scholarly journals Coronary Flow Reserve in Patients With Prior Spontaneous Coronary Artery Dissection and Recurrent Angina

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Tara Sedlak ◽  
Andrew Starovoytov ◽  
Karin Humphries ◽  
Jacqueline Saw
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Flow ◽  
Fibromuscular Dysplasia ◽  
Microvascular Dysfunction ◽  
Artery Dissection ◽  
Coronary Microvascular Dysfunction ◽  
Coronary Artery Dissection ◽  
Flow Reserve ◽  
Index Of Microcirculatory Resistance

Background A significant proportion of patients with spontaneous coronary artery dissection (SCAD) have ongoing chronic chest pain despite healing of their dissection. We sought to determine whether coronary microvascular dysfunction contributes to post‐SCAD chronic chest pain by performing coronary reactivity testing in the cardiac catheterization laboratory. Methods and Results Eighteen patients consented to coronary reactivity testing at least 3 months post‐SCAD. Coronary flow reserve (CFR) and index of microcirculatory resistance were measured in the previously affected SCAD artery and 1 non‐SCAD artery. CFR <2.5 was defined as diagnostic of coronary microvascular dysfunction. An abnormal index of microcirculatory resistance was defined as >25 units. Seventeen women underwent coronary reactivity testing (1 had chronic dissection and was excluded). All presented with myocardial infarction and 2 underwent coronary stenting during the initial SCAD event. Fibromuscular dysplasia was present in 70.6% upon screening renal, iliac, and cerebrovascular arteries. Twelve patients (70.6%) had CFR <2.5 and 13 (76.5%) had an index of microcirculatory resistance >25 in at least 1 artery. There was no difference in the frequency of a low CFR measurement between SCAD and non‐SCAD arteries. Conclusions Among patients with chronic chest pain after an SCAD event, >70% had coronary microvascular dysfunction as indicated by abnormal CFR or index of microcirculatory resistance in at least 1 coronary artery on invasive coronary reactivity testing. Presence of coronary microvascular dysfunction in both SCAD and non‐SCAD arteries suggests that underlying microvascular abnormalities from vasculopathies such as coronary fibromuscular dysplasia may be the underlying etiology.

scholarly journals Prevalence and characteristics of coronary microvascular dysfunction among chest pain patients in the emergency department

2018 ◽  
Vol 9 (1) ◽  
pp. 5-13 ◽  
Author(s):  
Basmah Safdar ◽  
Gail D’Onofrio ◽  
James Dziura ◽  
Raymond R Russell ◽  
Caitlin Johnson ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Emergency Department ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Flow Reserve ◽  
Coronary Flow ◽  
Coronary Microvascular Dysfunction ◽  
Flow Reserve ◽  
Artery Disease

Aims: Coronary microvascular dysfunction (CMD) is common in patients with non-obstructive coronary arteries but has not been described in low-risk symptomatic patients. We therefore assessed the prevalence and characteristics of CMD in low to moderate risk patients with chest pain in an emergency department. Methods and results: We used three-dimensional Rb82 cardiac positron emission tomography/computed tomography to diagnose coronary artery disease (known or new regional defect, any coronary calcification) and CMD (low coronary flow reserve without coronary artery disease) in chest pain patients after being ruled out for acute myocardial infarction. Exclusions included age 30 years or less, acute myocardial infarction, hemodynamic instability, heart failure and dialysis. Among 195 participants undergoing cardiac positron emission tomography/computed tomography, 42% had CMD, 36% had coronary artery disease and 22% had normal flows; 70% were women and 84% were obese. Patients with CMD and coronary artery disease had significantly lower coronary flow reserve than normal patients (mean coronary flow reserve 1.6 and 1.9 vs. 2.6, respectively, P<0.05). However, CMD patients were younger (mean age 51 vs. 61 years), and had fewer traditional cardiac risk factors ( P<0.05) than patients with coronary artery disease. Nearly one third (31%) of patients had a prior emergency department visit for chest pain within three years of index presentation. Women were four times as likely to have CMD as men (adjusted odds ratio 4.2; 95% confidence interval 1.8, 9.6) after controlling for age, race, hypertension, diabetes, smoking, dyslipidemia, obesity and family history of coronary artery disease. Conclusions: Despite their low-risk profile, nearly one half of symptomatic and mostly obese emergency department patients without evidence of myocardial infarction or coronary artery disease had CMD. The results could explain the high rates of return visits associated with chest pain, although their application to the general emergency department population require validation.

Abstract 14194: Triple Vessel Spontaneous Coronary Artery Dissection With Coronary Artery Fibromuscular Dysplasia

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Franz Schweis ◽  
Ara Rostomian ◽  
Derek Phan ◽  
Mingsum Lee ◽  
Anne Ichiuji ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Renal Artery ◽  
Fibromuscular Dysplasia ◽  
Left Ventricular ◽  
Artery Dissection ◽  
Management Approach ◽  
Spontaneous Coronary Artery Dissection ◽  
Coronary Angiogram ◽  
Coronary Artery Dissection

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare albeit well-established etiology of myocardial infarction and most commonly involves a single coronary vessel. We present a unique case of a patient presenting with chest pain and found to have triple vessel SCAD with associated findings suggestive of coronary artery fibromuscular dysplasia (FMD). Case Presentation: A 53 year-old woman with a past medical history of hypertension and chronic headaches presented with intermittent exertional substernal chest pain for two days. Labs were significant for an elevated Troponin-I of 0.12 ng/mL (normal < 0.04 ng/mL). Coronary angiogram revealed tortuous vessels with evidence of SCAD in multiple coronary arteries including the left anterior descending artery (LAD), posterior descending artery (PDA), and posterior left ventricular artery (PLV) (Figure A, B). Intracoronary nitroglycerin was administered during the procedure to ensure the findings were not due to coronary vasospasm. Due to the known association of SCAD and FMD, a renal angiogram was performed, which demonstrated a “beading” appearance of the right renal artery consistent with renal artery FMD. She was conservatively managed with medical therapy.A head computed tomography angiogram (CTA) was performed, which showed evidence of FMD of the bilateral vertebral arteries. A repeat coronary angiogram was performed six weeks after discharge. She was found to have complete resolution of SCAD in the LAD and PLV (Figure C, D). Interestingly, the PDA displayed a “string of beads” appearance concerning for intracoronary artery FMD (Figure D). Conclusion: Our case demonstrates evidence that coronary artery FMD may contribute to the underlying etiology of the coronary artery dissection. A conservative management approach resulted in a favorable outcome and the patient was able to avoid unnecessary intervention and potential related complications.

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.

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

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