh
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Arnav Kumar
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Ahmed Al‐Badri
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Rani Rabah
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Melroy D'Souza
- J. Willis Hurst Internal Medicine Residency Program Emory University School of Medicine Atlanta Georgia USA
| | - Sonu Gupta
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Michael McDaniel
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Viola Vaccarino
- Department of Epidemiology Rollins School of Public Health, Emory University Atlanta Georgia USA
| | - John Douglas
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Kreton Mavromatis
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Arshed Quyyumi
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
| | - Habib Samady
- Division of Cardiology, Department of Internal Medicine Emory Clinical Cardiovascular Research Institute Atlanta Georgia USA
- Division of Cardiology, Department of Internal Medicine Andreas Gruentzig Cardiovascular Center Atlanta Georgia USA
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8
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Stone RM, Ainslie PN, Kerstens TP, Wildfong KW, Tymko MM. Sex differences in the circulatory responses to an isocapnic cold pressor test. Exp Physiol 2018; 104:295-305. [PMID: 30578582 DOI: 10.1113/ep087232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/19/2018] [Indexed: 01/04/2023]
Abstract
NEW FINDINGS What is the central question of this study? Do sex differences exist in the cardiorespiratory responses to an isocapnic cold pressor test (CPT)? What is the main finding and its importance? During the CPT, there were no sex differences in the respiratory response; however, females demonstrated a reduced mean arterial pressure and reduced dilatation of the common carotid artery. Given that the CPT is predictive of future cardiovascular events, these data have clinical implications for improving the utility of the CPT to determine cardiovascular health risk. Sex differences should be taken into consideration when conducting and interpreting a CPT. ABSTRACT The cold pressor test (CPT) elicits a transient increase in sympathetic nervous activity, minute ventilation ( <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> </mml:math> ), mean arterial pressure (MAP) and common carotid artery (CCA) diameter in healthy individuals. Although the extent of dilatation of the CCA in response to the CPT has been used as a clinical indicator of cardiovascular health status, the potential sex differences have yet to be explored. In response to a CPT, we hypothesized that elevations in <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> </mml:math> and MAP and dilatation of the CCA would be attenuated in females compared with males. In 20 young, healthy participants (10 females), we measured the respiratory, cardiovascular and CCA responses during a CPT, which consisted of a 3 min immersion of the right foot into 0-1 ice water. Blood pressure (via finger photoplethysmography), heart rate (via electrocardiogram) and CCA diameter and velocity (via Duplex ultrasound) were simultaneously recorded immediately before and during the CPT. During the CPT, while controlling end-tidal gases to baseline values, the main findings were as follows: (i) no sex differences were present in absolute or relative changes in <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:msub><mml:mover><mml:mi>V</mml:mi> <mml:mo>̇</mml:mo></mml:mover> <mml:mi>E</mml:mi></mml:msub> </mml:math> (P = 0.801 and P = 0.179, respectively); (ii) the relative MAP and CCA diameter response were reduced in females by 51 and 55%, respectively (P = 0.008 and P = 0.029 versus males, respectively); and (iii) the relative MAP responses was positively correlated with the dilatation of the CCA in males (r = 0.42, P = 0.019), in females (r = 0.43, P = 0.019) and in males and females combined (r = 0.55, P < 0.001). Given that the CPT is used as a clinical tool to assess cardiovascular health status, sex differences should be considered in future studies.
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Affiliation(s)
- Rachel M Stone
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Thijs P Kerstens
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin W Wildfong
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Michael M Tymko
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
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Radico F, Zimarino M, Fulgenzi F, Ricci F, Di Nicola M, Jespersen L, Chang SM, Humphries KH, Marzilli M, De Caterina R. Determinants of long-term clinical outcomes in patients with angina but without obstructive coronary artery disease: a systematic review and meta-analysis. Eur Heart J 2018; 39:2135-2146. [DOI: 10.1093/eurheartj/ehy185] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 03/20/2018] [Indexed: 02/07/2023] Open
Affiliation(s)
- Francesco Radico
- Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University, C/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, Institute for Advanced Biomedical Technologies, University G. d’Annunzio, Via Luigi Polacchi, 66100, Chieti, Italy
| | - Marco Zimarino
- Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University, C/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy
| | - Fabio Fulgenzi
- Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University, C/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy
| | - Fabrizio Ricci
- Department of Neurosciences, Imaging and Clinical Sciences, Institute for Advanced Biomedical Technologies, University G. d’Annunzio, Via Luigi Polacchi, 66100, Chieti, Italy
| | - Marta Di Nicola
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University “G. d'Annunzio” Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Lasse Jespersen
- Department of Cardiology, Bispebjerg University Hospital, Bispebjerg Bakke 23, Copenhagen 2400, Denmark
| | - Su Min Chang
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, 6565 Fannin Street, Houston, TX 77030, USA
| | - Karin H Humphries
- Division of Cardiology, Department of Medicine, BC Centre for Improved Cardiovascular Health, St Paul's Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada
| | - Mario Marzilli
- Department of Cardiology, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy
| | - Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, “G. d’Annunzio” University, C/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy
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10
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van Mil ACCM, Tymko MM, Kerstens TP, Stembridge M, Green DJ, Ainslie PN, Thijssen DHJ. Similarity between carotid and coronary artery responses to sympathetic stimulation and the role of α 1-receptors in humans. J Appl Physiol (1985) 2018; 125:409-418. [PMID: 29565771 DOI: 10.1152/japplphysiol.00386.2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Carotid artery (CCA) dilation occurs in healthy subjects during cold pressor test (CPT), while the magnitude of dilation relates to cardiovascular risk. To further explore this phenomenon and mechanism, we examined carotid artery responses to different sympathetic tests, with and without α1-receptor blockade and assessed similarity to these responses between carotid and coronary arteries. In randomized order, 10 healthy participants (25 ± 3 yr) underwent sympathetic stimulation using the CPT (3-min left-hand immersion in ice-slush) and lower-body negative pressure (LBNP). Before and during sympathetic tests, CCA diameter and velocity (Doppler ultrasound) and left anterior descending (LAD) coronary artery velocity (echocardiography) were recorded across 3 min. Measures were repeated 90 min following selective α1-receptor blockade via oral prazosin (0.05 mg/kg body wt). CPT significantly increased CCA diameter, LAD maximal velocity, and velocity-time integral area-under-the-curve (all P < 0.05). In contrast, LBNP resulted in a decrease in CCA diameter, LAD maximal velocity, and velocity time integral (VTI; all P < 0.05). Following α1-receptor blockade, CCA and LAD velocity responses to CPT were diminished. In contrast, during LBNP (-30 mmHg), α1-receptor blockade did not alter CCA or LAD responses. Finally, changes in CCA diameter and LAD VTI responses to sympathetic stimulation were positively correlated ( r = 0.66, P < 0.01). We found distinct carotid artery responses to different tests of sympathetic stimulation, where α1 receptors partly contribute to CPT-induced responses. Finally, we found agreement between carotid and coronary artery responses. These data indicate similarity between carotid and coronary responses to sympathetic tests and the role of α1 receptors that is dependent on the nature of the sympathetic challenge. NEW & NOTEWORTHY We showed distinct carotid artery responses to cold pressor test (CPT; i.e., dilation) and lower-body negative pressure (LBNP; i.e., constriction). Blockade of α1-receptors significantly attenuated dilator responses in carotid and coronary arteries during CPT, while no changes were found during LBNP. Our findings indicate strong similarity between carotid and coronary artery responses to distinct sympathetic stimuli, and for the role of α-receptors.
