scholarly journals Prevalence of Coronary Endothelial and Microvascular Dysfunction in Women with Symptoms of Ischemia and No Obstructive Coronary Artery Disease Is Confirmed by a New Cohort: The NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation–Coronary Vascular Dysfunction (WISE-CVD)

2019 ◽  
Vol 2019 ◽  
pp. 1-8 ◽  
Author(s):  
R. David Anderson ◽  
John W. Petersen ◽  
Puja K. Mehta ◽  
Janet Wei ◽  
B. Delia Johnson ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Vascular Dysfunction ◽  
Hormone Replacement ◽  
Obstructive Coronary Artery Disease ◽  
Signs And Symptoms ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Cardiac Events ◽  
Flow Reserve ◽  
Artery Disease

Objective. In a separate, contemporary cohort, we sought to confirm findings of the original Women’s Ischemia Syndrome Evaluation (WISE). Background. The original WISE observed a high prevalence of both invasively determined coronary endothelial and coronary microvascular dysfunction (CMD) that predicted adverse events in follow-up. Methods. We comparatively studied the WISE-Coronary Vascular Dysfunction (CVD) cohort (2009-2011), with signs and symptoms of ischemia but without significant CAD, to the original WISE (1997-2001) cohort. CMD was defined as coronary flow reserve (CFR) ≤2.5, or endothelial dysfunction as epicardial coronary artery constriction to acetylcholine (ACH), or <20% epicardial coronary dilation to nitroglycerin (NTG). Results. In WISE (n=181) and WISE-CVD (n=235) women, mean age in both was 54 years, and 83% were white (WISE) vs 74% (WISE-CVD, p=0.04). Use of hormone replacement therapy was less frequent in WISE-CVD vs WISE (46% vs 57%, p=0.026) as was presence of hypertension (40% vs 52%, p=0.013), hyperlipidemia (20% vs 46%, p<0.0001), and smoking (46% vs 56%, p=0.036). Similar rates were observed in WISE-CVD and WISE cohorts for CMD (mean CFR 2.7±0.6 vs 2.6±0.8, p=0.35), mean change in diameter with intracoronary ACH (0.2±10.0 vs 1.6±12.8 mm, p=0.34), and mean change in diameter with intracoronary NTG (9.7±13.0 vs 9.8±13.5 mm, p=0.94), respectively. Conclusions. This study confirms prevalence of CMD in the contemporary WISE-CVD cohort similar to that of the original WISE cohort, despite a lower risk factor burden in WISE-CVD. Because these coronary functional abnormalities predict major adverse cardiac events, clinical trials of therapies targeting these abnormalities are indicated.

Abstract 14277: Serum Nt-prob-type Natriuretic Peptide is Associated With Coronary Microvascular Dysfunction in Patients With Angina and Non-obstructive Coronary Artery Disease

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ali Ahmad ◽  
Jaskanwal D Sara ◽  
Michel T Corban ◽  
Takumi Toya ◽  
Ilke Ozcan ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Natriuretic Peptide ◽  
Obstructive Coronary Artery Disease ◽  
Inverse Correlation ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Flow Reserve ◽  
Artery Disease ◽  
And Gender

Title: Serum NT-proB-type Natriuretic Peptide is associated with Coronary Microvascular Dysfunction in Patients with Angina and Non-obstructive Coronary Artery Disease Authors: Ali Ahmad, MD, Jaskanwal D. Sara, MBChB, Michel T. Corban, MD, Takumi Toya, MD, Ilke Özcan, MD, Lilach O. Lerman, MD PhD, Amir Lerman, MD Introduction: Coronary microvascular dysfunction (CMD) is prevalent in patients with heart failure with preserved ejection fraction. Subclinical ischemia and myocardial fibrosis in CMD might raise filling pressure, a hallmark of HFpEF, which induces secretion of NT-proB-type natriuretic peptide (NTpro-BNP). We sought to explore the relationship between CMD and NT-proBNP. Methods: We studied 698 patients with signs and/or symptoms of ischemia and with non-obstructive CAD (<40% angiographic stenosis) who underwent invasive CMD evaluation and had NT-proBNP checked within 6 weeks. CMD was defined as coronary flow reserve (CFR) (hyperemic flow/baseline flow as measured by the doppler wire) of ≤2.5 in response to intracoronary adenosine injection. Results: Overall mean age was 52.8±12.2 years, and women represented 69% of the patients. Log NT-proBNP showed a modest inverse correlation with CFR (Pearson’s R = -0.22, P<0.0001; Figure 1 ), which remained significant after adjusting for age and gender (Standardized ß coefficient = -0.14; P = 0.001). Patients with CMD had higher levels of NT-proBNP than those without (82 [44-190] vs. 62 (33-130], P <0.0001; Figure 2) . Conclusion: Declining coronary microvascular function is correlated with higher NT-proBNP levels. Patients with CMD had higher levels of NT-proBNP, a marker of elevated LV pressure, contributing to the possible role of CMD in early HFpEF pathophysiology. Keywords: Coronary microvascular dysfunction, NT-proBNP

