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Ziada KM. Vasospastic Angina: How Much Can We Know Before Provocative Testing? Circ Cardiovasc Imaging 2025; 18:e018177. [PMID: 40143811 DOI: 10.1161/circimaging.125.018177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2025]
Affiliation(s)
- Khaled M Ziada
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH
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2
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Jesser J, Nguyen T, Dmytriw AA, Yamagami H, Miao Z, Sommer LJ, Stockero A, Pfaff JAR, Ospel J, Goyal M, Patel AB, Pereira VM, Hanning U, Meyer L, van Zwam WH, Bendszus M, Wiesmann M, Möhlenbruch M, Weyland CS. Treatment practice of vasospasm during endovascular thrombectomy: an international survey. Stroke Vasc Neurol 2024; 9:490-496. [PMID: 38164618 PMCID: PMC11732841 DOI: 10.1136/svn-2023-002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND AIM The clinical importance and management of vasospasm as a complication during endovascular stroke treatment (EVT) has not been well studied. We sought to investigate current expert opinions in neurointervention and therapeutic strategies of iatrogenic vasospasm during EVT. METHODS We conducted an anonymous international online survey (4 April 2023 to 15 May 2023) addressing treatment standards of neurointerventionalists (NIs) practising EVT. Several illustrative cases of patients with vasospasm during EVT were shown. Two study groups were compared according to the NI's opinion regarding the potential influence of vasospasm on patient outcome after EVT using descriptive analysis. RESULTS In total, 534 NI from 56 countries responded, of whom 51.5% had performed >200 EVT. Vasospasm was considered a complication potentially influencing the patient's outcome by 52.6% (group 1) whereas 47.4% did not (group 2). Physicians in group 1 more often added vasodilators to their catheter flushes during EVT routinely (43.7% vs 33.9%, p=0.033) and more often treated severe large-vessel vasospasm with vasodilators (75.3% vs 55.9%; p<0.001), as well as extracranial vasospasm (61.4% vs 36.5%, p<0.001) and intracranial medium-vessel vasospasm (27.1% vs 11.2%, p<0.001), compared with group 2. In case of a large-vessel vasospasm and residual and amenable medium-vessel occlusion during EVT, the study groups showed different treatment strategies. Group 2 continued the EVT immediately more often, without initiating therapy to treat the vasospasm first (9.6% vs 21.1%, p<0.001). CONCLUSION There is disagreement among NIs about the clinical relevance of vasospasm during EVT and its management. There was a higher likelihood of use of preventive and active vasodilator treatment in the group that perceived vasospasm as a relevant complication as well as differing interventional strategies for continuing an EVT in the presence of a large-vessel vasospasm.
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Affiliation(s)
- Jessica Jesser
- Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Thanh Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Adam A Dmytriw
- St. Michael's Hospital, Departments of Medical Imaging and Neurosurgery, Neurovascular Center, University of Toronto, Toronto, Ontario, Canada
- Neuroendovascular Program, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | | | - Johannes Alex Rolf Pfaff
- University Insitute for Neuroradiology at PMU, Uniklinikum Salzburg—Christian-Doppler-Klinik, Salzburg, Austria
| | - Johanna Ospel
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Uta Hanning
- Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Wim H van Zwam
- Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin Bendszus
- Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Oancea AF, Morariu PC, Buburuz AM, Miftode IL, Miftode RS, Mitu O, Jigoranu A, Floria DE, Timpau A, Vata A, Plesca C, Botnariu G, Burlacu A, Scripcariu DV, Raluca M, Cuciureanu M, Tanase DM, Costache-Enache II, Floria M. Spectrum of Non-Obstructive Coronary Artery Disease and Its Relationship with Atrial Fibrillation. J Clin Med 2024; 13:4921. [PMID: 39201063 PMCID: PMC11355151 DOI: 10.3390/jcm13164921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 08/08/2024] [Accepted: 08/17/2024] [Indexed: 09/02/2024] Open
Abstract
This article aims to analyze the relationship between non-obstructive coronary artery disease (NOCAD) and atrial fibrillation (AF), exploring the underlying pathophysiological mechanisms and implications for clinical management. NOCAD and AF are prevalent cardiovascular conditions that often coexist, yet their interrelation is not well understood. NOCAD can lead to ischemic necrosis of cardiomyocytes and their replacement with fibrous tissue, sustaining focal ectopic activity in atrial myocardium. Atrial fibrillation, on the other hand, the most common sustained cardiac arrhythmia, is able to accelerate atherosclerosis and increase oxygen consumption in the myocardium, creating a mismatch between supply and demand, and thus promoting the development or worsening of coronary ischemia. Therefore, NOCAD and AF seem to be a complex interplay with one begets another.
