Microvascular angina: prevalence, pathophysiology and therapy

Coronary Vascular (DYS) Function and Invasive Physiology Assessment: Insights into Bolus and Continuous Thermodilution Methods

A considerable number of patients with angina or myocardial ischemia have no significant coronary artery disease on invasive angiography. In recent years, several steps towards a better comprehension of the pathophysiology of these conditions, angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), have been made. Nevertheless, several gaps in knowledge still remain. This review is intended to provide a comprehensive overview of ANOCA and INOCA, with a particular focus on pathophysiology, recent diagnostic innovations, gaps in knowledge and treatment modalities.

Randomized, crossover, controlled trial on the modulation of cardiac coronary sinus hemodynamics to develop a new treatment for microvascular disease: Protocol of the MACCUS trial

Background

Microvascular angina (MVA) is a frequent condition for which our understanding of the disease pathophysiology and therapeutic perspectives remain unsatisfactory. The current study is designed to test whether an improvement in microvascular resistances could be achieved by elevating backward pressure in the coronary venous system, based on the hypothesis that an increase in hydrostatic pressure could cause a dilatation of the myocardial arterioles, resulting in a reduction of vascular resistances. This approach might have potential clinical implications, as it might suggest that interventions aimed at increasing coronary sinus (CS) pressure might result in a decrease in angina in this subset of patients. The aim of our single-center, sham-controlled, crossover randomized trial is to investigate the effect of an acute increase in CS pressure on a number of parameters of coronary physiology, including parameters of coronary microvascular resistance and conductance.

Methods and analysis

A total of 20 consecutive patients with angina pectoris and coronary microvascular dysfunction (CMD) will be enrolled in the study. Hemodynamic parameters including aortic and distal coronary pressure, CS and right atrial pressure, and the coronary microvascular resistance index will be measured at rest and during hyperemia in a randomized crossover design during incomplete balloon occlusion ("balloon") and with the deflated balloon in the right atrium ("sham"). The primary end point of the study is the change in index of microvascular resistances (IMR) after acute modulation of CS pressure, while key secondary end points include changes in the other parameters.

Discussion

The aim of the study is to investigate whether occlusion of the CS is associated with a decrease in IMR. The results will provide mechanistic evidence for the development of a treatment for patients with MVA.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT05034224.

Risk Factors Predisposing to Angina in Patients with Non-Obstructive Coronary Arteries: A Retrospective Analysis

No hemodynamically significant atherosclerotic plaques are observed in up to 30% of patients reporting angina and undergoing coronary angiography. To investigate risk factors associated with non-obstructive coronary artery disease (NOCAD), we analyzed the medical records of, consecutively, 136 NOCAD subjects and 128 patients with significant stenosis in at least one coronary artery (the OCAD group). The blood concentrations of the TC (4.40 [3.78−5.63] mmol/L vs. 4.12 [3.42−5.01] mmol/L; p = 0.026), LDL-C (2.32 [1.80−3.50] mmol/L vs. 2.10 [1.50−2.70] mmol/L; p = 0.003), non-HDL-C (2.89 [2.29−4.19] mmol/L vs. 2.66 [2.06−3.39] mmol/L; p = 0.045), as well as the LDL-C/HDL-C ratio (1.75 [1.22−2.60] vs. 1.50 [1.10−1.95]; p = 0.018) were significantly increased in the NOCAD patients compared to the OCAD group due to the lower prevalence and intensity of the statin therapy in the NOCAD individuals (p < 0.001). Moreover, the abovementioned lipid parameters appeared to be valuable predictors of NOCAD, with the LDL-C (OR = 1.44; 95%CI = 1.14−1.82) and LDL-C/HDL-C (OR = 1.51; 95%CI = 1.13−2.02) showing the highest odds ratios. Furthermore, multivariable logistic regression models determined female sex as the independent risk factor for NOCAD (OR = 2.37; 95%CI = 1.33−4.20). Simultaneously, arterial hypertension substantially lowered the probability of NOCAD (OR = 0.21; 95%CI = 0.10−0.43). To conclude, female sex, the absence of arterial hypertension, as well as increased TC, LDL-C, non-HDL, and LDL-C/HDL-C ratio are risk factors for NOCAD in patients reporting angina, potentially as a result of poor hypercholesterolemia management.

