Takotsubo Cardiomyopathy: One More Angiographic Evidence of Microvascular Dysfunction

Background. Takotsubo cardiomyopathy (TC) aetiology has not been completely understood yet. One proposed pathogenic mechanism was coronary microvascular dysfunction (MVD). This study compared coronary flow and myocardial perfusion in patients with TC, microvascular angina (MVA), and a control group (CG). Methods. Out of 42 consecutive patients presented to our centre with TC from 2013 to 2017; we retrospectively selected 27 patients. We compared them with a sex- and age-matched group of 27 MVA cases and 27 patients with normal coronary arteries (CG). The flow was evaluated in the three coronary arteries as TIMI flow and TIMI frame count (TFC). Myocardial perfusion was studied with Blush-Score and Quantitative Blush Evaluator (QuBE). Results. TFC, in TC, revealed flow impairment in the three arteries compared to the CG (left anterior descending artery (LAD): 22±8, 15±4; p=0.001) (right coronary artery: 12±4, 10±3; p=0,025) (left circumflex: 14±4, CG 11±3; p=0,006). QuBE showed myocardial perfusion impairment in the LAD territory in TC comparing with both the CG (8,9 (7,2–11,5) versus 11,4 (10–15,7); p=0,008) and the MVA group (8,9 (7,2–11,5) versus 13,5 (10–16); p=0,006). Conclusions. Our study confirmed that coronary flow is impaired in TC, reflecting a MVD. Myocardial perfusion defect was detected only in the LAD area.

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Coronary Microvascular Dysfunction: An Update

University Heart Journal ◽

10.3329/uhj.v16i1.44843 ◽

2020 ◽

Vol 16 (1) ◽

pp. 43-49

Author(s):

Sm Mustafa Zaman ◽

Harisul Hoque ◽

Khurshed Ahmed ◽

Md Mukhlesur Rahman ◽

Msi Tipu Chowdhury ◽

...

Keyword(s):

Magnetic Resonance ◽

Myocardial Perfusion ◽

Current Knowledge ◽

Systolic Dysfunction ◽

Microvascular Dysfunction ◽

Coronary Microvascular Dysfunction ◽

Resonance Spectroscopy ◽

Channel Blockers ◽

Converting Enzyme Inhibitors ◽

Microvascular Angina

Structural and functional abnormalities of the microcirculation can impair myocardial perfusion which is called coronary microvascular dysfunction and the resulting ischemia is known as microvascular ischaemia. Most of the researches have focused on the epicardial coronary arteries while addressing angina pectoris. Although the importance of the coronary microcirculation in maintaining appropriate myocardial perfusion has been recognized for several decades, the substantial morbidity of coronary microvascular dysfunction (CMD) has not been appreciated until recently. It is not possible to diagnose of microvascular angina clinically with the current knowledge. Resting or exercise electrocardiogram is nondiagnostic. Imaging with speckle tracking in echocardiography may reveal focal diastolic and/or systolic dysfunction. Other noninvasive investigations includes, Contrast stress echocardiography, 99Tc-sestamibi imaging, cardiovascular magnetic resonance (CMR),Nuclear magnetic resonance spectroscopy may show some degree of abnormality. Invasive methods like intracoronary adenosine and acetylecholine test may guide us to diagnose CMD. No guideline directed medical therapy is still available for the CMD. Risk factors modification like smoking cessation and weight-loss may improve endothelial dysfunction and CMD. Beta blockers, calcium channel blockers, Angiotensin converting enzyme inhibitors and statin are now used in different clinical condition related to microvascular angina. After these medical treatment patient with microvascular angina have higher risk of MACE compared with people without angina. So, physicians must be aware of this potentially fatal but under recognized clinical entity. University Heart Journal Vol. 16, No. 1, Jan 2020; 43-49

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Clinico-pathophysiological considerations in coronary microvascular disorders

Vessel Plus ◽

10.20517/2574-1209.2021.68 ◽

2022 ◽

Author(s):

Sarena La ◽

Rosanna Tavella ◽

Sivabaskari Pasupathy ◽

John F. Beltrame

Keyword(s):

Coronary Arteries ◽

Myocardial Ischaemia ◽

Pain Perception ◽

Microvascular Dysfunction ◽

Coronary Microvascular Dysfunction ◽

Microvascular Angina ◽

Common Clinical Presentation ◽

Microvascular Spasm ◽

Underlying Mechanisms ◽

Microvascular Resistance

Around half of the patients undergoing an elective coronary angiogram to investigate typical stable angina symptoms are found to have non-obstructive coronary arteries (defined as < 50% stenosis). These patients are younger with a female predilection. While underlying mechanisms responsible for these presentations are heterogeneous, structural and functional abnormalities of the coronary microvasculature are highly prevalent. Thus, coronary microvascular dysfunction (CMD) is increasingly recognised as an important consideration in patients with non-obstructive coronary arteries. This review will focus on primary coronary microvascular disorders and summarise the four common clinical presentation pictures which can be considered as endotypes - Microvascular Ischaemia (formerly “Syndrome X”), Microvascular Angina, Microvascular Spasm, and Coronary Slow Flow. Furthermore, the pathophysiological mechanisms associated with CMD are also heterogenous. CMD may arise from an increased microvascular resistance, impaired microvascular dilation, and/or inducible microvascular spasm, ultimately causing myocardial ischaemia and angina. Alternatively, chest pain may arise from hypersensitivity of myocardial pain receptors rather than myocardial ischaemia. These two major abnormalities should be considered when assessing an individual clinical picture, and ultimately, the question arises whether to target the heart or the pain perception to treat the anginal symptoms.