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Affiliation(s)
- Alexandru-Florinel Oancea
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Paula Cristina Morariu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Ana Maria Buburuz
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Ionela-Larisa Miftode
- Department of Internal Medicine II, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.-L.M.); (A.V.); (C.P.)
- St Parascheva Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania
| | - Radu Stefan Miftode
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Ovidiu Mitu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Alexandru Jigoranu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Diana-Elena Floria
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Amalia Timpau
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Andrei Vata
- Department of Internal Medicine II, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.-L.M.); (A.V.); (C.P.)
- St Parascheva Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania
| | - Claudia Plesca
- Department of Internal Medicine II, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.-L.M.); (A.V.); (C.P.)
- St Parascheva Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania
| | - Gina Botnariu
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
- Unit of Diabetes, Nutrition and Metabolic Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandru Burlacu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Cardiovascular Disease Institute, 700503 Iasi, Romania
| | - Dragos-Viorel Scripcariu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Regional Institute of Oncology, 700483 Iasi, Romania
| | - Mitea Raluca
- Faculty of Medicine Victor Papilian, University of Lucian Blaga, 550169 Sibiu, Romania;
| | - Magdalena Cuciureanu
- Department of Pharmacology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Daniela Maria Tanase
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Irina Iuliana Costache-Enache
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
| | - Mariana Floria
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-F.O.); (R.S.M.); (O.M.); (A.J.); (D.-E.F.); (A.T.); (A.B.); (D.-V.S.); (D.M.T.); (I.I.C.-E.); (M.F.)
- Saint Spiridon Emergency Hospital, 700115 Iasi, Romania;
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Tudurachi A, Anghel L, Tudurachi BS, Zăvoi A, Ceasovschih A, Sascău RA, Stătescu C. Beyond the Obstructive Paradigm: Unveiling the Complex Landscape of Nonobstructive Coronary Artery Disease. J Clin Med 2024; 13:4613. [PMID: 39200755 PMCID: PMC11354865 DOI: 10.3390/jcm13164613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/03/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
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.
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Affiliation(s)
- Andreea Tudurachi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
| | - Larisa Anghel
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Bogdan-Sorin Tudurachi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Alexandra Zăvoi
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Alexandr Ceasovschih
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
- “St. Spiridon” Clinical Emergency Hospital, Independence Boulevard No. 1, 700111 Iasi, Romania
| | - Radu Andy Sascău
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
| | - Cristian Stătescu
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I. M. Georgescu”, 700503 Iași, Romania; (A.T.); (A.Z.); (R.A.S.); (C.S.)
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania;
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5
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Woudstra J, Feenstra RGT, Vink CEM, Marques KMJ, Boerhout CKM, de Jong EAM, de Waard GA, van de Hoef TP, Chamuleau SAJ, Eringa EC, Piek JJ, Appelman Y, Beijk MAM. Comparison of the Diagnostic Yield of Intracoronary Acetylcholine Infusion and Acetylcholine Bolus Injection Protocols During Invasive Coronary Function Testing. Am J Cardiol 2024; 217:49-58. [PMID: 38417650 DOI: 10.1016/j.amjcard.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 03/01/2024]
Abstract
Coronary endothelial dysfunction (CED) and coronary artery spasm (CAS) are causes of angina with no obstructive coronary arteries in patients. Both can be diagnosed by invasive coronary function testing (ICFT) using acetylcholine (ACh). This study aimed to evaluate the diagnostic yield of a 3-minute ACh infusion as compared with a 1-minute ACh bolus injection protocol in testing CED and CAS. We evaluated 220 consecutive patients with angina and no obstructive coronary arteries who underwent ICFT using continuous Doppler flow measurements. Per protocol, 110 patients were tested using 3-minute infusion, and thereafter 110 patients using 1-minute bolus injections, because of a protocol change. CED was defined as a <50% increase in coronary blood flow or any epicardial vasoconstriction in reaction to low-dose ACh and CAS according to the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria, both with and without T-wave abnormalities, in reaction to high dose ACh. The prevalence of CED was equal in both protocols (78% vs 79%, p = 0.869). Regarding the endotypes of CAS according to COVADIS, the equivocal endotype was diagnosed less often in the 3 vs 1-minute protocol (24% vs 44%, p = 0.004). Including T-wave abnormalities in the COVADIS criteria resulted in a similar diagnostic yield of both protocols. Hemodynamic changes from baseline to the low or high ACh doses were comparable between the protocols for each endotype. In conclusion, ICFT using 3-minute infusion or 1-minute bolus injections of ACh showed a similar diagnostic yield of CED. When using the COVADIS criteria, a difference in the equivocal diagnosis was observed. Including T-wave abnormalities as a diagnostic criterion reclassified equivocal test results into CAS and decreased this difference. For clinical practice, we recommend the inclusion of T-wave abnormalities as a diagnostic criterion for CAS and the 1-minute bolus protocol for practicality.