Efficacy and safety of Qi-Jing Hui-Xin Decoction in the treatment of coronary microvascular angina: study protocol for a randomized, controlled, multi-center clinical trial

BACKGROUND

With the increased understanding of heart disease, microvascular angina (MVA) is receiving greater attention from clinicians. Studies have shown that patients with MVA have significantly higher major cardiovascular events and all-cause mortality than the control population, and the search for effective treatments is of great clinical importance. Both basic and clinical studies have shown that Qi-Jing Hui-Xin Decoction (QJHX) can relieve angina symptoms and improve clinical efficacy, but there is a lack of high-quality clinical studies to provide a research basis. This article introduces the evaluation protocol of QJHX for the adjunctive treatment of MVA.

METHODS/DESIGN

This is a prospective randomized controlled trial. The trial will enroll 150 patients with MVA. On the basis of Western drug treatment, patients will be randomized into two groups, and the experimental group will receive QJHX treatment for 12 weeks and follow-up at 24 week. The primary indicators are the clinical efficacy of angina pectoris and the evidence of traditional Chinese medicine (TCM) efficacy. Secondary indicators are the Seattle Angina Scale score, serum lipid levels, electrocardiogram, and echocardiogram diagnosis. Additional indicators are endothelial function and immunoinflammatory factors. Adverse events will be monitored throughout the trial.

DISCUSSION

Integrated traditional Chinese and Western medicine is commonly used for angina in China. This study will evaluate the clinical effectiveness and safety of adding QJHX based on standardized Western medications. The results of the trial will provide high-level clinical research-based evidence for the application of QJHX in MVA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900027015 . Registered on 28 October 2019.

Cardiovascular magnetic resonance image analysis and mechanism study for the changes after treatments for primary microvascular angina pectoris

ABSTRACT

Most cases of primary microvascular angina pectoris (PMVA) are diagnosed clinically, but the etiology and pathological mechanisms are unknown. The effect of routine clinical medications is minimal, and PMVA can progress to serious cardiovascular events. To improve the diagnosis and effective treatment of this disease, this study was designed to diagnose PMVA via cardiovascular magnetic resonance (CMR) and the coronary angiography thrombolysis in myocardial infarction (TIMI) blood flow grade, as well as to analyze vascular endothelial function to elucidate the pathogenesis of PMVA and compare the effects of routine clinical medications.The present randomized controlled trial including a parallel control group will be conducted on 63 PMVA patients in our cardiovascular department. The patients will be selected and randomly divided into the control, diltiazem, and nicorandil groups. The control group will be administered routine drug treatments (aspirin, atorvastatin, betaloc ZOK, perindopril, and isosorbidemononitrate sustained-release tablets). The diltiazem group will be additionally treated with 90 mg qd diltiazem sustained-release capsules. The nicorandil group was additionally given 5 mg tid nicorandil tablets. Coronary angiography will be performed before treatment, the severity and frequency of chest pain will be evaluated before and after 9 months of treatment, and homocysteine and von Willebrand factor levels will be measured. Electrocardiography, echocardiography, dynamic electrocardiography, a treadmill exercise test, and CMR will be performed. Sex, age, body mass index, complications, smoking, and family history will also be recorded. The SPSS19.0 statistical software package will be used to analyze the data. The measurements will be expressed as the mean ± standard deviation. Measurement data will be compared between the groups using Student's t-test. A relative number description will be used for the counting data, and the chi-squaretest will be used to compare the groups. A multivariate logistic regression analysis will be performed A P-value < .05 will be considered significant.The direct indices (CMR and coronary angiographic TIMI blood flow grade) may improve after adding diltiazem or nicorandil during routine drug treatments (such as aspirin, statins, and nitrates) in PMVA patients, and indirect indices (homocysteine and von Willebrand factor levels) may be reduced.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (http://www.chictr.org.cn/showprojen.aspx?proj=41894), No. CHiCTR1900025319, Registered on August 23, 2019; pre initiation.