The coronary microcirculation and coronary microvascular dysfunction

2021 ◽  
pp. 18-21
Author(s):  
Romana Herscovici ◽  
C. Noel Bairey Merz
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Signs And Symptoms ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Cardiac Syndrome ◽  
Artery Disease

The role of revascularization in the treatment of obstructive coronary artery disease is well established, and its impact on improving survival has been proven. Nevertheless, patients with signs and symptoms considered of cardiac origin but with no obstructive coronary artery disease on coronary angiography are increasingly seen. Initially described as a ‘paradox’ or cardiac syndrome X and subsequently defined as microvascular angina, angina-like chest pain and evidence of ischaemia with non-obstructive coronary artery disease, is the consequence of altered coronary microvascular response to various stimuli despite non-obstructed epicardial vessels.

scholarly journals Coronary Microvascular Dysfunction

2020 ◽  
Vol 9 (9) ◽  
pp. 2880
Author(s):  
Federico Vancheri ◽  
Giovanni Longo ◽  
Sergio Vancheri ◽  
Michael Henein
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Coronary Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Flow Reserve ◽  
Artery Disease

Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed “ischemia with non-obstructive coronary artery disease” (INOCA) and for a small proportion of “myocardial infarction with non-obstructive coronary artery disease” (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

scholarly journals Sex differences in non-obstructive coronary artery disease

2020 ◽  
Vol 116 (4) ◽  
pp. 829-840 ◽  
Author(s):  
Nida Waheed ◽  
Suzette Elias-Smale ◽  
Waddah Malas ◽  
Angela H Maas ◽  
Tara L Sedlak ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Sex Differences ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Diagnostic Testing ◽  
Microvascular Dysfunction ◽  
Adverse Outcomes ◽  
Coronary Microvascular Dysfunction ◽  
Cardiac Events ◽  
Artery Disease

Abstract Ischaemic heart disease is a leading cause of morbidity and mortality in both women and men. Compared with men, symptomatic women who are suspected of having myocardial ischaemia are more likely to have no obstructive coronary artery disease (CAD) on coronary angiography. Coronary vasomotor disorders and coronary microvascular dysfunction (CMD) have been increasingly recognized as important contributors to angina and adverse outcomes in patients with no obstructive CAD. CMD from functional and structural abnormalities in the microvasculature is associated with adverse cardiac events and mortality in both sexes. Women may be particularly susceptible to vasomotor disorders and CMD due to unique factors such as inflammation, mental stress, autonomic, and neuroendocrine dysfunction, which predispose to endothelial dysfunction and CMD. CMD can be detected with coronary reactivity testing and non-invasive imaging modalities; however, it remains underdiagnosed. This review focuses on sex differences in presentation, pathophysiologic risk factors, diagnostic testing, and prognosis of CMD.

scholarly journals Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease)

2020 ◽  
Vol 116 (4) ◽  
pp. 771-786 ◽  
Author(s):  
Udo Sechtem ◽  
David Brown ◽  
Shigeo Godo ◽  
Gaetano Antonio Lanza ◽  
Hiro Shimokawa ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Diagnostic Methods ◽  
Coronary Microvascular Dysfunction ◽  
Fractional Flow ◽  
Complex Situation ◽  
Flow Reserve ◽  
Artery Disease

Abstract Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.