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Affiliation(s)
- Anke C C M van Mil
- Department of Physiology, Radboudumc, Nijmegen , The Netherlands.,Research Institute for Sport and Exercise Sciences, Liverpool John Moores University , Liverpool , United Kingdom
| | - Michael M Tymko
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Thijs P Kerstens
- Department of Physiology, Radboudumc, Nijmegen , The Netherlands
| | - Mike Stembridge
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada.,Cardiff School of Sport, Cardiff Metropolitan University , Cardiff , United Kingdom
| | - Daniel J Green
- School of Sports Science, Exercise and Health, the University of Western Australia , Nedlands , Australia
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Dick H J Thijssen
- Department of Physiology, Radboudumc, Nijmegen , The Netherlands.,Research Institute for Sport and Exercise Sciences, Liverpool John Moores University , Liverpool , United Kingdom
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11
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Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and meta-analysis. Int J Cardiol 2018; 254:1-9. [DOI: 10.1016/j.ijcard.2017.10.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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12
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Tymko MM, Kerstens TP, Wildfong KW, Ainslie PN. Cerebrovascular response to the cold pressor test - the critical role of carbon dioxide. Exp Physiol 2017; 102:1647-1660. [DOI: 10.1113/ep086585] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/15/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Michael M. Tymko
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science; University of British Columbia; Kelowna BC Canada
| | | | - Kevin W. Wildfong
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science; University of British Columbia; Kelowna BC Canada
| | - Philip N. Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Science; University of British Columbia; Kelowna BC Canada
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13
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Correlation of carotid artery reactivity with cardiovascular risk factors and coronary artery vasodilator responses in asymptomatic, healthy volunteers. J Hypertens 2017; 35:1026-1034. [PMID: 28129249 DOI: 10.1097/hjh.0000000000001274] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Carotid artery reactivity (CAR%), involving carotid artery diameter responses to a cold pressor test (CPT), is a noninvasive measure of conduit artery function in humans. This study examined the impact of age and cardiovascular risk factors on the CAR% and the relationship between CAR% and coronary artery vasodilator responses to the CPT. METHODS Ultrasound was used to measure resting and peak carotid artery diameters during the CPT, with CAR% being calculated as the relative change from baseline (%). We compared CAR% between young (n = 50, 24 ± 3 years) and older participants (n = 44, 61 ± 8 years), and subsequently assessed relationships between CAR% and traditional cardiovascular risk factors in 50 participants (44 ± 21 years). Subsequently, we compared left anterior descending (LAD) artery velocity (using transthoracic Doppler) with carotid artery diameter (i.e. CAR%) during the CPT (n = 33, 37 ± 17 years). RESULTS A significantly larger CAR% was found in young versus older healthy participants (4.1 ± 3.7 versus 1.8 ± 2.6, P < 0.001). Participants without cardiovascular risk factors demonstrated a higher CAR% than those with at least two risk factors (2.9 ± 2.9 versus 0.5 ± 2.9, P = 0.019). Carotid artery diameter and LAD velocity increased during CPT (P < 0.001). Carotid diameter and change in velocity correlated with LAD velocity (r = 0.486 and 0.402, P < 0.004 and 0.02, respectively). CONCLUSION Older age and cardiovascular risk factors are related to lower CAR%, while CAR% shows good correlation with coronary artery responses to the CPT. Therefore, CAR% may represent a valuable technique to assess cardiovascular risk, while CAR% seems to reflect coronary artery vasodilator function.
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14
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Shaw J, Anderson T. Coronary endothelial dysfunction in non-obstructive coronary artery disease: Risk, pathogenesis, diagnosis and therapy. Vasc Med 2015; 21:146-55. [PMID: 26675331 DOI: 10.1177/1358863x15618268] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Up to half of patients with signs and symptoms of stable ischemic heart disease have non-obstructive coronary artery disease (NoCAD). Recent evidence demonstrates that two-thirds of patients with NoCAD have demonstrable coronary endothelial dysfunction represented by microvascular or diffuse epicardial spasm following acetylcholine challenge. Patients with coronary endothelial dysfunction are recognized to have significant health services use and morbidity as well as increased risk of developing flow-limiting coronary artery disease and myocardial events, including death. Currently, there are few centers that test for this etiology owing to lack of knowledge, limited evidence for treatment options and invasive diagnostic strategies. This article reviews the pathophysiology, epidemiology, diagnosis and treatment of coronary endothelial dysfunction as a subgroup of NoCAD.
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Affiliation(s)
- Jeffrey Shaw
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary, Faculty of Medicine Health Sciences Centre, Calgary, Alberta, Canada
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15
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Olsen RB, Bruehl S, Nielsen CS, Rosseland LA, Eggen AE, Stubhaug A. Chronic pain and cardiovascular stress responses in a general population: the Tromsø Study. J Behav Med 2014; 37:1193-201. [PMID: 24793322 DOI: 10.1007/s10865-014-9568-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 04/21/2014] [Indexed: 12/22/2022]
Abstract
We tested whether cardiovascular stress responsiveness is elevated in individuals experiencing chronic pain in a large general population sample. Blood pressure (BP) and heart rate (HR) were assessed at rest, during the cold pressor test, and during subsequent recovery in 554 individuals reporting daily chronic pain and 3,082 individuals free of chronic pain. After correcting for potential confounds, differences as a function of chronic pain status were noted for only 5 of 23 cardiovascular outcomes despite very high statistical power. Compared to the pain-free group, the chronic pain group displayed higher baseline HR/mean arterial pressure (MAP) ratio (p = .03), greater systolic BP (SBP) reactivity during the cold pressor test (p = .04), and higher HR/MAP ratio (p = .047) and significantly less SBP (p = .017) and MAP (p = .041) return to baseline during recovery. Findings suggest that changes in cardiovascular stress responsiveness associated with chronic pain are of limited clinical significance and unlikely to contribute to increased cardiovascular risk in the chronic pain population.
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Affiliation(s)
- Roy Bjørkholt Olsen
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital, Rikshospitalet, Nydalen, PO Box 4950, 0424, Oslo, Norway,
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16
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Ichikawa Y, Kitagawa K, Kato S, Dohi K, Hirano T, Ito M, Sakuma H. Altered coronary endothelial function in young smokers detected by magnetic resonance assessment of myocardial blood flow during the cold pressor test. Int J Cardiovasc Imaging 2014; 30 Suppl 1:73-80. [PMID: 24519431 DOI: 10.1007/s10554-014-0387-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 02/03/2014] [Indexed: 01/15/2023]
Abstract
Endothelial dysfunction is a key element in early atherogenesis. The purposes of this study were to evaluate the feasibility of magnetic resonance (MR) assessment of altered myocardial blood flow (MBF) in response to the cold pressor test (CPT) and to determine if coronary endothelial dysfunction in young smokers can be detected with this noninvasive approach. Fourteen healthy non-smokers (31 ± 6 years) and 12 smokers (34 ± 8 years) were studied. Breath-hold phase-contrast cine MR imaging (PC-MRI) of the coronary sinus (CS) were obtained at rest and during the CPT. MBF was measured as CS flow divided by left ventricle mass and the rate pressure product. In non-smokers, MBF was 0.88 ± 0.19 ml/min/g at rest and significantly increased to 1.13 ± 0.26 ml/min/g during the CPT (P = 0.0001). In smokers, MBF was 0.94 ± 0.26 ml/min/g at rest and 0.96 ± 0.30 ml/min/g during the CPT (P = 0.73). ΔMBF (MBF during the CPT-MBF at rest) was significantly reduced in smokers compared with non-smokers (0.02 ± 0.20 vs. 0.26 ± 0.18 ml/min/g, P = 0.005). The intra-class correlation coefficient between measurements by two observers was 0.90 for ΔMBF. A significant reduction in MBF response to CPT was demonstrated in young smokers with PC-MRI at 1.5 T. This noninvasive method has great potential for assessment of coronary endothelial function.
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Affiliation(s)
- Yasutaka Ichikawa
- Department of Radiology, Matsusaka Central Hospital, 102 Kobou, Kawai, Matsusaka, Mie, 515-8566, Japan,
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17
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Flow-mediated-paradoxical vasoconstriction is independently associated with asymptomatic myocardial ischemia and coronary artery disease in type 2 diabetic patients. Cardiovasc Diabetol 2014; 13:20. [PMID: 24428877 PMCID: PMC3901336 DOI: 10.1186/1475-2840-13-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/31/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To investigate whether flow-mediated dilation (FMD) impairment, which precedes overt atherosclerosis, is associated with silent myocardial ischemia (SMI) and asymptomatic coronary artery disease (CAD) in type 2 diabetes. METHODS Forearm FMD was measured by ultrasonography in 25 healthy control, 30 non-diabetic overweight or obese patients and 118 asymptomatic type 2 diabetic patients with a high cardiovascular risk profile. SMI (abnormal stress myocardial scintiscan and/or stress dobutamine echocardiogram) and CAD (coronary angiography in the patients with SMI) were assessed in the diabetic cohort. RESULTS FMD was lower in diabetic patients (median 0.61% (upper limits of first and third quartiles -1.22;3.2)) than in healthy controls (3.95% (1.43;5.25), p < 0.01) and overweight/obese patients (4.25% (1.74;5.56), p < 0.01). SMI was present in 60 diabetic patients, including 21 subjects with CAD. FMD was lower in patients with SMI than in those without (0.12% (-2.3;1.58) vs 1.64% (0;3.69), p < 0.01), with a higher prevalence of paradoxical vasoconstriction (50.0% vs 29.3%, p < 0.05). FMD was also lower in patients with than without CAD (-1.22% (-2.5;1) vs 1.13% (-0.4;3.28), p < 0.01; paradoxical vasoconstriction 61.9% vs 34.4%, p < 0.05). Logistic regression analyses considering the parameters predicting SMI or CAD in univariate analyses with a p value <0.10 showed that paradoxical vasoconstriction (odds ratio 2.7 [95% confidence interval 1.2-5.9], p < 0.05) and nephropathy (OR 2.6 [1.2-5.7], p < 0.05) were independently associated with SMI; and only paradoxical vasoconstriction (OR 3.1 [1.2-8.2], p < 0.05) with CAD. The negative predictive value of paradoxical vasoconstriction to detect CAD was 88.7%. CONCLUSIONS In diabetic patients, FMD was independently associated with SMI and asymptomatic CAD. TRIAL REGISTRATION Trial registration number NCT00685984.