Coronavirus disease-19 and cardiovascular disease: A risk factor or a risk marker?

Severe acute respiratory syndrome coronavirus-2 causes the clinical syndrome of coronavirus disease of 2019 (COVID-19) which has become a global pandemic resulting in significant morbidity and mortality. While the virus primarily affects the respiratory system, it also causes a wide variety of complex cardiac manifestations such as acute myopericarditis, acute coronary syndrome, congested heart failure, cardiogenic shock and cardiac arrhythmias. There are numerous proposed mechanisms of cardiac injury, including direct cellular injury, pro-inflammatory cytokine storm, myocardial oxygen-demand mismatch, and systemic inflammation causing multi-organ failure. Additionally, medications commonly used to treat COVID-19 patients have various cardiovascular side effects. We aim to provide a succinct review about the pathophysiology and cardiac manifestations of COVID-19, as well as treatment considerations and the various adaptations made to the current healthcare structure as a result of the pandemic.

[The consequences of the lockdown on cardiovascular diseases]

BACKGROUND

The Sars COV-2 infection causing the covid-19 disease has started in December 2019 inWuhan, China, then spread quickly to more than 100 countries in less than 3 months. On March, 11th the WHO declared officially the pandemic of Covid 19. In the absence of an effective treatment of the SARS-Cov2 the measures of social distancing and lockdown remain the most effectives ways against the pandemic. However, these measures can have repercussions in particular on patients followed for chronic diseases, the goal of our study will be to evaluate the impact of the lockdown on non-Covid cardiac patients.

METHODS

We have chosen a random sample of patients followed in the cardiology department of the CHU Tangier Tetouan Alhouceima, and we collected their demographic data as well as the symptoms, vital constants, lifestyle before and 60 days after the lockdown.

RESULTS

A total of 100 patients were included in the study. The average age of our population is 55.34 years±15.86. The average BMI (body mass index) is 26.40 Kg/m²±5.84. The coronary artery disease was present in 27% of the patients, valvular disease in 40% and heart failure in 37%. Finally, arrhythmias appear in 22% and more than the half of our sample has high blood pressure. We noted a significant weight gain of 1.71 Kg (P<0.000) after 60 days of lockdown, with an increase of BMI of 0,58 kg/m² (P<0,005). The percentage of patients with SBP (systolic blood pressure) ≥140mmHg has evolved from 38 to 44%, thus an increase of 6 % (P<0,0001), while the percentage of the patients with DBP (diastolic blood pressure) ≥90mmHg has passed from 21 to 15 % (thus a decrease of 6 %, P<0,0001). Twenty patients stop smoking, thus a decrease of 7% (P<0,0001). The sedentary lifestyle rate presented an elevation of 22% (P<0,0001). The daily calorie intake has increased of 35,4 % and 46,8 % of the patients increased their salt intake by more than 4 g per day. The increase of the daily calorie intake concerned more the men than the women (41,9 % of men vs 31,3 % of the women). In the population with high blood pressure, we have not observed a statistically significant difference of the SBP, the DBP and the heart rate between the beginning and two months after the lockdown. Concerning patients with heart Failure, we have noted an worsen of the symptoms of HF. Thus, 8,1% of the patients presenting a stage two dyspnea has passed to a stage three of the NYHA (32,4 vs 40,5%), while the percentage of patients with lower limbs edema has increased of 13,5% but in a non-statistically significant way (P=0,267). We have noticed a diet gap with an increase of salt intakes (more than 4g per day) in more than the half of this subpopulation (55,6 %) during the period of the lockdown. In the subpopulation of patients with valvular pathology, we have identified a worsening of the dyspnea in 7,5% of the patients; this one has passed from stage two to stage three of the NHYA with an increase of the percentage of patients with lower limbs edema from 7,5% to 25% (P=0,065). Furthermore, we have noticed an incidence of 10% of cardiovascular events (2 cases of myocardial infarction [among which one has deceased], one death because of end stage heart failure, three hospitalizations for congestive heart failure, two cases of aortic dissections and 2 cases of rapid atrial fibrillation).

