Coronary functional assessment in non-obstructive coronary artery disease: Present situation and future direction

Effect of exercise training in patients with angina with nonobstructive coronary arteries: a systematic review and meta-analysis

Angina with nonobstructive coronary arteries (ANOCA) is a highly prevalent heart disease. The evidence on exercise training (ET) for the treatment of ANOCA, however, is still inadequate. This meta-analysis aims to provide a comprehensive assessment of the effect of ET in patients with ANOCA. Studies were searched from PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, VIP, and WanFang from inception to 15 January 2024. The quality of included studies was assessed using the Cochrane risk of bias tool. Heterogeneity among the studies was evaluated using Cochran's Q test and I2 statistic, and subgroup analysis based on gender was performed to explore potential sources of heterogeneity. A total of 12 studies were included in this meta-analysis. The pooled results showed that ET significantly increased the peak oxygen uptake (peak VO 2 ) [weighted mean difference (WMD) = 6.11, 95% confidence interval (CI): 4.73 to 7.50], left ventricular ejection fraction (WMD = 7.66, 95% CI: 5.53 to 9.78), and 6 min walking test (WMD = 55.55; 95% CI: 16.23 to 94.87). Nitric oxide (WMD = 20.18, 95% CI: 19.16 to 21.21) and peripheral arterial tonometry (WMD = 0.16, 95% CI: 0.11 to 0.21) were higher, and matrix metalloproteinase-9 (WMD = -8.02, 95% CI: -9.21 to -6.84) was lower in ET group. In conclusion, our findings indicated that ET could improve cardiopulmonary function, exercise capacity, and endothelial function, which could be recommended for the treatment of ANOCA patients.

Clinical impact of CCT-FFR as first-strategy in patients with symptomatic stable coronary artery disease: A systematic review and meta-analysis

AIMS

Despite the promising results, the clinical implications of the CCT-FFR is already debated. This metanalysis aimed to determine the potential benefits of incorporating FFRCT into stable CAD management.

METHODS

After searching for studies comparing outcomes of patients with suspected stable CAD who underwent CCT-FFR as a first strategy versus non-urgent cardiovascular testing after a clinical judgment, we calculated odds ratios (ORs) and 95 ​% confidence intervals (CIs) using a random-effects or fixed-effects meta-analysis model depending on heterogeneity significance.

RESULTS

5 studies (3 RCTs and 2 observational studies) globally encompassing 5282 patients (CCT-FFR ​= ​2604 patients, Control Group ​= ​2678 patients) were included in the quantitative analysis. The rates of ICA overall (OR 1.57, 95%CI 1.36-1.81, p value ​< ​0.001) and those without obstructive CAD (OR 6.63, 95%CI 4.79-9.16, p value ​< ​0.001) were reduced in the CCTAFFR group, as compared to the control group. Moreover, CCT-FFR patients underwent coronary revascularization more frequently than patients in the control arm (OR 0.48,CI 0.38-0.62, p value ​< ​0.001). There was no significance difference between the two strategies in terms of 1 year MACE (OR 1.11,CI 0.86-1.44, p value 0.42), nonfatal MI (OR 0.73, CI 0.41-1.33, p value 0.31), all-cause mortality (OR 1.29,CI 0.47-3.54, p value 0.63) and unplanned revascularization for angina (OR 0.99, 95%CI 0.65-1.49, p value 0.95).

CONCLUSIONS

In conclusion, in the management of stable CAD, the use of CCT-FFR was associated with lower overall rates of ICA but higher rates of coronary revascularization with comparable 1-year clinical impact.

SGK1 contributes to ferroptosis in coronary heart disease through the NEDD4L/NF-κB pathway

The prevalence of coronary heart disease (CHD) has increased significantly with the aging population worldwide. It is unclear whether ferroptosis occurs during CHD. Hence, we aimed to investigate the potential mechanisms associated with ferroptosis in CHD. Bioinformatics was used to characterize differentially expressed genes (DEGs) in CHD-related datasets (GSE21610 and GSE66360). There were 76 and 689 DEGs in the GSE21610 and GSE66360, respectively, and they predominantly associated with immune and inflammatory responses. DDX3Y, EIF1AY, KDM5D, RPS4Y1, SGK1, USP9Y, and NSG1 were intersecting DEGs of GSE21610 and GSE66360. Their expression pattern in circulating endothelial cells (ECs) derived from healthy individuals and CHD patients are consistent with the results of bioinformatics analysis, especially SGK1. In vitro, SGK1 knockdown alleviated the Erastin-induced downregulation of SLC7A11, GPX4, GSH, and GSSG, as well as the upregulation of lipid peroxidation, Fe accumulation, and mitochondrial damage in mouse aortic ECs (MAECs). Notably, SGK1 may interact with NEDD4L according to the String database. Moreover, SGK1 promoted NEDD4L and p-P65 expression in MAECs. Interestingly, the effect of SGK1 knockdown on ferroptosis in MAECs was rescued by overexpression of NEDD4L or PMA (NF-κB pathway activator). In vivo, SGK1 knockdown facilitated the recovery of body weight, blood lipids, and aortic tissue structure in CHD animal models. Furthermore, SGK1 knockdown alleviated Fe accumulation in the aorta and inactivated the NEDD4L-NF-κB pathway. In conclusion, SGK1 contributes to EC ferroptosis by regulating the NEDD4L-NF-κB pathway. SGK1 could be recognized as a therapeutic target related to ferroptosis in CHD.