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18
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Huang R, Abdelmoneim SS, Nhola LF, Mulvagh SL. Relationship between HgbA1c and myocardial blood flow reserve in patients with type 2 diabetes mellitus: noninvasive assessment using real-time myocardial perfusion echocardiography. J Diabetes Res 2014; 2014:243518. [PMID: 25097860 PMCID: PMC4101949 DOI: 10.1155/2014/243518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/09/2014] [Indexed: 12/23/2022] Open
Abstract
To study the relationship between glycosylated hemoglobin (HgbA1c) and myocardial perfusion in type 2 diabetes mellitus (T2DM) patients, we prospectively enrolled 24 patients with known or suspected coronary artery disease (CAD) who underwent adenosine stress by real-time myocardial perfusion echocardiography (RTMPE). HgbA1c was measured at time of RTMPE. Microbubble velocity (β min(-1)), myocardial blood flow (MBF, mL/min/g), and myocardial blood flow reserve (MBFR) were quantified. Quantitative MCE analysis was feasible in all patients (272/384 segments, 71%). Those with HgbA1c > 7.1% had significantly lower βreserve and MBFR than those with HgbA1c ≤ 7.1% (P < 0.05). In patients with suspected CAD, there was a significant inverse correlation between MBFR and HgbA1c (r = -0.279, P = 0.01); however, in those with known CAD, this relationship was not significant (r = -0.117, P = 0.129). Using a MBFR cutoff value > 2 as normal, HgbA1c > 7.1% significantly increased the risk for abnormal MBFR, (adjusted odds ratio: 1.92, 95% CI: 1.12-3.35, P = 0.02). Optimal glycemic control is associated with preservation of MBFR as determined by RTMPE, in T2DM patients at risk for CAD.
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Affiliation(s)
- Runqing Huang
- Mayo Clinic Cardiovascular Ultrasound and Hemodynamic Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Division of Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Sahar S. Abdelmoneim
- Mayo Clinic Cardiovascular Ultrasound and Hemodynamic Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Division of Cardiovascular Medicine, Assiut University, Assiut 71515, Egypt
| | - Lara F. Nhola
- Mayo Clinic Cardiovascular Ultrasound and Hemodynamic Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sharon L. Mulvagh
- Mayo Clinic Cardiovascular Ultrasound and Hemodynamic Laboratory, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- *Sharon L. Mulvagh:
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Gutiérrez E, Flammer AJ, Lerman LO, Elízaga J, Lerman A, Fernández-Avilés F. Endothelial dysfunction over the course of coronary artery disease. Eur Heart J 2013; 34:3175-81. [PMID: 24014385 DOI: 10.1093/eurheartj/eht351] [Citation(s) in RCA: 208] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The vascular endothelium regulates blood flow in response to physiological needs. Endothelial dysfunction is closely related to atherosclerosis and its risk factors, and it constitutes an intermediate step on the progression to adverse events throughout the natural history of coronary artery disease (CAD), often affecting clinical outcomes. Understanding the relation of endothelial function with CAD provides an important pathophysiological insight, which can be useful both in clinical and research management. In this review, we summarize the current knowledge on endothelial dysfunction and its prognostic influence throughout the natural history of CAD, from early atherosclerosis to post-transplant management.
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Affiliation(s)
- Enrique Gutiérrez
- Servicio de Cardiología, Instituto de Investigación Sanitaria, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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20
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Hamilton SJ, Watts GF. Endothelial dysfunction in diabetes: pathogenesis, significance, and treatment. Rev Diabet Stud 2013; 10:133-56. [PMID: 24380089 DOI: 10.1900/rds.2013.10.133] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Type 2 diabetes (T2D) markedly increases the risk of cardiovascular disease. Endothelial dysfunction (ED), an early indicator of diabetic vascular disease, is common in T2D and independently predicts cardiovascular risk. Although the precise pathogenic mechanisms for ED in T2D remain unclear, at inception they probably involve uncoupling of both endothelial nitric oxide synthase activity and mitochondrial oxidative phosphorylation, as well as the activation of vascular nicotinamide adenine dinucleotide phosphate oxidase. The major contributing factors include dyslipoproteinemia, oxidative stress, and inflammation. Therapeutic interventions are designed to target these pathophysiological factors that underlie ED. Therapeutic interventions, including lifestyle changes, antiglycemic agents and lipid-regulating therapies, aim to correct hyperglycemia and atherogenic dyslipidemia and to improve ED. However, high residual cardiovascular risk is seen in both research and clinical practice settings. Well-designed studies of endothelial function in appropriately selected volunteers afford a good opportunity to test new therapeutic interventions, paving the way for clinical trials and utilization in the care of the diabetic patient. However, based on the results from a recent clinical trial, niacin should not be added to a statin in individuals with low high-density lipoprotein cholesterol and very well controlled low-density lipoprotein cholesterol.
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Affiliation(s)
- Sandra J Hamilton
- Combined Universities Centre for Rural Health, University of Western Australia, Geraldton, Australia
| | - Gerald F Watts
- School of Medicine and Pharmacology, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
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21
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Pearson JT, Jenkins MJ, Edgley AJ, Sonobe T, Joshi M, Waddingham MT, Fujii Y, Schwenke DO, Tsuchimochi H, Yoshimoto M, Umetani K, Kelly DJ, Shirai M. Acute Rho-kinase inhibition improves coronary dysfunction in vivo, in the early diabetic microcirculation. Cardiovasc Diabetol 2013; 12:111. [PMID: 24059472 PMCID: PMC3734116 DOI: 10.1186/1475-2840-12-111] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Activation of RhoA/Rho-kinase (ROCK) is increasingly implicated in acute vasospasm and chronic vasoconstriction in major organ systems. Therefore we aimed to ascertain whether an increase in ROCK activity plays a role in the deterioration of coronary vascular function in early stage diabetes. METHODS Synchrotron radiation microangiography was used to determine in vivo coronary responses in diabetic (3 weeks post streptozotocin 65 mg/kg ip) and vehicle treated male Sprague-Dawley rats (n = 8 and 6). Changes in vessel number and calibre during vasodilator stimulation before and after blockade of nitric oxide synthase and cyclooxygenase were compared between rats. Acute responses to ROCK inhibitor, fasudil (10 mg/kg iv) was evaluated. Further, perivascular and myocardial fibrosis, arterial intimal thickening were assessed by histology, and capillary density, nitrotyrosine and ROCK1/2 expressions were evaluated by immunohistochemical staining. RESULTS Diabetic rats had significantly elevated plasma glucose (P < 0.001 vs control), but did not differ in fibrotic scores, media to lumen ratio, capillary density or baseline visible vessel number or calibre. Responses to acetylcholine and sodium nitroprusside stimulation were similar between groups. However, in comparison to control rats the diabetic rats showed more segmental constrictions during blockade, which were not completely alleviated by acetylcholine, but were alleviated by fasudil. Further, second order vessel branches in diabetic rats were significantly more dilated relative to baseline (37% vs 12% increase, P < 0.05) after fasudil treatment compared to control rats, while visible vessel number increased in both groups. ROCK2 expression was borderline greater in diabetic rat hearts (P < 0.053). CONCLUSIONS We found that ahead of the reported decline in coronary endothelial vasodilator function in diabetic rats there was moderate elevation in ROCK expression, more widespread segmental constriction when nitric oxide and prostacyclin production were inhibited and notably, increased calibre in second and third order small arteries-arterioles following ROCK inhibition. Based on nitrotyrosine staining oxidative stress was not significantly elevated in early diabetic rats. We conclude that tonic ROCK mediated vasoconstriction contributes to coronary vasomotor tone in early diabetes.
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Affiliation(s)
- James T Pearson
- Department of Physiology, Monash University, Melbourne, Australia
- Monash Biomedical Imaging Facility, Melbourne, Australia
- Australian Synchrotron, Melbourne, Australia
| | - Mathew J Jenkins
- Department of Physiology, Monash University, Melbourne, Australia
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Amanda J Edgley
- Department of Physiology, Monash University, Melbourne, Australia
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Takashi Sonobe
- National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Mandar Joshi
- The Ritchie Centre, Monash Institute of Medical Research, Melbourne, Australia
| | - Mark T Waddingham
- Department of Physiology, Monash University, Melbourne, Australia
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Yutaka Fujii
- National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Daryl O Schwenke
- Department of Physiology, Otago University, Dunedin, New Zealand
| | | | - Misa Yoshimoto
- National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Keiji Umetani
- Japan Synchrotron Radiation Research Institute, Harima, Japan
| | - Darren J Kelly
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Mikiyasu Shirai
- National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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Cosson E, Nguyen MT, Chanu B, Balta S, Takbou K, Valensi P. The report of male gender and retinopathy status improves the current consensus guidelines for the screening of myocardial ischemia in asymptomatic type 2 diabetic patients. Nutr Metab Cardiovasc Dis 2013; 23:557-565. [PMID: 22502874 DOI: 10.1016/j.numecd.2012.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/30/2011] [Accepted: 01/25/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS American Diabetes Association (ADA), French-speaking Societies for diabetes & cardiology (ALFEDIAM-SFC) and Cardiac Radionuclide Imaging (CRI) have proposed guidelines for the screening of silent myocardial ischemia (SMI). The aim of the study was to evaluate their diagnostic values and how to improve them. METHODS AND RESULTS 731 consecutive type 2 diabetic patients with ≥1 additional risk factor were screened between 1992 and 2006 for SMI by stress myocardial scintigraphy and for silent coronary artery disease (CAD) by coronary angiography. A total of 215 (29.4%) patients had SMI, and 79 of them had CAD. ADA (Odds Ratio 1.7 [95% Confidence Interval: 1.2-2.5]; p < 0.05), ALFEDIAM-SFC (OR 1.5 [1.0-2.5], p < 0.05) and CRI criteria (OR 2.0 [1.4-2.8], p < 0.01) predicted SMI. Considering the presence of male gender and retinopathy added to the prediction of SMI allowed by ADA criteria (c statistic: area under the curve AROC 0.651 [0.605-0.697] versus 0.582 [0.534-0.630]), p < 0.01 and ALFEDIAM-SFC criteria (AROC 0.672 [0.620-0.719] versus 0.620 [0.571-0.670], p < 0.05). CRI prediction of SMI was improved by considering the presence of macroproteinuria and retinopathy (AROC 0.621 [0.575-0.667] versus 0.594 [0.548-0.641], p < 0.01). Severe retinopathy (OR 3.4 [1.2-9.4], p < 0.05), smoking habits (OR 2.1 [1.1-4.2], p < 0.05) and triglyceride levels (OR 1.3 [1.0-1.6], p < 0.05) were independent predictors of CAD in the patients with SMI. CONCLUSION Current guidelines criteria are able to predict SMI but prediction may be improved by considering male gender and the presence of retinopathy. CAD is more frequent in the patients with SMI who are current smokers, have severe retinopathy and higher triglyceride levels.