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Diagnostic Approach to Patients with Stable Angina and No Obstructive Coronary Arteries

European Cardiology Review ◽

10.15420/ecr.2019.22.2 ◽

2019 ◽

Vol 14 (2) ◽

pp. 97-102 ◽

Cited By ~ 2

Author(s):

Gaetano Antonio Lanza

Keyword(s):

Coronary Arteries ◽

Microvascular Dysfunction ◽

Definitive Diagnosis ◽

Diagnostic Approach ◽

Coronary Microvascular Dysfunction ◽

Stress Tests ◽

Transthoracic Doppler Echocardiography ◽

Microvascular Angina ◽

Non Invasive ◽

Intracoronary Doppler

The diagnosis of microvascular angina (MVA) is usually considered in patients presenting with angina symptoms and evidence of MI on non-invasive stress tests but normal coronary arteries at angiography. A definitive diagnosis of MVA, however, would require the presence of coronary microvascular dysfunction. Several invasive (e.g. intracoronary Doppler wire recording and thermodilution) and non-invasive (e.g. PET, cardiac MRI, transthoracic Doppler echocardiography) methods can be applied to obtain a diagnosis. Both endothelium- dependent and -independent coronary microvascular dilator function, as well as increased microvascular constrictor activity, should be investigated. The main issues in the assessment of clinical and diagnostic findings in patients with suspected MVA are discussed and a diagnostic approach is suggested.

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Abstract 5636: Major Depression is Associated with Decreased Coronary Flow Reserve Detected by Positron Emission Tomography

Circulation ◽

10.1161/circ.118.suppl_18.s_976-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Viola Vaccarino ◽

J D Bremner ◽

John Votaw ◽

Tracy Faber ◽

Emir Veledar ◽

...

Keyword(s):

Risk Factors ◽

Positron Emission Tomography ◽

Myocardial Perfusion ◽

Coronary Flow Reserve ◽

Coronary Flow ◽

Microvascular Dysfunction ◽

Emission Tomography ◽

Coronary Microvascular Dysfunction ◽

Flow Reserve ◽

Positron Emission

Introduction. Major depressive disorder (MDD) is associated with coronary heart disease, but the underlying mechanisms are unclear. Coronary flow reserve (CFR) in response to adenosine is an index of coronary microvascular dysfunction which predisposes to myocardial ischemia. We examined the relationship between MDD and CFR in a genetically informative sample. Methods. We studied 141 twin pairs drawn from the Vietnam Era Twin Registry who were born between 1946 and 1956 (mean age 54). For all twins, a lifetime history of MDD was determined with the Structured Clinical Interview for Psychiatry Disorders; 53 pairs were discordant for MDD and 88 pairs were free of MDD. Standard cardiovascular risk factors were obtained by interview and examination. We performed myocardial perfusion imaging and blood flow quantitation with [13N] ammonia positron emission tomography at rest and after adenosine stress. A perfusion defect score summed the number and severity of defects across 20 myocardial regions. CFR was measured as the ratio of maximum flow to baseline flow at rest. Mixed-effect and GEE models were used to conduct matched-pair analyses. Results. There was no difference in the distribution of abnormal scans, in summed rest or stress defect scores, and in heart rate/blood pressure responses to adenosine between twins with and without MDD. Among the DZ twin pairs discordant for MDD, the mean CFR was lower in twins with MDD than their brothers without MDD (2.36 ± 0.66 vs 2.75 ± 0.90; p=0.03); no significant difference in mean CFR was found in MZ discordant pairs (2.90±0.78 vs 2.64±0.64, p=0.13). The zygosity by MDD interaction was significant (p=0.01). Results did not change substantially after adjusting for cardiovascular disease risk factors and antidepressant use (adjusted interaction p=0.007). There were no differences in myocardial perfusion comparing twins in discordant pairs with twins in healthy pairs. Conclusions. MDD is associated with lower CFR in spite of no differences in visible perfusion defects, suggesting microvascular dysfunction. This association is largely due to shared genetic liability between depression and CFR, suggesting a common underlying pathophysiological process linking depression and coronary microvascular dysfunction. This research has received full or partial funding support from the American Heart Association, AHA National Center.

