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Kanaji Y, Ahmad A, Sara JDS, Ozcan I, Akhiyat N, Prasad A, Raphael CE, Kakuta T, Lerman LO, Lerman A. Coronary Vasomotor Dysfunction Is Associated With Cardiovascular Events in Patients With Nonobstructive Coronary Artery Disease. JACC Cardiovasc Interv 2024; 17:474-487. [PMID: 38418053 DOI: 10.1016/j.jcin.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Coronary vasomotor dysfunction (CVDys) can be comprehensively classified on the basis of anatomy and functional mechanisms. OBJECTIVES The aim of this study was to evaluate the association between different CVDys phenotypes and outcomes in patients with angina and nonobstructive coronary artery disease (ANOCA). METHODS Patients with ANOCA who underwent coronary reactivity testing using an intracoronary Doppler guidewire to assess microvascular and epicardial coronary endothelium-dependent and endothelium-independent function were enrolled. Endothelium-dependent microvascular and epicardial coronary dysfunction were defined as a <50% change in coronary blood flow in response to intracoronary acetylcholine (Ach) infusion and a <-20% change in coronary artery diameter in response to Ach. Endothelium-independent microvascular and epicardial coronary dysfunction were defined as coronary flow reserve < 2.5 during adenosine-induced hyperemia and change in cross-sectional area in response to intracoronary nitroglycerin administration < 20%. Major adverse cardiac and cerebrovascular events (cardiovascular death, nonfatal MI, heart failure, stroke, and late revascularization) served as clinical outcomes. RESULTS Among the 1,196 patients with ANOCA, the prevalence of CVDys was 24.5% and 51.8% among those with endothelium-independent and endothelium-dependent microvascular dysfunction, respectively, and 47.4% and 25.4% among those with endothelium-independent and endothelium-dependent epicardial coronary dysfunction, respectively. During 6.3 years (Q1-Q3: 2.5-12.9 years) of follow-up, patients with endothelium-dependent microvascular dysfunction, endothelium-dependent epicardial coronary dysfunction, or endothelium-independent microvascular dysfunction showed significantly higher event rates compared with those without (19.5% vs 12.0% [P < 0.001], 19.7% vs 14.6% [P = 0.038] and 22.2% vs 13.8% [P = 0.001], respectively). Coronary flow reserve (HR: 0.757; 95% CI: 0.604-0.957) and percentage change in coronary blood flow in response to Ach infusion (HR: 0.998; 95% CI: 0.996-0.999) remained significant predictors of major adverse cardiac and cerebrovascular event after adjustment for conventional risk factors. CONCLUSIONS CVDys phenotype is differentially associated with worse outcomes, and endothelium-dependent and endothelium-independent microvascular function provide independent prognostic information in patients with ANOCA.
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Affiliation(s)
- Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ilke Ozcan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadia Akhiyat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Mahendiran T, De Bruyne B. ANOCA and the Endothelium: A Link That Can NO Longer Be Ignored. JACC Cardiovasc Interv 2024; 17:488-490. [PMID: 38418054 DOI: 10.1016/j.jcin.2023.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 03/01/2024]
Affiliation(s)
- Thabo Mahendiran
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
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Beltrame JF. Comprehensive Diagnostic Assessment in MINOCA. JACC Cardiovasc Imaging 2023; 16:533-535. [PMID: 36752448 DOI: 10.1016/j.jcmg.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 01/27/2023]
Affiliation(s)
- John F Beltrame
- University of Adelaide, South Adelaide, South Australia, Australia; and the Central Adelaide Local Health Network (CALHN), South Australia, Australia.