OUR OBSERVATION

Depending on the results of this study, the sanitary lockdown induced important repercussions on the patients followed for cardiac diseases, hence the necessity of an awareness of these patients, and mostly a restructuring of our care system strongly disturbed by the Covid 19.

Exploring the impact of the COVID-19 pandemic on provision of cardiology services: a scoping review

The coronavirus disease-19 (COVID-19) pandemic has forced hospitals to prioritize COVID-19 patients, restrict resources, and cancel all non-urgent elective cardiac procedures. Clinical visits have only been facilitated for emergency purposes. Fewer patients have been admitted to the hospital for both ST-segment elevation myocardial infarctions (STEMI) and non-ST segment elevation myocardial infarctions (NSTEMI) and a profound decrease in heart failure services has been reported. A similar reduction in the patient presentation is seen for ischemic heart disease, decompensated heart failure, and endocarditis. Cardiovascular services, including catheterization, primary percutaneous coronary intervention (PPCI), cardiac investigations such as electrocardiograms (ECGs), exercise tolerance test (ETT), dobutamine stress test, computed tomography (CT) angiography, transesophageal echocardiography (TOE) have been reported to have declined and performed on a priority basis. The long-term implications of this decline have been discussed with major concerns of severe cardiac complications and vulnerabilities in cardiac patients. The pandemic has also had psychological impacts on patients causing them to avoid seeking medical help. This review discusses the effects of the COVID-19 pandemic on the provision of various cardiology services and aims to provide strategies to restore cardiovascular services including structural changes in the hospital to make up for the reduced staff personnel, the use of personal protective equipment in healthcare workers, and provides alternatives for high-risk cardiac imaging, cardiac interventions, and procedures. Implementation of the triage system, risk assessment scores, and telemedicine services in patients and their adaptation to the cardiovascular department have been discussed.

Цукровий діабет і хронічний коронарний синдром

Хронічний коронарний синдром (ХКС) характеризується розвитком епізодів ішемії внаслідок дисбалансу між потребами та кровопостачанням міокарда. Зазвичай такі епізоди провокуються фізичними або емоційними навантаженнями чи іншими стресовими ситуаціями, проте можуть виникати й спонтанно. Класичним проявом ішемії міокарда є напади стенокардії. У деяких випадках захворювання певний час може бути безсимптомним і дебютувати одразу гострим коронарним синдромом. ХКС може мати довготривалий доклінічний період на тлі підтвердженого коронарного атеросклерозу. В огляді проведений аналіз літературних джерел, присвячених сучасному стану проблеми цукрового діабету (ЦД) і ХКС. Зокрема, аналізуються питання, пов’язані з особливостями оцінки ризику, основних чинників, що зумовлюють дуже високий ризик атеросклеротичних серцево-судинних захворювань, класифікацією, основними характеристиками ХКС та його особливостями при ЦД, діагностикою ХКС (дозоване фізичне навантаження (велоергометрія, тредміл-тест) або стрес-тести, однофотонна емісійна комп’ютерна томографія, стрес-ехокардіографія; стрес-магнітно-резонансна томографія, позитронно-емісійна томографія із застосуванням радіоактивних маркерів). Аналізуються питання консервативної терапії ХКС на тлі ЦД (призначення антиагрегантів, блокаторів β-адренорецепторів, блокаторів кальцієвих каналів, нітратів, інгібіторів ангіотензинперетворювального ферменту, міокардіальних цитопротекторів, статинів). Лікування пацієнта з поєднанням ЦД і ХКС буде успішним лише в тому випадку, якщо призначено адекватну, безпечну в плані гіпоглікемій і можливих серцево-судинних ризиків цукрознижувальну терапію, з одного боку, і метаболічно нейтральну антиангінальну терапію— з іншого. Без сумніву, необхідно звернути увагу на корекцію факторів ризику ССЗ, АГ і ХСН.