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Affiliation(s)
- Janneke Woudstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands.
| | - Rutger G T Feenstra
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Caitlin E M Vink
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Koen M J Marques
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Coen K M Boerhout
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Elize A M de Jong
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Guus A de Waard
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Utrecht, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Etto C Eringa
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands; Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC Heart Centre, Amsterdam, The Netherlands
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Gowda SN, Garapati SS, Kurrelmeyer K. Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle. Methodist Debakey Cardiovasc J 2024; 20:81-93. [PMID: 38495657 PMCID: PMC10941714 DOI: 10.14797/mdcvj.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/10/2024] [Indexed: 03/19/2024] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.
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Affiliation(s)
- Smitha Narayana Gowda
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Sai sita Garapati
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
| | - Karla Kurrelmeyer
- Methodist DeBakey Cardiology Associates
- Houston Methodist Hospital, Houston, Texas, US
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7
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Gurgoglione FL, Vignali L, Montone RA, Rinaldi R, Benatti G, Solinas E, Leone AM, Galante D, Campo G, Biscaglia S, Porto I, Benenati S, Niccoli G. Coronary Spasm Testing with Acetylcholine: A Powerful Tool for a Personalized Therapy of Coronary Vasomotor Disorders. Life (Basel) 2024; 14:292. [PMID: 38541619 PMCID: PMC10970947 DOI: 10.3390/life14030292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 11/11/2024] Open
Abstract
Coronary vasomotor disorders (CVD) are characterized by transient hypercontraction of coronary vascular smooth muscle cells, leading to hypercontraction of epicardial and/or microvascular coronary circulation. CVDs play a relevant role in the pathogenesis of ischemia, angina and myocardial infarction with non-obstructive coronary arteries. Invasive provocative testing with intracoronary Acetylcholine (ACh) administration is the gold standard tool for addressing CVD, providing relevant therapeutic and prognostic implications. However, safety concerns preclude the widespread incorporation of the ACh test into clinical practice. The purpose of this review is to shed light on the pathophysiology underlying CVD and on the clinical role of the ACh test, focusing on safety profile and prognostic implications. We will also discuss contemporary evidence on the management of CVD and the role of the ACh test in driving a personalized approach of patients with CVD.
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Affiliation(s)
| | - Luigi Vignali
- Division of Cardiology, Parma University Hospital, 43126 Parma, Italy; (L.V.); (G.B.); (E.S.)
| | - Rocco Antonio Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy;
| | - Giorgio Benatti
- Division of Cardiology, Parma University Hospital, 43126 Parma, Italy; (L.V.); (G.B.); (E.S.)
| | - Emilia Solinas
- Division of Cardiology, Parma University Hospital, 43126 Parma, Italy; (L.V.); (G.B.); (E.S.)
| | - Antonio Maria Leone
- Center of Excellence in Cardiovascular Sciences, Ospedale Isola Tiberina, Gemelli Isola Roma, 00186 Rome, Italy; (A.M.L.); (D.G.)
| | - Domenico Galante
- Center of Excellence in Cardiovascular Sciences, Ospedale Isola Tiberina, Gemelli Isola Roma, 00186 Rome, Italy; (A.M.L.); (D.G.)