From chest pain to coronary functional testing: Clinical and economic impact of coronary microvascular dysfunction

BACKGROUND

Coronary functional testing to formally diagnose coronary microvascular dysfunction (CMD) reduces cardiovascular events and alleviates angina. This study aims to investigate the extensive and complex journey that patients with CMD undergo, from the onset of chest pain to eventual diagnosis.

METHODS

Data from the Coronary Microvascular Disease Registry (CMDR) were analyzed, including information on the date of first documentation of chest pain, number of non-invasive and invasive tests the patient underwent, emergency department visits, and hospitalizations. In addition, we estimated the total cost per patient. A total of 61 patients with CMD diagnosis were included in this analysis.

RESULTS

Most patients in our cohort were older than 50 years of age. The median time from initial chest pain symptoms to diagnosis was 0.62 (interquartile range [IQR]: 0.06-2.96) years. During this period, patients visited the emergency department a median of 1.0 (IQR: 0.0-2.0) times. Diagnostic tests included 3.0 (IQR: 2.0-6.0) electrocardiograms, 3.0 (IQR: 0.0-6.0) high-sensitivity troponin tests, and 1.0 (IQR: 1.0-2.0) echocardiograms. Prior to diagnosis of CMD, 13 (21.3 %) patients had left heart catheterization without coronary functional testing. Non-invasive testing for ischemia was conducted in 43 (70.5 %) patients. Alternative non-cardiac diagnoses were given to 11 (18.0 %) patients during the diagnostic process, with referrals made to gastroenterology for 16 (26.2 %) and pulmonology for 10 (16.4 %) patients. The cost was almost $2000/patient.

CONCLUSION

Timely identification of CMD offers promising opportunities for prompt symptom alleviation, accompanied by reduced visits to the emergency department, cardiovascular testing, invasive medical procedures, and consequently reduced healthcare expenses.

Beyond the Obstructive Paradigm: Unveiling the Complex Landscape of Nonobstructive Coronary Artery Disease

Traditionally focused on obstructive atherosclerosis, contemporary research indicates that up to 70% of patients undergoing coronary angiography for angina and ischemic symptoms do not exhibit significant stenoses. Nonobstructive coronary artery disease (CAD) has emerged as a prevalent phenotype among these patients. This review emphasizes the emerging understanding that nonobstructive coronary artery disease, encompassing conditions such as ANOCA (Angina with No Obstructive Coronary Artery Disease), INOCA (Ischemia with No Obstructive Coronary Artery Disease), and MINOCA (Myocardial Infarction with No Obstructive Coronary Arteries), represents the most prevalent phenotype in cardiac patients. It delves into the complex pathophysiology underlying these conditions, focusing on microvascular dysfunction and coronary vasoreactivity, which contribute to myocardial ischemia despite the absence of significant coronary obstructions. Additionally, the review critically examines the limitations of current treatments which primarily target obstructive lesions and underscores the necessity for tailored therapies that address the specific microvascular and immunoinflammatory pathways involved in nonobstructive CAD. The main focus of this review is to advocate for a shift in diagnostic and therapeutic strategies to better identify and manage this widely prevalent yet under-recognized subset of CAD.

A Randomized Controlled Study of Enhanced External Counterpulsation with Cardiac Rehabilitation in Patients with Nonobstructive Coronary Artery Disease and Coronary Microvascular Dysfunction

Treatment with enhanced external counterpulsation (EECP) or cardiac rehabilitation (CR) benefits patients with coronary heart disease; this paper intends to explore the feasibility of EECP combined with CR in patients with nonobstructive coronary heart disease (NOCAD) and coronary microcirculation disorders (CMD).In January 2021-2022 month June our income NOCAD patients as the research object, the line of cardiac magnetic resonance (CMR), myocardial perfusion reserve (MPR) < 2.0 coronary microcirculation disorders (CMD, 80 cases). Random indicator method 80 CMD patients divided into two groups, 40 cases in each. Usual treatment group: conventional drugs and CR therapy. EECP treatment group: on the basis of standard treatment group, employ EECP therapy. Comparing the two groups before and after the treatment curative effect cardiac function index, endothelial unction index, adverse cardiovascular events, etc.After EECP treatment, the treatment group showed a higher effective rate compared to the usual treatment group (P < 0.05). EECP group curative effect, left ventricular ejection fraction,plasma NO and vascular endothelial growth factor levels higher than the usual group, the incidence of adverse cardiovascular events is lower than the usual group. The difference was statistically significant (P < 0.05).EECP combined with cardiac rehabilitation in patients with CMD symptoms has better effect and safety and provides reference for treatment of CMD patients.