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Affiliation(s)
- E Cosson
- AP-HP, Jean Verdier Hospital, Department of Endocrinology-Diabetology-Nutrition and Paris-Nord University, CRNH-IdF, Bondy, France.
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Monahan KD, Feehan RP, Sinoway LI, Gao Z. Contribution of sympathetic activation to coronary vasodilatation during the cold pressor test in healthy men: effect of ageing. J Physiol 2013; 591:2937-47. [PMID: 23478134 DOI: 10.1113/jphysiol.2013.251298] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The sympathetic nervous system is an important regulator of coronary blood flow. The cold pressor test (CPT) is a powerful sympathoexcitatory stressor. We tested the hypotheses that: (1) CPT-induced sympathetic activation elicits coronary vasodilatation in young adults that is impaired with advancing age and (2) combined α- and β-adrenergic blockade diminishes/abolishes these age-related differences. Vascular responses of the left anterior descending artery to the CPT were determined by transthoracic Doppler echocardiography before (pre-blockade) and during (post-blockade) systemic co-administration of α- and β-adrenergic antagonists in young (n = 9; 26 ± 1 years old, mean ± SEM) and older healthy men (n = 9; 66 ± 2 years old). Coronary vascular resistance (CVR; mean arterial pressure/coronary blood velocity) was used as an index of vascular tone. CPT decreased CVR (i.e. coronary vasodilatation occurred) in young ( -33 ± 6%), but not older men ( -3 ± 4%; P < 0.05 vs. young) pre-blockade. Adrenergic blockade abolished CPT-induced coronary vasodilatation in young men ( -33 ± 6% vs. 0 ± 6%, pre-blockade vs. post-blockade, respectively; P < 0.05) such that responses post-blockade mirrored those of older men ( -3 ± 4% vs. 8 ± 9%; both P > 0.05 compared to young pre-blockade). Impaired CPT-induced coronary vasodilatation could not be explained by a reduced stimulus for vasodilatation as group and condition effects persisted when CVR responses were expressed relative to myocardial oxygen demand (rate-pressure product). These data indicate that the normal coronary vascular response to sympathetic activation in young men is pronounced vasodilatation and this effect is lost with age as the result of an adrenergic mechanism. These findings may help explain how acute sympathoexcitation may precipitate angina and coronary ischaemic events, particularly in older adults.
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Affiliation(s)
- Kevin D Monahan
- Penn State Hershey Heart and Vascular Institute, The Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033-2390, USA.
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Silverthorn DU, Michael J. Cold stress and the cold pressor test. ADVANCES IN PHYSIOLOGY EDUCATION 2013; 37:93-6. [PMID: 23471256 DOI: 10.1152/advan.00002.2013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Temperature and other environmental stressors are known to affect blood pressure and heart rate. In this activity, students perform the cold pressor test, demonstrating increased blood pressure during a 1- to 2-min immersion of one hand in ice water. The cold pressor test is used clinically to evaluate autonomic and left ventricular function. This activity is easily adapted to an inquiry format that asks students to go to the scientific literature to learn about the test and then design a protocol for carrying out the test in classmates. The data collected are ideal for teaching graphical presentation of data and statistical analysis.
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Affiliation(s)
- Dee U Silverthorn
- Section of Integrative Biology, University of Texas, Austin, TX 78712, USA.
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25
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Valenta I, Dilsizian V, Quercioli A, Schelbert HR, Schindler TH. The Influence of Insulin Resistance, Obesity, and Diabetes Mellitus on Vascular Tone and Myocardial Blood Flow. Curr Cardiol Rep 2011; 14:217-25. [PMID: 22205177 DOI: 10.1007/s11886-011-0240-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ines Valenta
- Department of Specialities in Medicine, Divisions of Cardiology and Nuclear Medicine, University Hospitals of Geneva, Geneva, Switzerland
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26
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van den Heuvel M, Sorop O, Koopmans SJ, Dekker R, de Vries R, van Beusekom HMM, Eringa EC, Duncker DJ, Danser AHJ, van der Giessen WJ. Coronary microvascular dysfunction in a porcine model of early atherosclerosis and diabetes. Am J Physiol Heart Circ Physiol 2011; 302:H85-94. [PMID: 21984550 DOI: 10.1152/ajpheart.00311.2011] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Detailed evaluation of coronary function early in diabetes mellitus (DM)-associated coronary artery disease (CAD) development is difficult in patients. Therefore, we investigated coronary conduit and small artery function in a preatherosclerotic DM porcine model with type 2 characteristics. Streptozotocin-induced DM pigs on a saturated fat/cholesterol (SFC) diet (SFC + DM) were compared with control pigs on SFC and standard (control) diets. SFC + DM pigs showed DM-associated metabolic alterations and early atherosclerosis development in the aorta. Endothelium-dependent vasodilation to bradykinin (BK), with or without blockade of nitric oxide (NO) synthase, endothelium-independent vasodilation to an exogenous NO-donor (S-nitroso-N-acetylpenicillamine), and vasoconstriction to endothelin (ET)-1 with blockade of receptor subtypes, were assessed in vitro. Small coronary arteries, but not conduit vessels, showed functional alterations including impaired BK-induced vasodilatation due to loss of NO (P < 0.01 vs. SFC and control) and reduced vasoconstriction to ET-1 (P < 0.01 vs. SFC and control), due to a decreased ET(A) receptor dominance. Other vasomotor responses were unaltered. In conclusion, this model demonstrates specific coronary microvascular alterations with regard to NO and ET-1 systems in the process of early atherosclerosis in DM. In particular, the altered ET-1 system correlated with hyperglycemia in atherogenic conditions, emphasizing the importance of this system in DM-associated CAD development.
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Affiliation(s)
- Mieke van den Heuvel
- Department of Cardiology, Division of Pharmacology, Vascular and Metabolic Diseases, Cardiovascular Research School COEUR, Erasmus University Medical Center, Rotterdam, The Netherlands
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27
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Littarru GP, Tiano L, Belardinelli R, Watts GF. Coenzyme Q(10) , endothelial function, and cardiovascular disease. Biofactors 2011; 37:366-73. [PMID: 21674640 DOI: 10.1002/biof.154] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 03/09/2011] [Indexed: 01/15/2023]
Abstract
Since the time a precise role of coenzyme Q(10) (CoQ(10) ) in myocardial bioenergetics was established, the involvement of CoQ in the pathophysiology of heart failure was hypothesized. This provided the rationale for numerous clinical trials of CoQ(10) as adjunctive treatment for heart failure. A mild hypotensive effect of CoQ was reported in the early years of clinical use of this compound. We review early human and animal studies on the vascular effects of CoQ. We then focus on endothelial dysfunction in type 2 diabetes and the possible impact on this condition of antioxidants and nutritional supplements, and in particular the therapeutic effects of CoQ. The effect of CoQ(10) on endothelial dysfunction in ischemic heart disease is also reviewed together with recent data highlighting that treatment with CoQ(10) increases extracellular SOD activity.
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Affiliation(s)
- Gian Paolo Littarru
- Department of Biochemistry, Biology & Genetics, Marche Polytechnic University, Ancona, Italy.