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Weber B, Parks S, Huck DM, Kim A, Bay C, Brown JM, Divakaran S, Hainer J, Bibbo C, Taqueti V, Dorbala S, Blankstein R, Woolley AE, Di Carli MF. Prior SARS-CoV-2 Infection Is Associated With Coronary Vasomotor Dysfunction as Assessed by Coronary Flow Reserve From Cardiac Positron Emission Tomography. J Am Heart Assoc 2022; 11:e025844. [PMID: 36250654 PMCID: PMC9673657 DOI: 10.1161/jaha.122.025844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiovascular complications from COVID-19 contribute to its high morbidity and mortality. The effect of COVID-19 infection on the coronary vasculature is not known. The objective of this study was to investigate the prevalence of coronary vasomotor dysfunction identified by coronary flow reserve from cardiac positron emission tomography in patients with previous COVID-19 infection. Methods and Results All patients who had polymerase chain reaction-confirmed SARS-CoV-2 infection referred for myocardial stress perfusion positron emission tomography imaging at Brigham and Women's Hospital from April 2020 to July 2021 were compared with a matched control group without prior SARS-CoV-2 infection imaged in the same period. The main outcome was the prevalence of coronary vasomotor dysfunction. Myocardial perfusion and myocardial blood flow reserve were quantified using N13-ammonia positron emission tomography imaging. Thirty-four patients with prior COVID-19 were identified and compared with 103 matched controls. The median time from polymerase chain reaction-confirmed SARS-CoV-2 to cardiac positron emission tomography was 4.6 months (interquartile range,1.2-5.6 months). There were 16 out of 34 (47%) patients previously hospitalized for COVID-19 infection. Baseline cardiac risk factors were common, and 18 (53%) patients in the COVID-19 group had abnormal myocardial perfusion. Myocardial blood flow reserve was abnormal (<2) in 44.0% of the patients with COVID-19 compared with 11.7% of matched controls (P<0.001). The mean myocardial blood flow reserve was 19.4% lower in patients with COVID-19 compared with control patients (2.00±0.45 versus 2.48±0.47, P<0.001). Conclusions Myocardial blood flow reserve was impaired in patients with prior COVID-19 infection compared with cardiovascular risk factor-matched controls, suggesting a relationship between SARS-CoV-2 infection and coronary vascular health. These data highlight the need to assess long-term consequences of COVID-19 on vascular health in future prospective studies.
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Affiliation(s)
- Brittany Weber
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Sean Parks
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Daniel M. Huck
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Andy Kim
- Division of Infectious Disease, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Camden Bay
- Department of RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Jenifer M. Brown
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Courtney Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Viviany Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Ann E. Woolley
- Division of Infectious Disease, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA,Cardiovascular Division, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMA
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Jansen TPJ, Konst RE, de Vos A, Paradies V, Teerenstra S, van den Oord SCH, Dimitriu-Leen A, Maas AHEM, Smits PC, Damman P, van Royen N, Elias-Smale SE. Efficacy of Diltiazem to Improve Coronary Vasomotor Dysfunction in ANOCA: The EDIT-CMD Randomized Clinical Trial. JACC Cardiovasc Imaging 2022; 15:1473-1484. [PMID: 35466050 DOI: 10.1016/j.jcmg.2022.03.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The randomized, placebo-controlled EDIT-CMD (Efficacy of Diltiazem to Improve Coronary Microvascular Dysfunction: A Randomized Clinical Trial) evaluated the effect of diltiazem on coronary vasomotor dysfunction (CVDys), as assessed by repeated coronary function testing (CFT), angina, and quality of life. BACKGROUND Diltiazem is recommended and frequently prescribed in patients with angina and nonobstructive coronary artery disease (ANOCA), suspected of CVDys. However, studies substantiating its effect is this patient group are lacking. METHODS A total of 126 patients with ANOCA were included and underwent CFT. CVDys, defined as the presence of vasospasm (after intracoronary acetylcholine provocation) and/or microvascular dysfunction (coronary flow reserve: <2.0, index of microvascular resistance: ≥25), was confirmed in 99 patients, of whom 85 were randomized to receive either oral diltiazem or placebo up to 360 mg/d. After 6 weeks, a second CFT was performed. The primary end point was the proportion of patients having a successful treatment, defined as normalization of 1 abnormal parameter of CVDys and no normal parameter becoming abnormal. Secondary end points were changes from baseline to 6-week follow-up in vasospasm, index of microvascular resistance, coronary flow reserve, symptoms (Seattle Angina Questionnaire), or quality of life (Research and Development Questionnaire 36). RESULTS In total, 73 patients (38 diltiazem vs 35 placebo) underwent the second CFT. Improvement of the CFT did not differ between the groups (diltiazem vs placebo: 21% vs 29%; P = 0.46). However, more patients on diltiazem treatment progressed from epicardial spasm to microvascular or no spasm (47% vs 6%; P = 0.006). No significant differences were observed between the diltiazem and placebo group in microvascular dysfunction, Seattle Angina Questionnaire, or Research and Development Questionnaire 36. CONCLUSIONS This first performed randomized, placebo-controlled trial in patients with ANOCA showed that 6 weeks of therapy with diltiazem, when compared with placebo, did not substantially improve CVDys, symptoms, or quality of life, but diltiazem therapy did reduce prevalence of epicardial spasm. (Efficacy of Diltiazem to Improve Coronary Microvascular Dysfunction: A Randomized Clinical Trial [EDIT-CMD]; NCT04777045).
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Affiliation(s)
- Tijn P J Jansen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Regina E Konst
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Annemiek de Vos
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels van Royen
- 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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Affiliation(s)
- Juan Carlos Kaski
- Molecular and Clinical Sciences Research InstituteSt George’s, University of LondonUnited Kingdom
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