Chemokine Fractalkine and Non-Obstructive Coronary Artery Disease-Is There a Link?

Non-obstructive coronary artery disease (NO-CAD) constitutes a heterogeneous group of conditions collectively characterized by less than 50% narrowing in at least one major coronary artery with a fractional flow reserve (FFR) of ≤0.80 observed in coronary angiography. The pathogenesis and progression of NO-CAD are still not fully understood, however, inflammatory processes, particularly atherosclerosis and microvascular dysfunction are known to play a major role in it. Chemokine fractalkine (FKN/CX3CL1) is inherently linked to these processes. FKN/CX3CL1 functions predominantly as a chemoattractant for immune cells, facilitating their transmigration through the vessel wall and inhibiting their apoptosis. Its concentrations correlate positively with major cardiovascular risk factors. Moreover, promising preliminary results have shown that FKN/CX3CL1 receptor inhibitor (KAND567) administered in the population of patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), inhibits the adverse reaction of the immune system that causes hyperinflammation. Whereas the link between FKN/CX3CL1 and NO-CAD appears evident, further studies are necessary to unveil this complex relationship. In this review, we critically overview the current data on FKN/CX3CL1 in the context of NO-CAD and present the novel clinical implications of the unique structure and function of FKN/CX3CL1 as a compound which distinctively contributes to the pathomechanism of this condition.

Diffuse non-obstructive coronary artery disease: two clinical faces of the same disease-a case report

Background

Coronary artery disease has a long preclinical phase before manifesting itself clinically due to diffuse non-obstructive disease, stenoses, or thrombosis.

Case summary

We present a case of a middle-aged male complaining of atypical chest pain, then severe retrosternal pain, and, eventually, effort angina. We performed non-invasive testing, coronary angiography, intravascular imaging, and flow reserve tests, each as appropriate. Cardiovascular risk control, optimization of drug therapy, and percutaneous coronary intervention were considered trying to comply with the best clinical practice.

Discussion

Diffuse non-obstructive coronary artery disease may present clinically in different ways. Exercise stress test might be sufficient to assess effort angina before a potential angiography. Flow reserve tests across the diseased vessel can distinguish between diffuse and focal pattern of the disease and assist in the adequate selection of therapy. Finally, intravascular imaging is invaluable for the assessment of the plaque risk features.

The cytokine trio - visfatin, placental growth factor and fractalkine - and their role in myocardial infarction with non-obstructive coronary arteries (MINOCA)

Myocardial infarction with nonobstructive coronary arteries (MINOCA) remains a puzzling clinical entity. It is characterized by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries in angiography. Given the complex etiology including multiple possible scenarios with varied pathogenetic mechanisms, profound investigation of the plausible biomarkers of MINOCA may bring further pathophysiological insights and novel diagnostic opportunities. Cytokines have a great diagnostic potential and are used as biomarkers for many diseases. An unusual trio of visfatin, placental growth factor (PlGF) and fractalkine (CX3CL1) can directly promote vascular dysfunction, inflammation and angiogenesis through the activation of the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling. They are redundant in physiological processes and become overexpressed in the pathomechanisms underlying MINOCA. The knowledge about their concentration might serve as a valuable diagnostic and/or therapeutic tool for assessing vascular endothelial function. Here we analyze the current knowledge on visfatin, PlGF and CX3CL1 in the context of MINOCA and present the novel clinical implications of their combined expression as predictors or indicators of this condition.

MINOCA biomarkers: Non-atherosclerotic aspects

Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) is an important subtype of myocardial infarction. Although comprising less than 50% stenosis in the main epicardial coronary arteries, it constitutes a severe health risk. A variety of approaches have been recommended, but definitive diagnosis remains elusive. In addition, the lack of a comprehensive understanding of underlying pathophysiology makes clinical management difficult and unpredictable. This review highlights ongoing efforts to identify relevant biomarkers in MINOCA to improve diagnosis, individualize treatment and better predict outcomes.

Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study

BACKGROUND

Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies.

METHODS

A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework.

RESULTS

The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon.

CONCLUSION

The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.