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Noninvasive Visualization of Coronary Artery Endothelial Function in Healthy Subjects and in Patients With Coronary Artery Disease. J Am Coll Cardiol 2010; 56:1657-65. [DOI: 10.1016/j.jacc.2010.06.036] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 06/07/2010] [Accepted: 06/14/2010] [Indexed: 11/30/2022]
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Hueb W, Lopes N, Soares PR, Gersh BJ, Lima EG, Vieira RDO, Garzillo CL, Garcia RR, Pereira AC, Strunz CM, Meneguetti C, Tsutsui J, Parga J, Lemos P, Hueb A, Ushida A, Maranhão R, Chamone DA, Ramires JA. Hypotheses, rationale, design, and methods for prognostic evaluation in type 2 diabetic patients with angiographically normal coronary arteries. The MASS IV-DM Trial. BMC Cardiovasc Disord 2010; 10:47. [PMID: 20920271 PMCID: PMC2956708 DOI: 10.1186/1471-2261-10-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 09/29/2010] [Indexed: 11/15/2022] Open
Abstract
Background The MASS IV-DM Trial is a large project from a single institution, the Heart Institute (InCor), University of São Paulo Medical School, Brazil to study ventricular function and coronary arteries in patients with type 2 diabetes mellitus. Methods/Design The study will enroll 600 patients with type 2 diabetes who have angiographically normal ventricular function and coronary arteries. The goal of the MASS IV-DM Trial is to achieve a long-term evaluation of the development of coronary atherosclerosis by using angiograms and coronary-artery calcium scan by electron-beam computed tomography at baseline and after 5 years of follow-up. In addition, the incidence of major cardiovascular events, the dysfunction of various organs involved in this disease, particularly microalbuminuria and renal function, will be analyzed through clinical evaluation. In addition, an effort will be made to investigate in depth the presence of major cardiovascular risk factors, especially the biochemical profile, metabolic syndrome inflammatory activity, oxidative stress, endothelial function, prothrombotic factors, and profibrinolytic and platelet activity. An evaluation will be made of the polymorphism as a determinant of disease and its possible role in the genesis of micro- and macrovascular damage. Discussion The MASS IV-DM trial is designed to include diabetic patients with clinically suspected myocardial ischemia in whom conventional angiography shows angiographically normal coronary arteries. The result of extensive investigation including angiographic follow-up by several methods, vascular reactivity, pro-thrombotic mechanisms, genetic and biochemical studies may facilitate the understanding of so-called micro- and macrovascular disease of DM.
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Affiliation(s)
- Whady Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil.
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30
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Haemodynamical Variables Versus Endothelial Hormones in Hypertensive and Type 2 Diabetic Patients With Endothelial Dysfunction. Am J Ther 2010; 17:306-19. [DOI: 10.1097/mjt.0b013e3181c2de61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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The relation between microalbuminuria and coronary collateral vessel development in patients with unstable coronary artery disease. Coron Artery Dis 2009; 20:431-4. [PMID: 19704373 DOI: 10.1097/mca.0b013e3283277650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Microalbuminuria, considered a marker for systemic vascular disease, is a significant predictor of increased risk for cardiovascular morbidity and mortality in the general population. The relationship between microalbuminuria and cardiovascular disease is unknown. The aim of this study is to examine the association between microalbuminuria and coronary collateral vessel (CCV) development in nondiabetic and nonhypertensive patients with unstable coronary artery disease (USCAD). One hundred and six patients that had USCAD without hypertension and diabetes participated in the study. Microalbuminuria was assessed by radioimmunoassay in 24-h urine collections performed on the first day, and coronary angiography was performed 2-4 days after admissions. In total, 26 patients (mean age 56+/-14 years) had the criteria of the microalbuminuria group and 80 patients with normoalbuminuria (mean age 59+/-11 years), who had one or more diseased vessels with 80% or more stenosis, were included in the control group. The CCVs are graded according to the Rentrop scoring system and a Rentrop grade >or=1 was accepted as CCV development. CCV development was detected in eight (23%) of 26 patients in the microalbuminuria group and in 53 (74%) of 80 patients in the normoalbuminuria group. CCV development in the patients in the normoalbuminuria group was significantly different from that of the patients in the microalbuminuria group (r = -0.15, P = 0.006). In conclusion, these findings suggest that CCV development is poorer in the microalbuminuria group than the normoalbuminuria group. This study shows that in patients with USCAD, microalbuminuria, which is related to systemic vascular disease, affects CCV development negatively.
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32
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Simonsen U, Rodriguez-Rodriguez R, Dalsgaard T, Buus NH, Stankevicius E. Novel approaches to improving endothelium-dependent nitric oxide-mediated vasodilatation. Pharmacol Rep 2009; 61:105-15. [PMID: 19307698 DOI: 10.1016/s1734-1140(09)70012-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 02/03/2009] [Indexed: 01/27/2023]
Abstract
Endothelial dysfunction, which is defined by decreased endothelium-dependent vasodilatation, is associated with an increased number of cardiovascular events. Nitric oxide (NO) bioavailability is reduced by altered endothelial signal transduction or increased formation of radical oxygen species reacting with NO. Endothelial dysfunction is therapeutically reversible and physical exercise, calcium channel blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor antagonists improve flow-evoked endothelium-dependent vasodilation in patients with hypertension and diabetes. We have investigated three different approaches, with the aim of correcting endothelial dysfunction in cardiovascular disease. Thus, (1) we evaluated the effect of a cell permeable superoxide dismutase mimetic, tempol, on endothelial dysfunction in small arteries exposed to high pressure, (2) investigated the endothelial signal transduction pathways involved in vasorelaxation and NO release induced by an olive oil component, oleanolic acid, and (3) investigated the role of calcium-activated K channels in the release of NO induced by receptor activation. Tempol increases endothelium-dependent vasodilatation in arteries from hypertensive animals most likely through the lowering of radical oxygen species, but other mechanisms also appear to contribute to the effect. While oleanolic acid leads to the release of NO by calcium-independent phosphorylation of endothelial NO synthase, endothelial calcium-activated K channels and an influx of calcium play an important role in G-protein coupled receptor-evoked release of NO. Thus, all three approaches increase bioavailability of NO in the vascular wall, but it remains to be addressed whether these actions have any direct benefit at a clinical level.
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Affiliation(s)
- Ulf Simonsen
- Department of Pharmacology, Faculty of Health Sciences, Aarhus University, Aarhus C, Denmark.
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33
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Nguyen PK, Meyer C, Engvall J, Yang P, McConnell MV. Noninvasive assessment of coronary vasodilation using cardiovascular magnetic resonance in patients at high risk for coronary artery disease. J Cardiovasc Magn Reson 2008; 10:28. [PMID: 18513419 PMCID: PMC2467421 DOI: 10.1186/1532-429x-10-28] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 05/30/2008] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Impaired coronary vasodilation to both endothelial-dependent and endothelial-independent stimuli have been associated with atherosclerosis. Direct measurement of coronary vasodilation using x-ray angiography or intravascular ultrasound is invasive and, thus, not appropriate for asymptomatic patients or for serial follow-up. In this study, high-resolution coronary cardiovascular magnetic resonance (CMR) was used to investigate the vasodilatory response to nitroglycerine (NTG) of asymptomatic patients at high risk for CAD. METHODS A total of 46 asymptomatic subjects were studied: 13 high-risk patients [8 with diabetes mellitus (DM), 5 with end stage renal disease (ESRD)] and 33 age-matched controls. Long-axis and cross-sectional coronary artery images were acquired pre- and 5 minutes post-sublingual NTG using a sub-mm-resolution multi-slice spiral coronary CMR sequence. Coronary cross sectional area (CSA) was measured on pre- and post-NTG images and % coronary vasodilation was calculated. RESULTS Patients with DM and ESRD had impaired coronary vasodilation to NTG compared to age-matched controls (17.8 +/- 7.3% vs. 25.6 +/- 7.1%, p = 0.002). This remained significant for ESRD patients alone (14.8 +/- 7.7% vs. 25.6 +/- 7.1%; p = 0.003) and for DM patients alone (19.8 +/- 6.3% vs. 25.6 +/- 7.1%; p = 0.049), with a non-significant trend toward greater impairment in the ESRD vs. DM patients (14.8 +/- 7.7% vs. 19.8 +/- 6.3%; p = 0.23). CONCLUSION Noninvasive coronary CMR demonstrates impairment of coronary vasodilation to NTG in high-risk patients with DM and ESRD. This may provide a functional indicator of subclinical atherosclerosis and warrants clinical follow up to determine prognostic significance.
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Affiliation(s)
- Patricia K Nguyen
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
| | - Craig Meyer
- Department of Biomedical Engineering, University of Virginia, Virginia, USA
| | - Jan Engvall
- Department of Clinical Physiology, Linköping Heart Center, Linköping, Sweden
| | - Phillip Yang
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
| | - Michael V McConnell
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, USA
- Department of Electrical Engineering, Stanford University, Stanford, USA
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Bosevski M, Borozanov V, Tosev S, Georgievska-Ismail L. Is assessment of peripheral endothelial dysfunction useful tool for risk stratification of type 2 diabetic patients with manifested coronary artery disease? Int J Cardiol 2007; 131:290-2. [PMID: 17964674 DOI: 10.1016/j.ijcard.2007.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Revised: 08/13/2007] [Accepted: 08/18/2007] [Indexed: 10/22/2022]
Abstract
Endothelial dysfunction, per se, in coronary arteries can stratify a risk in coronary artery disease patients. Selected studies evaluating endotheliopathy as predictor of events in patients with type 2 diabetes, but without coronary artery disease. We hypothesized that peripheral endothelial dysfunction could predict prognosis of type 2 diabetic patients who presented coronary artery disease. Our data presented endothelial dysfunction as prognostic marker of cardiovascular events in type 2 diabetic patients with manifested coronary artery disease, according univariate regression model.