The effectiveness and safety of nicorandil in the treatment of patients with microvascular angina: A protocol for systematic review and meta-analysis

BACKGROUND

Microvascular angina has become a clinical and frequent cardiovascular disease in recent years, which is complicated and there is no clear treatment. Today, Western medicine still deals with microvascular angina with standardized treatment based on the stable angina. Firstly, it is to control the risk factors of atherosclerosis, and the second is to reduce the oxygen consumption of the patient's heart muscle. In the previous randomized controlled clinical trials, it has shown that nicorandil can improve the symptoms of angina for the treatment of microvascular angina, but there is a lack of high-quality randomized controlled trials on the clinical effectiveness and safety of nicorandil in the treatment of microvascular angina, and the lack of evaluation of its effectiveness and safety. Therefore, this paper aims to understand whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug through the method of systematic evaluation.

METHODS

Retrieval of relevant network electronic databases by computer: SinoMed, CNKI, WanFang Data, VIP, PubMed, EMbase and The Cochrane Library, the retrieval time is from the establishment of each database to December 2017, to collect randomized controlled studies of nicorandil in the treatment of microvascular angina. At the same time, it is supplemented by manual search of the included literature references, as far as possible to increase the included literature imformation. Two researchers independently browse the topics and abstracts, and select, find, read the full text of the relevant literature, and screen the literature according to the criteria for inclusion and exclusion established in advance, then extract the data, and cross-check, and resolve the differences through multi-person discussion. Data analysis of collected information is performed by using RevMan 5.3 software.

RESULTS

The data of the included literature are statistically analyzed by meta-analysis, and the key outcome indicators are used to determine whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug.

CONCLUSION

Through the method of evidence-based medicine, this study finds the existing problems and defects in the current research, which will provide high-quality evidence-based medical evidence for nicorandil's treatment of microvascular angina, and it help the clinical treatment and further research.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/DSQG9.

Perspective: cardiovascular disease and the Covid-19 pandemic

We summarize the cardiovascular risks associated with Covid-19 pandemic, discussing the risks for both infected and non-infected patients.

(Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance

Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.

Level of Anxiety and Depression in Cardiac Syndrome X

OBJECTIVE

Cardiac syndrome X (CSX) is defined as angina-like symptoms, abnormalities on stress testing, and normal epicardial coronary arteries on coronary angiography. The aim of this study was to determine the Hospital Anxiety and Depression scores of patients with CSX and to compare with healthy controls. Materials/Subjects and Methods: Patients undergoing coronary angiography between January 2015 and December 2016 because of clinical indications, including abnormal noninvasive test results were examined. Two hundred and 10 subjects (110 patients with CSX, 100 controls) were enrolled. Demographic characteristics including age, education level, marriage status, and history of stressful life events were recorded. The Turkish version of the Hospital Anxiety and Depression scale was evaluated in the study population.

RESULTS

Anxiety, depression, and total scores in the patients with CSX were significantly higher than those in the control group (p < 0.001, p < 0.003, p < 0.001, respectively). Among women, anxiety, depression, total scores, and stressful life events were significantly higher in the CSX group (p = 0.006, p = 0.015, p = 0.001, p < 0.001, respectively). Patients with lower educational status had higher anxiety scores (p = 0.03), stressful life events, and HAD-A > 10 were the only independent predictors of CSX in logistic regression analysis with comparable ORs 2.256 (95% CI 1.057-4.817, p = 0.03) and 2,399 (95% CI 1.248-4.613, p = 0.009) respectively.

CONCLUSION

The results of our research suggest that patients with CSX have a high prevalence of stress and psychiatric disturbances. Interventions targeted toward improving the quality of life and to give psychological support may have the potential benefits especially for women and individuals with lower education.