Abstract 15094: Prevalence of Coronary Microvascular Dysfunction in Women With Angina and No Obstructive Coronary Artery Disease: Preliminary Results From the iPower Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Naja D Mygind ◽  
Marie M Michelsen ◽  
Adam A Pena ◽  
Rebekka Faber ◽  
Jens Kastrup ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Angina Pectoris ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Coronary Microvascular Dysfunction ◽  
High Dose ◽  
Transthoracic Doppler Echocardiography ◽  
Flow Reserve ◽  
Artery Disease

Background: Women are more often than men found to have no obstructive coronary artery disease (CAD) when evaluated with a coronary angiogram (CAG) due to angina pectoris and suspected ischemic heart disease. Coronary microvessel dysfunction (CMD) is a possible explanation, and can be assessed by transthoracic Doppler echocardiography (TTDE) with measurement of coronary flow reserve (CFR). Reduced CFR carries an adverse prognosis despite absence of obstructive CAD. The aim of the ongoing iPower study is to evaluate CFR in women with angina pectoris and no obstructive CAD. Methods: Women with angina pectoris and a CAG without obstructive coronary artery disease (>50%) are systematically invited to participate. Assessment includes demographic and clinical data, blood samples and TTE during rest and high-dose dipyridamole stress (0.84mg/kg) with measurement of CFR by Doppler of the left anterior descending artery. Results: To date (May 21st 2014) 3500 women have been screened (flowchart), 793 women have been included (response rate 23%). Mean age was 62.4 (+/-9.6) and the burden of risk factors was relatively high (Table 1). CFR was successfully measured in 763 patients (96%). Median (IQR) CFR was 2.4 (2.0-2.8). Cut-off point for CMD of both 2 and 2.5 has been used previously. In this population, 214 (28%) had a CFR≤2 and 468 (61%) a CFR≤2.5. Conclusions: To our knowledge, iPower is the largest and most comprehensive study systematically assessing CMD in women with angina pectoris and no obstructive CAD. Non-invasive CFR assessment is feasible, and microvascular function impaired in a large proportion. Future follow-up will determine the prognostic value of CFR as a measure of CMD.

Abstract 9946: Impact of Sex Differences on Invasive Measures of Coronary Microvascular Dysfunction in Patients With Angina in the Absence of Obstructive Coronary Artery Disease

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Yuhei Kobayashi ◽  
Yasuhiro Honda ◽  
William F Fearon ◽  
Shigemitsu Tanaka ◽  
Peter J Fitzgerald ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Sex Differences ◽  
Coronary Artery ◽  
Coronary Flow ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Microvascular Function ◽  
Coronary Microvascular Dysfunction ◽  
Flow Reserve ◽  
Artery Disease

Background: Coronary microvascular dysfunction is associated with worse long-term outcomes, especially in women. Coronary flow reserve (CFR) is typically used to interrogate microvascular function; however its variability limits reliability. Alternatively, the index of microcirculatory resistance (IMR) is a direct measure of the microvasculature, but has been less thoroughly studied. We investigated sex differences in CFR and IMR in patients with angina in the absence of obstructive coronary artery disease (CAD). Methods: We prospectively enrolled 117 women and 40 men with angina in the absence of obstructive CAD. We performed CFR, IMR, fractional flow reserve (FFR), and quantitative coronary angiography (QCA) in the left anterior descending artery. Coronary flow was assessed with a thermodilution method by obtaining mean transit time (Tmn: an inverse correlate to absolute flow) at rest and hyperemia. IMR was measured as distal coronary pressure at hyperemia x hyperemic Tmn. Results: All patients had minimal or no atherosclerosis by QCA (%diameter stenosis: 23.2±12.3%), and epicardial disease was milder in women (FFR: 0.88±0.04 vs. 0.87±0.04, p=0.04). IMR was similar between the sexes (20.7±9.8 vs. 19.1±8.0, p=0.45), but CFR was lower in women (3.8±1.6 vs. 4.8±1.9, p=0.004). This was primarily due to a shorter resting Tmn in women (p=0.005), while hyperemic Tmn was identical (p=0.79) (Figure). The shorter resting Tmn in women, reflecting increased resting coronary flow, accounted for the lower CFR. In multivariate analysis, female sex was an independent predictor of lower CFR and shorter resting Tmn, but not a predictor of IMR or hyperemic Tmn. Conclusions: Despite women and men having similar microvascular function by IMR, CFR is lower in women. This discrepancy appears to be due to differences in resting coronary flow between the sexes. The impact of sex differences should be considered in interpretation of physiologic indices using resting coronary flow.

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