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35
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Hamilton SJ, Chew GT, Watts GF. Therapeutic regulation of endothelial dysfunction in type 2 diabetes mellitus. Diab Vasc Dis Res 2007; 4:89-102. [PMID: 17654442 DOI: 10.3132/dvdr.2007.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Endothelial dysfunction is universal in diabetes, being intimately involved with the development of cardiovascular disease. The pathogenesis of endothelial dysfunction in diabetes is complex. It is initially related to the effects of fatty acids and insulin resistance on 'uncoupling' of both endothelial nitric oxide synthase activity and mitochondrial function. Oxidative stress activates protein kinase C (PKC), polyol, hexosamine and nuclear factor kappa B pathways, thereby aggravating endothelial dysfunction. Improvements in endothelial function in the peripheral circulation in diabetes have been demonstrated with monotherapies, including statins, fibrates, angiotensin-converting enzyme (ACE) inhibitors, metformin and fish oils. These observations are supported by large clinical end point trials. Other studies show benefits with certain antioxidants, L-arginine, folate, PKC-inhibitors, peroxisome proliferator activated receptor (PPAR)-alpha and -gamma agonists and phosphodiesterase (PDE-5) inhibitors. However, the benefits of these agents remain to be shown in clinical end point trials. Combination treatments, for example, statins plus ACE inhibitors and statins plus fibrates, have also been demonstrated to have additive benefits on endothelial function in diabetes, but there are no clinical outcome data to date. Measurement of endothelial dysfunction in cardiovascular research can provide fresh opportunities for exploring the mechanism of benefit of new therapeutic regimens and for planning and designing large clinical trials.
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Affiliation(s)
- Sandra J Hamilton
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Kiviniemi TO, Toikka JO, Koskenvuo JW, Saraste A, Saraste M, Pärkkä JP, Raitakari OT, Hartiala JJ. Vasodilation of epicardial coronary artery can be measured with transthoracic echocardiography. ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:362-70. [PMID: 17188799 DOI: 10.1016/j.ultrasmedbio.2006.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Revised: 08/08/2006] [Accepted: 08/17/2006] [Indexed: 05/13/2023]
Abstract
Transthoracic Doppler echocardiography (TTE) has been introduced as a noninvasive tool to measure coronary flow velocity reserve (CFVR). Velocity measurement, however, fails to take into account epicardial coronary artery vasodilation during hyperemia and this may cause underestimation of CFVR measurements. Therefore, we sought to determine whether the vasodilation of epicardial coronary artery can be measured during cold pressor test (CPT) and adenosine infusion simultaneously with the flow velocity measurement using TTE. We studied 41 healthy nonsmoking men with a linear high-frequency 8.0-MHz transducer. The CPT and adenosine infusion dilated the diameter of the distal left anterior descending coronary artery (LAD) from 1.4 +/- 0.4 mm to 1.5 +/- 0.4 mm (14 +/- 13%, p < 0.01) and from 1.4 +/- 0.4 mm to 1.8 +/- 0.5 mm (31 +/- 19%, p < 0.01), respectively. The CPT increased flow velocity and calculated coronary blood flow rate (velocity time integral x cross-sectional area) from 0.23 +/- 0.05 m/s to 0.36 +/- 0.13 m/s (31 +/- 34%, p < 0.01) and from 8.1 +/- 4.2 mL/min to 11.4 +/- 6.0 mL/min (47 +/- 51%, p < 0.01). CFVR and calculated coronary blood flow rate reserve were 3.9 +/- 1.0 and 6.0 +/- 1.9, respectively. In Bland-Altman analysis, velocity measurements underestimated the vasodilation response of the CPT and adenosine compared with the measurements where epicardial diameter dilation was taken into account. Intra- and interobserver variability of diameter measurements was low (coefficient of variation [CV] 2.6 to 6.5%). Day-to-day, within-day and intersonographer variabilities were of similar magnitude (CV 4.6 to 8.2%), suggesting good reproducibility. This study demonstrates that TTE can be used to assess changes in both epicardial coronary artery diameter and flow velocity simultaneously in the distal LAD artery.
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Affiliation(s)
- Tuomas O Kiviniemi
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland.
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37
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Fornengo P, Bosio A, Epifani G, Pallisco O, Mancuso A, Pascale C. Prevalence of silent myocardial ischaemia in new-onset middle-aged Type 2 diabetic patients without other cardiovascular risk factors. Diabet Med 2006; 23:775-9. [PMID: 16842483 DOI: 10.1111/j.1464-5491.2006.01910.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Coronary artery disease (CAD) is the leading cause of death in patients with Type 2 diabetes and is often asymptomatic. Silent myocardial ischaemia (SMI) is frequent in diabetic subjects and is responsible for a late diagnosis of CAD; its early detection is important. There are some data about the prevalence of SMI in Type 2 diabetic patients at high risk for cardiovascular disease, while no data are available in subjects at the onset of diabetes without other cardiovascular risk factors. METHODS We screened 274 consecutive patients (mean age 64.3 +/- 8.4 years, 66% male) at the time of diagnosis of Type 2 diabetes; we enrolled 111 subjects without other cardiovascular disease risk factors (dyslipidaemia, hypertension, peripheral vascular disease, retinopathy, microalbuminuria, history of heart disease) and with normal resting electrocardiogram (ECG). Participants performed a maximal ECG exercise protocol and, if positive, underwent coronary angiography. RESULTS The ECG exercise test was positive in 19 patients (17.1%); of those 14 (13%) had angiographic coronary disease (one with three-vessel disease, three with two vessels and 10 with one vessel involved). The positive predictive value of the exercise ECG for predicting angiographic coronary disease was 73%. CONCLUSIONS The prevalence of SMI was 17% and angiographic coronary disease was found in 13% of middle-aged subjects with new-onset Type 2 diabetes without other cardiovascular risk factors. This prevalence is similar to that observed in studies of subjects with long duration diabetes who have additional cardiovascular risk factors.
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Affiliation(s)
- P Fornengo
- Division of Internal Medicine and Service of Cardiology, Cottolengo Hospital, Turin, Italy.
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Shimbo D, Grahame-Clarke C, Miyake Y, Rodriguez C, Sciacca R, Di Tullio M, Boden-Albala B, Sacco R, Homma S. The association between endothelial dysfunction and cardiovascular outcomes in a population-based multi-ethnic cohort. Atherosclerosis 2006; 192:197-203. [PMID: 16762358 DOI: 10.1016/j.atherosclerosis.2006.05.005] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 04/24/2006] [Accepted: 05/03/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Brachial artery flow-mediated dilation (FMD) may predict cardiovascular events in selected high-risk patients. Whether FMD testing predicts cardiovascular events in asymptomatic, lower risk individuals from the general population is unknown. METHODS AND RESULTS As a part of a multi-ethnic, prospective cohort study, the Northern Manhattan Study, we examined FMD by high-resolution ultrasonography in 842 community participants who were free of stroke or myocardial infarction. Lower FMD levels predicted cardiovascular events (myocardial infarction, stroke and vascular death) at 36 months of follow-up (hazard ratio (HR)=1.12 for every 1% decrease in FMD, 95% CI 1.01-1.25, p=0.03). The risk of events in patients with FMD in the lower two tertiles (FMD<7.5%) was significantly higher than those in the highest tertile (HR=3.28, 95% CI 1.07-10.06, p=0.04 for lowest versus highest tertile, and HR=3.05, 95% CI 1.03-9.66, p=0.04 for middle versus highest tertile). In a multivariate analysis including cardiovascular risk factors, the increase in risk associated with FMD was no longer statistically significant. CONCLUSIONS Non-invasive FMD testing predicts incident cardiovascular events in this multi-ethnic, population-based sample, but its predictive value is not independent of cardiovascular risk factors.
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Affiliation(s)
- Daichi Shimbo
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, NY, United States
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Kim HK, Sohn DW, Lee SE, Kim YJ, Oh BH, Park YB. Coronary blood flow after cold exposure and the effect of warm-up exercise. J Am Soc Echocardiogr 2006; 19:386-90. [PMID: 16581477 DOI: 10.1016/j.echo.2005.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cold pressor test (CPT) results indicate that coronary blood flow (CBF) increases after sudden cold exposure. Traditionally, warm-up exercise (WEx) has been recommended before cold exposure; however, the physiologic effects of WEx on CBF have not been elucidated. Therefore, this study was undertaken to evaluate the effect of WEx on CBF after cold exposure. METHODS Fifteen healthy young men were enrolled in this study. CBF at the distal left anterior descending coronary artery was assessed by transthoracic Doppler echocardiography at baseline and after CPT. The same measurements were made with WEx and weight-bearing exercise before CPT after a 20-minute recovery period between each measurement. In the CBF velocities, the time-velocity integral of diastolic flow (Dtvi) was measured in addition to blood pressure and heart rate (HR). RESULTS The product of Dtvi x HR increased significantly after CPT. Increments in Dtvi x HR after CPT with WEx before CPT were significantly higher than CPT alone (130 +/- 82% vs 68 +/- 37%, P < .05). However, increments in Dtvi x HR after CPT with weight-bearing exercise before CPT were not significantly different from those observed for CPT alone (74 +/- 50% vs 68 +/- 37%, P = not significant). CONCLUSION Our study suggests that WEx can augment an increased CBF after cold exposure. This augmentation of CBF increase after cold exposure may help the body meet increased physiologic demands imposed on it by cold exposure. However, this phenomenon was not observed for anaerobic weight-bearing exercise.