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy; (G.C.); (S.B.)
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy; (G.C.); (S.B.)
| | - Italo Porto
- Department of Internal Medicine, University of Genoa, 16126 Genoa, Italy; (I.P.); (S.B.)
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino—Italian IRCCS Cardiology Network, 16126 Genoa, Italy
| | - Stefano Benenati
- Department of Internal Medicine, University of Genoa, 16126 Genoa, Italy; (I.P.); (S.B.)
| | - Giampaolo Niccoli
- Division of Cardiology, Parma University Hospital, University of Parma, 43126 Parma, Italy;
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Heusch G. Myocardial ischemia/reperfusion: Translational pathophysiology of ischemic heart disease. MED 2024; 5:10-31. [PMID: 38218174 DOI: 10.1016/j.medj.2023.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 01/15/2024]
Abstract
Ischemic heart disease is the greatest health burden and most frequent cause of death worldwide. Myocardial ischemia/reperfusion is the pathophysiological substrate of ischemic heart disease. Improvements in prevention and treatment of ischemic heart disease have reduced mortality in developed countries over the last decades, but further progress is now stagnant, and morbidity and mortality from ischemic heart disease in developing countries are increasing. Significant problems remain to be resolved and require a better pathophysiological understanding. The present review attempts to briefly summarize the state of the art in myocardial ischemia/reperfusion research, with a view on both its coronary vascular and myocardial aspects, and to define the cutting edges where further mechanistic knowledge is needed to facilitate translation to clinical practice.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
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Jenkins K, Pompei G, Ganzorig N, Brown S, Beltrame J, Kunadian V. Vasospastic angina: a review on diagnostic approach and management. Ther Adv Cardiovasc Dis 2024; 18:17539447241230400. [PMID: 38343041 PMCID: PMC10860484 DOI: 10.1177/17539447241230400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 02/15/2024] Open
Abstract
Vasospastic angina (VSA) refers to chest pain experienced as a consequence of myocardial ischaemia caused by epicardial coronary spasm, a sudden narrowing of the vessels responsible for an inadequate supply of blood and oxygen. Coronary artery spasm is a heterogeneous phenomenon that can occur in patients with non-obstructive coronary arteries and obstructive coronary artery disease, with transient spasm causing chest pain and persistent spasm potentially leading to acute myocardial infarction (MI). VSA was originally described as Prinzmetal angina or variant angina, classically presenting at rest, unlike most cases of angina (though in some patients, vasospasm may be triggered by exertion, emotional, mental or physical stress), and associated with transient electrocardiographic changes (transient ST-segment elevation, depression and/or T-wave changes). Ischaemia with non-obstructive coronary arteries (INOCA) is not a benign condition, as patients are at elevated risk of cardiovascular events including acute coronary syndrome, hospitalization due to heart failure, stroke and repeat cardiovascular procedures. INOCA patients also experience impaired quality of life and associated increased healthcare costs. VSA, an endotype of INOCA, is associated with major adverse events, including sudden cardiac death, acute MI and syncope, necessitating the study of the most effective treatment options currently available. The present literature review aims to summarize current data relating to the diagnosis and management of VSA and provide details on the sequence that treatment should follow.