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Optimale Diagnostik und Therapie der mikrovaskulären Angina pectoris

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/s-0043-104469 ◽

2017 ◽

Vol 142 (21) ◽

pp. 1586-1593 ◽

Cited By ~ 2

Author(s):

Peter Ong ◽

Udo Sechtem

Keyword(s):

Angina Pectoris ◽

Coronary Flow Reserve ◽

Coronary Flow ◽

Beta Blockers ◽

Microvascular Dysfunction ◽

Coronary Microvascular Dysfunction ◽

Channel Blockers ◽

Microvascular Angina ◽

Flow Reserve ◽

Diagnostik Und Therapie

AbstractPatients with microvascular angina are characterized by angina pectoris with proof of myocardial ischemia in the absence of any relevant epicardial stenosis and without myocardial disease (type 1 coronary microvascular dysfunction according to Crea and Camici). Structural and functional alterations of the coronary microvessels (diameter < 500 µm) are the reason for this phenomenon. Frequently such alterations are associated with cardiovascular risk factors. Patients with angina pectoris without epicardial stenoses represent for 10 – 50 % of all patients undergoing coronary angiography depending on the clinical presentation. Diagnostic approaches include non-invasive (e. g. combination of coronary CT-angiography and positron emission tomography/echo Doppler-based coronary flow reserve measurements) as well as invasive procedures (coronary flow reserve measurements in response to adenosine, intracoronary acetylcholine testing). Pharmacological treatment of these patients is often challenging and should be based on the characterization of the underlying mechanisms. Moreover, strict risk factor control and individually titrated combinations of antianginal substances (e. g. beta blockers, calcium channel blockers, nitrates, ranolazine, ivabradine etc.) are recommended.

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The many faces of myocardial ischaemia and angina

Cardiovascular Research ◽

10.1093/cvr/cvz160 ◽

2019 ◽

Vol 115 (10) ◽

pp. 1460-1470 ◽

Cited By ~ 9

Author(s):

Bernard I Levy ◽

Gerd Heusch ◽

Paolo G Camici

Keyword(s):

Blood Flow ◽

Coronary Arteries ◽

Myocardial Ischaemia ◽

Obstructive Coronary Artery Disease ◽

Coronary Spasm ◽

Microvascular Dysfunction ◽

Coronary Microvascular Dysfunction ◽

Microvascular Angina ◽

Number Of Patients ◽

Metabolic Vasodilation

Abstract Obstructive disease of the epicardial coronary arteries is the main cause of angina. However, a number of patients with anginal symptoms have normal coronaries or non-obstructive coronary artery disease (CAD) despite electrocardiographic evidence of ischaemia during stress testing. In addition to limited microvascular vasodilator capacity, the coronary microcirculation of these patients is particularly sensitive to vasoconstrictor stimuli, in a condition known as microvascular angina. This review briefly summarizes the determinants and control of coronary blood flow (CBF) and myocardial perfusion. It subsequently analyses the mechanisms responsible for transient myocardial ischaemia: obstructive CAD, coronary spasm and coronary microvascular dysfunction in the absence of epicardial coronary lesions, and variable combinations of structural anomalies, impaired endothelium-dependent and/or -independent vasodilation, and enhanced perception of pain. Lastly, we exemplify mechanism of angina during tachycardia. Distal to a coronary stenosis, coronary dilator reserve is already recruited and can be nearly exhausted at rest distal to a severe stenosis. Increased heart rate reduces the duration of diastole and thus CBF when metabolic vasodilation is no longer able to increase CBF. The increase in myocardial oxygen consumption and resulting metabolic vasodilation in adjacent myocardium without stenotic coronary arteries further acts to divert blood flow away from the post-stenotic coronary vascular bed through collaterals.

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Silent severe myocardial ischemia in a past illicit drug user imaged with myocardial perfusion scintigraphy

Perfusion ◽

10.1177/02676591211028175 ◽

2021 ◽

pp. 026765912110281

Author(s):

Chrissa Sioka ◽

Georgios Georgiou ◽

Christos Katsouras ◽

Konstantinos Pappas ◽

Dimitris-Nikiforos Kiortsis ◽

...

Keyword(s):

Drug Use ◽

Myocardial Perfusion ◽

Myocardial Ischemia ◽

Illicit Drugs ◽

Illicit Drug ◽

Microvascular Dysfunction ◽

Illicit Drug Use ◽

Coronary Microvascular Dysfunction ◽

Illicit Drug User ◽

Cardiac Symptoms

Patients with illicit drug use may have deleterious acute and chronic cardiac effects. We present a case of a 42-year-old man, former alcohol and various illicit drugs user, who was admitted to the psychiatric unit for management of psychosis. Because of his previous drug and alcohol history, a cardiological evaluation was performed which revealed silent severe myocardial ischemia detected by myocardial perfusion imaging (MPI). The myocardial ischemia was attributed to coronary microvascular dysfunction, occurring several years after quitting the illicit drugs. This study highlights the potential myocardial ischemia that may occur in patients with previous alcohol and illicit drug use, and the role of MPI, a non-invasive test that can provide important information regarding the myocardial status of such patients, even without obvious cardiac symptoms or findings.

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