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Affiliation(s)
- Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Chongno-gu, Seoul, Korea
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Abstract
Cardiovascular diseases are the leading cause of morbidity and mortality in people with diabetes. Vascular abnormalities can be observed long before atherosclerosis develops and in sites not usually prone to atherosclerosis. These vascular abnormalities are known to be due to endothelial dysfunctions, one of the most frequent of which is depressed endothelium-dependent dilation. In patients with diabetes, this is mainly linked to decreased bioavailability of nitric oxide. Although inactivation of tetrahydrobiopterin, a co-factor of NO-synthase, may depress nitric oxide production, the latter is more likely due to the inactivation of nitric oxide by superoxide anions: enhanced oxidative stress increases their production in people with diabetes. Moreover, hyperglycemia directly activates oxidative stress, which in turn depresses endothelium-dependent vasodilation. Glycemia and oxidative stress are positively correlated in people with diabetes. However, while depression of endothelium-dependent dilation may be a visible functional manifestation of oxidative stress, the oxidative stress itself is mainly responsible for the cascade of endothelial events that play a key role in development of vascular atherosclerosis and its complications. Especially important among these events are the activation of NF-kappaB and the oxidation of LDL-cholesterol. Although antioxidants provide short-term improvement of endothelial function in humans, all studies of the effectiveness of preventive antioxidant therapy have been disappointing. Control of hyperglycemia thus remains the best way to improve endothelial function and to prevent atherosclerosis and other cardiovascular complications of diabetes.
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Affiliation(s)
- A Nitenberg
- Service de physiologie et d'explorations fonctionnelles, Hôpital Jean Verdier, avenue du 14-Juillet, 93143 Bondy Cedex.
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Valensi P, Pariès J, Brulport-Cerisier V, Torremocha F, Sachs RN, Vanzetto G, Cosson E, Lormeau B, Attali JR, Maréchaud R, Estour B, Halimi S. Predictive value of silent myocardial ischemia for cardiac events in diabetic patients: influence of age in a French multicenter study. Diabetes Care 2005; 28:2722-7. [PMID: 16249546 DOI: 10.2337/diacare.28.11.2722] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Silent myocardial ischemia (SMI) in asymptomatic subjects with no history of myocardial infarction or angina is a frequent condition in diabetic patients. The aim of the study was to examine the predictive value of SMI for cardiac events in a multicenter cohort and to determine whether this value is higher in patients with a particular clinical profile. RESEARCH DESIGN AND METHODS A total of 370 asymptomatic diabetic patients with at least two additional cardiovascular risk factors was recruited in four departments of diabetology. SMI was assessed by either exercise or dipyridamole single-photon emission-computed tomography myocardial perfusion imaging with thallium-201. If dipyridamole stress was used, an electrocardiogram stress test was performed separately on another day. Follow-up duration was 3-89 months (38 +/- 23 months). RESULTS There was evidence of SMI in 131 patients (35.4%) on at least one positive noninvasive test. The patients with SMI were significantly older and had significantly higher serum triglycerides and lower HDL cholesterol levels. Cardiac events occurred in 53 patients (14.3%). Major cardiac events (death or myocardial infarction) occurred in 38 patients (10%) and other events (unstable angina, heart failure, or coronary revascularization) occurred in 15 patients. The patients who had cardiac events were older and had higher serum triglyceride levels at baseline. There was a significant association between SMI and cardiac events (hazard ratio 2.79 [95% CI 1.54-5.04]) and in particular major cardiac events (3 [1.53-5.87]). In the patients >60 years of age, the prevalence of SMI was higher (43.4 vs. 30.2% in those <60 years). SMI was associated with a significant risk of cardiac events (2.89 [1.31-6.39]) and in particular major cardiac events (3.66 [1.36-9.87]) for the patients >60 years old but not for those <60 years old. CONCLUSIONS In asymptomatic diabetic patients with additional cardiovascular risk factors, SMI is a potent predictor of cardiac events and should be assessed preferably in the patients >60 years of age.
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Affiliation(s)
- Paul Valensi
- Department of Endocrinology-diabetology-Nutrition, Jean Verdier Hospital, Bondy Cedex, France.
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Cosson E, Attali JR, Valensi P. Markers for silent myocardial ischemia in diabetes. Are they helpful? DIABETES & METABOLISM 2005; 31:205-13. [PMID: 15959427 DOI: 10.1016/s1262-3636(07)70187-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Silent myocardial ischemia (SMI) and silent coronary stenoses (CS) are two to seven times more frequent in diabetic patients than in non-diabetic patients. In addition to this, they have a higher predictive value for cardiovascular events than the classical cardiovascular risk factors, either taken alone or combined. Coronary arterial disease is the leading cause of mortality and morbidity in the diabetic population. Altogether, these data suggest that screening for SMI and silent CS is an important issue. We assume that detecting SMI and silent CS improves patient management, and leads to optimised follow-up, action taken on nutrition, exercise and lifestyle, management of the cardiovascular risk factors, and revascularisation procedures whenever possible. However, screening for SMI and silent CS is expensive and may induce morbidity. Selecting the patients with a high a priori risk of SMI and silent CS is therefore of major concern. Carotid or lower limb peripheral arterial disease, proteinuria, male gender, an age greater than 60 years, and two or more cardiovascular risk factors among smoking, microalbuminuria, dyslipidemia, hypertension, a family history of premature cardiac disease, and cardiac autonomic neuropathy have been demonstrated to be the best current predictors of SMI and silent CS. New markers, such as adhesion molecules, Lp(a), inflammation parameters or homocysteine, and endothelium function assessment might be of further help in the future.
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Affiliation(s)
- E Cosson
- Department of Endocrinology-Diabetology-Nutrition, Paris-Nord University, Jean Verdier Hospital, AP-HP, Bondy, France.
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Asselbergs FW, van der Harst P, Jessurun GAJ, Tio RA, van Gilst WH. Clinical impact of vasomotor function assessment and the role of ACE-inhibitors and statins. Vascul Pharmacol 2005; 42:125-40. [PMID: 15792930 DOI: 10.1016/j.vph.2005.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Impaired endothelial function is recognised as one of the earliest events of atherogenesis. Endothelium-dependent vasomotion has been the principal method to assess endothelial function. In this article, we will discuss the clinical value of the different techniques to evaluate endothelium-dependent vasomotion. To date, there seems not to be a simple and reliably endothelial function test to identify asymptomatic subjects at increased risk for cardiovascular disease in clinical practice. Recent studies indicate that pharmacological interventions, in particular with ACE-inhibitors and statins, might improve endothelial function. However, there is no solid evidence that improvement of endothelial function is a necessity for the observed reduction in cardiovascular events by these compounds. Overall, at this moment, there is no place in clinical practice for the use of endothelial function as a method for risk assessment or target of pharmacological interventions.
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Affiliation(s)
- Folkert W Asselbergs
- Department of Clinical Pharmacology, University of Groningen, Groningen, The Netherlands.
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Schindler TH, Nitzsche EU, Schelbert HR, Olschewski M, Sayre J, Mix M, Brink I, Zhang XL, Kreissl M, Magosaki N, Just H, Solzbach U. Positron emission tomography-measured abnormal responses of myocardial blood flow to sympathetic stimulation are associated with the risk of developing cardiovascular events. J Am Coll Cardiol 2005; 45:1505-12. [PMID: 15862426 DOI: 10.1016/j.jacc.2005.01.040] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2004] [Revised: 01/19/2005] [Accepted: 01/25/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We sought to assess prospectively whether patients with normal coronary angiograms but with impaired myocardial blood flow (MBF) increases to cold pressor testing (CPT) are at increased risk for cardiovascular events. BACKGROUND Invasive angiographic assessments of coronary vasomotor function have demonstrated an impairment of endothelium-related coronary flow increases to independently predict future cardiovascular events. It is unknown whether noninvasive positron emission tomography (PET)-measured MBF alterations to sympathetic stimulation with CPT are associated with the risk of developing cardiovascular events. METHODS A total of 72 patients (44 men, 28 women, age 58 +/- 8 years) referred for diagnostic cardiac catheterization were studied. Myocardial blood flow was measured in absolute units with (13)N-ammonia using PET, at baseline and during CPT in each patient. Cardiovascular events (cardiovascular death, acute coronary syndrome, myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, ischemic stroke, or peripheral revascularization) were assessed as clinical outcome parameters over a mean follow-up period of 66 +/- 8 months. Patients were assigned to three groups: group 1, patients with >/=40% increase in MBF (%DeltaMBF), n = 22; group 2, patients with >0 and <40% increases in MBF, n = 32; and group 3, patients with decreases in MBF (</=0%), n = 18. RESULTS During follow-up, one of the group 1 patients developed a cerebral stroke. In group 2, 15 cardiovascular events occurred in 9 patients and in group 3, 7 patients experienced 9 cardiovascular events (p </= 0.0001, univariate by log-rank test). Impaired MBF increases in group 2 and group 3 were associated with a significantly higher incidence of cardiovascular events by Kaplan-Meier analysis (p = 0.033, log-rank test). After adjusting for known coronary risk factors, MBF responses to CPT revealed a nonsignificant trend to be independently associated with a higher incidence for cardiovascular events (p = 0.065, multivariate by Cox regression model). CONCLUSIONS Noninvasive PET-measured impaired MBF increases to sympathetic stimulation are associated with the risk of developing cardiovascular events.