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Affiliation(s)
- Kenny Jenkins
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Nandine Ganzorig
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Brown
- Cardiovascular Care Partnership, British Cardiovascular Society, London, UK
| | - John Beltrame
- Basil Hetzel Institute for Translational Health Research, Adelaide Medical School, University of Adelaide and Royal Adelaide Hospital and The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University Medical School, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Pan JC, Lyu LJ, Liu QD, Yang W, Li XH, Han YM, Sun JY, Dong M, Zhang PF, Zhang M. Association between resting myocardial work indices and stress myocardial perfusion in patients with angina and non-obstructive coronary artery disease. Quant Imaging Med Surg 2023; 13:4563-4577. [PMID: 37456330 PMCID: PMC10347314 DOI: 10.21037/qims-22-321] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 03/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Myocardial work (MW) indices and longitudinal strain (LS) are sensitive markers of early left ventricular systolic dysfunction. Stress computed tomography myocardial perfusion imaging (CT-MPI) can assess early myocardial ischemia. The association between resting MW indices and stress myocardial perfusion remains unclear. This study compares resting MW indices with LS to assess stress myocardial perfusion in angina patients with non-obstructive coronary artery disease (CAD). METHODS Eighty-four patients who underwent resting echocardiography, coronary computed tomography angiography, and stress CT-MPI were reviewed. Seventeen myocardial segments were divided into three regions according to the epicardial coronary arteries. Global indices included global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). Regional indices included regional longitudinal strain (RLS), regional work index (RWI), and regional work efficiency (RWE). Reduced global perfusion was defined as an average stress myocardial blood flow (MBF) <116 mL/100 mL/min for the whole heart. Reduced regional perfusion was defined as an average stress MBF <116 mL/100 mL/min for the coronary territories. No patients demonstrated obstructions in the epicardial coronary arteries (stenosis diameter <50%). The MW indices and LS were compared. Receiver operating characteristic curves were constructed and logistic regression analyses were used to investigate the predictors of reduced myocardial perfusion. RESULTS Patients with reduced stress perfusion demonstrated reduced GLS, GWI, GCW, and GWE (P<0.05) and increased GWW (P<0.05). After adjustment for age and sex, GWE was still independently associated with reduced myocardial perfusion (odds ratio =0.386, 95% confidence interval: 0.214-0.697; P<0.05). Receiver operating characteristic curves reflected the good diagnostic ability of GWE and its superiority to GLS (area under the curve: 0.858 vs. 0.741). The optimal cutoff GWE value was 95% (sensitivity, 70%; specificity, 90%). Regions with lower stress perfusion showed lower RLS, RWI, and RWE (P<0.05). The optimal cutoff value of RWE for predicting reduced regional perfusion was 95%, with an area under the curve of 0.780, a sensitivity of 62%, and a specificity of 83%. CONCLUSIONS Resting MW indices perform well in assessing global and regional stress myocardial perfusion in angina patients with non-obstructive CAD, and GWE is superior to GLS in the global evaluations.
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Affiliation(s)
- Ji-Chen Pan
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li-Juan Lyu
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Quan-De Liu
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Yang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xin-Hao Li
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ye-Ming Han
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun-Yan Sun
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mei Dong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peng-Fei Zhang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mei Zhang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Giga V, Boskovic N, Djordjevic-Dikic A, Beleslin B, Nedeljkovic I, Stankovic G, Tesic M, Jovanovic I, Paunovic I, Aleksandric S. Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65. Diagnostics (Basel) 2023; 13:2229. [PMID: 37443623 DOI: 10.3390/diagnostics13132229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The prognosis of patients with chest pain after a negative exercise test is good, but some adverse events occur in this low-risk group. The aim of our study was to identify predictors of long-term adverse events after a negative exercise test in patients with chest pain and a lower intermediate (15-65%) pre-test probability of coronary artery disease (CAD) and to assess the prognostic value of exercise electrocardiography and exercise stress echocardiography in this group of patients. METHODS We identified from our stress test laboratory database 862 patients with chest pain without previously known CAD and with a pre-test probability of CAD ranging from 15 to 65% (mean 41 ± 14%) who underwent exercise testing. Patients were followed for the occurrence of death, non-fatal myocardial infarction (MI) and clinically guided revascularization. RESULTS During the median follow-up of 94 months, 87 patients (10.1%) had an adverse event (AE). A total of 30 patients died (3.5%), 23 patients suffered non-fatal MI (2.7%) and 34 patients (3.9%) had clinically guided revascularization (20 patients percutaneous and 14 patients surgical revascularizations). Male gender, age, the presence of diabetes and a slow heart rate recovery (HRR) in the first minute after exercise were independently related to the occurrence of AEs. Adverse events occurred in 10.3% of patients who were tested by exercise stress echocardiography and in 10.0% of those who underwent stress electrocardiography (p = 0.888). CONCLUSION The risk of AEs after negative exercise testing in patients with a pre-test probability of CAD of 15-65% is low. Male patients with a history of diabetes and slow HRR in the first minute after exercise have an increased risk of an adverse outcome.
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Affiliation(s)
- Vojislav Giga
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Nedeljkovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Goran Stankovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Jovanovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Paunovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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