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Affiliation(s)
- Thomas H Schindler
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-6948, USA.
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Park SM, Shim WJ, Ahn JC, Lim DS, Kim YH, Ro YM. Changes of coronary blood flow in vasospastic angina under cold stimulation by transthoracic Doppler echocardiography. J Korean Med Sci 2005; 20:204-8. [PMID: 15831987 PMCID: PMC2808592 DOI: 10.3346/jkms.2005.20.2.204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This study was done to evaluate changes of microvascular function under cold stimulation by measuring coronary flow velocities (CFVs) in vasospastic angina (VA) patients using transthoracic Doppler echocardiography (TTDE). 14 patients with VA and 15 healthy controls were included. CFVs were measured at the distal left anterior descending coronary artery by TTDE at baseline and under cold stimulation. Hyperemia was induced by intravenous adenosine infusion (140 microg/kg/min). At baseline, CFVs and coronary flow reserve (CFR) were not different between controls and VA patients. Under cold stimulation, the degree of increment of CFV with adenosine was lower in VA patients than in controls. Comparing baseline with cold stimulation, coronary flow reserve (CFR) increased (3.1+/-0.7 to 3.8 +/-1.0, p=0.06) in controls. In contrast, in VA patients, CFR was decreased (2.8 +/-0.9 to 2.6 +/-0.7, p=0.05) and coronary vascular resistance index markedly increased (0.35 to 0.43, p=0.01). Throughout the study, no patient experienced chest pain or ECG changes. In VA patients, CFR was preserved at baseline, but coronary blood flow increase in response to cold stimulation was blunted and CFR was decreased. These findings suggest that endothelial dependent vasodilation is impaired at the coronary microvascular and the epicardial artery level in VA under cold stimulation.
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Affiliation(s)
- Seong Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Wan Joo Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Jung Cheon Ahn
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Do Sun Lim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Young Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
| | - Young Moo Ro
- Division of Cardiology, Department of Internal Medicine, Korea University Medical College, Seoul, Korea
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Abstract
Cardiac positron emission tomography (PET) imaging has advanced from primarily a research tool to a practical, high-performance clinical imaging modality. The widespread availability of state-of-the-art PET gamma cameras, the commercial availability of perfusion and viability PET imaging tracers, reimbursement for PET perfusion and viability procedures by government and private health insurance plans, and the availability of computer software for image display of perfusion, wall motion, and viability images have all been a key to cardiac PET imaging becoming a routine clinical tool. Although myocardial perfusion PET imaging is an option for all patients requiring stress perfusion imaging, there are identifiable patient groups difficult to image with conventional single-photon emission computed tomography imaging that are particularly likely to benefit from PET imaging, such as obese patients, women, patients with previous nondiagnostic tests, and patients with poor left ventricular function attributable to coronary artery disease considered for revascularization. Myocardial PET perfusion imaging with rubidium-82 is noteworthy for high efficiency, rapid throughput, and in a high-volume setting, low operational costs. PET metabolic viability imaging continues to be a noninvasive standard for diagnosis of viability imaging. Cardiac PET imaging has been shown to be cost-effective. The potential of routine quantification of resting and stress blood flow and coronary flow reserve in response to pharmacologic and cold-pressor stress offers tantalizing possibilities of enhancing the power of PET myocardial perfusion imaging. This can be achieved by providing assurance of stress quality control, in enhancing diagnosis and risk stratification in patients with coronary artery disease, and expanding diagnostic imaging into the realm of detection of early coronary artery disease and endothelial dysfunction subject to risk factor modification. Combined PET and x-ray computed tomography imaging (PET-CT) results in enhanced patient throughput and efficiency. The combination of multislice computed tomography scanners with PET opens possibilities of adding coronary calcium scoring and noninvasive coronary angiography to myocardial perfusion imaging and quantification. Evaluation of the clinical role of these creative new possibilities warrants investigation.
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Affiliation(s)
- Josef Machac
- Department of Radiology, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, NY 10029, USA.
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Forst T, Lübben G, Hohberg C, Kann P, Sachara C, Gottschall V, Friedrich C, Rosskopf R, Pfützner A. Influence of Glucose Control and Improvement of Insulin Resistance on Microvascular Blood Flow and Endothelial Function in Patients with Diabetes Mellitus Type 2. Microcirculation 2005; 12:543-50. [PMID: 16207627 DOI: 10.1080/10739680500253402] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The study was performed to investigate the effect of improving metabolic control with pioglitazone in comparison to glimepiride on microvascular function in patients with diabetes mellitus type 2. METHODS A total of 179 patients were recruited and randomly assigned to one treatment group. Metabolic control (HbA1c), insulin resistance (HOMA index), and microvascular function (laser Doppler fluxmetry) were observed at baseline and after 3 and 6 months. RESULTS HbA1c improved in both treatment arms (pioglitazone: 7.52 +/- 0.85% to 6.71 +/- 0.89%, p < .0001; glimepiride: 7.44 +/- 0.89% to 6.83 +/- 0.85%, p < .0001). Insulin-resistance decreased significantly in the pioglitazone group (6.15 +/- 4.05 to 3.85 +/- 1.92, p < .0001) and remained unchanged in the glimepiride group. The microvascular response to heat significantly improved in both treatment groups (pioglitazone 48.5 [15.2; 91.8] to 88.8 [57.6; 124.1] arbitrary units [AU], p < .0001; glimepiride 53.7 [14.1; 91.9] to 87.9 [52.9, 131.0] AU, p < .0001, median [lower and upper quartile]). Endothelial function as measured with the acetylcholine response improved in the pioglitazone group (38.5 [22.2; 68.0] to 60.2 [36.9; 82.8], p = .0427) and remained unchanged in the glimepiride group. CONCLUSIONS Improving metabolic control has beneficial effects in microvascular function in type 2 diabetic patients. Treatment of type 2 diabetic patients with pioglitazone exerts additional effects on endothelial function beyond metabolic control.
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Affiliation(s)
- Thomas Forst
- Institute for Clinical Research and Development, Mainz, Germany.
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Current literature in diabetes. Diabetes Metab Res Rev 2004; 20:487-94. [PMID: 15570584 DOI: 10.1002/dmrr.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Prior JO, Monbaron D, Koehli M, Calcagni ML, Ruiz J, Bischof Delaloye A. Prevalence of symptomatic and silent stress-induced perfusion defects in diabetic patients with suspected coronary artery disease referred for myocardial perfusion scintigraphy. Eur J Nucl Med Mol Imaging 2004; 32:60-9. [PMID: 15309331 DOI: 10.1007/s00259-004-1591-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2004] [Accepted: 04/28/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE Silent myocardial ischaemia--as evaluated by stress-induced perfusion defects on myocardial perfusion scintigraphy (MPS) in patients without a history of chest pain--is frequent in diabetes and is associated with increased rates of cardiovascular events. Its prevalence has been determined in asymptomatic diabetic patients, but remains largely unknown in diabetic patients with suspected coronary artery disease (CAD) in the clinical setting. In this study we therefore sought (a) to determine the prevalence of symptomatic and silent perfusion defects in diabetic patients with suspected CAD and (b) to characterise the eventual predictors of abnormal perfusion. METHODS The patient population comprised 133 consecutive diabetic patients with suspected CAD who had been referred for MPS. Studies were performed with exercise (41%) or pharmacological stress testing (1-day protocol, (99m)Tc-sestamibi, 201Tl or both). We used semi-quantitative analysis (20-segment polar maps) to derive the summed stress score (SSS) and the summed difference score (SDS). RESULTS Abnormal MPS (SSS> or =4) was observed in 49 (37%) patients (SSS=4.9+/-8.4, SDS=2.4+/-4.7), reversible perfusion defects (SDS> or =2) in 40 (30%) patients [SSS=13.3+/-10.9; SDS=8.0+/-5.6; 20% moderate to severe (SDS>4), 7% multivessel] and fixed defects in 21 (16%) patients. Results were comparable between patients with and patients without a history of chest pain. Of 75 patients without a history of chest pain, 23 (31%, 95% CI=21-42%) presented reversible defects (SSS=13.9+/-11.3; SDS=7.4+/-1.2), indicative of silent ischaemia. Reversible defects were associated with inducible ST segment depression during MPS stress [odds ratio (OR)=3.2, p<0.01). Fixed defects were associated with erectile dysfunction in males (OR=3.7, p=0.02) and lower aspirin use (OR=0.25, p=0.02). CONCLUSION Silent stress-induced perfusion defects occurred in 31% of the patients, a rate similar to that in patients with a history of chest pain. MPS could identify these patients with a potentially increased risk of cardiovascular events.
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Affiliation(s)
- John O Prior
- Division of Nuclear Medicine, Centre Hospitalier Universitaire Vaudois (CHUV University Hospital), 1011, Lausanne, Switzerland.
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