scholarly journals ‘Primary’ Microvascular Angina: Clinical Characteristics, Pathogenesis and Management

2018 ◽  
Vol 13 (3) ◽  
pp. 108 ◽  
Author(s):  
Gaetano Antonio Lanza ◽  
Antonio De Vita ◽  
Juan-Carlos Kaski ◽  
◽  
◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Characteristics ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Diagnostic Tools ◽  
Coronary Microvascular Dysfunction ◽  
Pharmacological Treatments ◽  
Microvascular Angina ◽  
Non Invasive ◽  
Prognostic Implications

Microvascular angina (MVA), i.e. angina caused by abnormalities of the coronary microcirculation, is increasingly recognised in clinical practice. The pathogenetic mechanisms of MVA are heterogeneous and may involve both structural and functional alterations of coronary microcirculation, and functional abnormalities may variably involve an impairment of coronary microvascular dilatation and an increased microvascular constrictor activity. Both invasive and non-invasive diagnostic tools exist to identify patients with MVA in clinical practice. Prognosis has been reported to be good in primary MVA patients, although the prognostic implications of coronary microvascular dysfunction (CMVD) in more heterogeneous populations of angina patients need further assessment. Management of primary MVA can be challenging, but pharmacological and non-pharmacological treatments exist that allow satisfactory control of symptoms in most patients

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

2019 ◽  
Vol 14 (2) ◽  
pp. 97-102 ◽  
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.

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).

Diagnosis of coronary microvascular dysfunction in the clinic

2020 ◽  
Vol 116 (4) ◽  
pp. 841-855 ◽  
Author(s):  
Peter Ong ◽  
Basmah Safdar ◽  
Andreas Seitz ◽  
Astrid Hubert ◽  
John F Beltrame ◽  
...  
Keyword(s):  
Coronary Flow ◽  
Coronary Thrombosis ◽  
Coronary Spasm ◽  
Microvascular Dysfunction ◽  
Coronary Microcirculation ◽  
Coronary Microvascular Dysfunction ◽  
Human Beings ◽  
Transthoracic Doppler Echocardiography ◽  
Non Invasive ◽  
Flow Reserve

Abstract The coronary microcirculation plays a pivotal role in the regulation of coronary blood flow and cardiac metabolism. It can adapt to acute and chronic pathologic conditions such as coronary thrombosis or long-standing hypertension. Due to the fact that the coronary microcirculation cannot be visualized in human beings in vivo, its assessment remains challenging. Thus, the clinical importance of the coronary microcirculation is still often underestimated or even neglected. Depending on the clinical condition of the respective patient, several non-invasive (e.g. transthoracic Doppler-echocardiography assessing coronary flow velocity reserve, cardiac magnetic resonance imaging, positron emission tomography) and invasive methods (e.g. assessment of coronary flow reserve (CFR) and microvascular resistance (MVR) using adenosine, microvascular coronary spasm with acetylcholine) have been established for the assessment of coronary microvascular function. Individual patient characteristics, but certainly also local availability, methodical expertise and costs will influence which methods are being used for the diagnostic work-up (non-invasive and/or invasive assessment) in a patient with recurrent symptoms and suspected coronary microvascular dysfunction. Recently, the combined invasive assessment of coronary vasoconstrictor as well as vasodilator abnormalities has been titled interventional diagnostic procedure (IDP). It involves intracoronary acetylcholine testing for the detection of coronary spasm as well as CFR and MVR assessment in response to adenosine using a dedicated wire. Currently, the IDP represents the most comprehensive coronary vasomotor assessment. Studies using the IDP to better characterize the endotypes observed will hopefully facilitate development of tailored and effective treatments.

PET-CT and detection of coronary artery disease

2021 ◽  
pp. 421-434
Author(s):  
Marcelo F. Di Carli
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Microvascular Dysfunction ◽  
Quantitative Information ◽  
Left Ventricular ◽  
Coronary Microvascular Dysfunction ◽  
Non Invasive ◽  
Atherosclerotic Burden ◽  
Pet Ct ◽  
Artery Disease

Myocardial perfusion PET/CT imaging has emerged as a powerful and comprehensive non-invasive approach for the management of patients with suspected or known coronary artery disease (CAD). The multiparametric PET/CT approach provides quantitative information about the extent and severity of focal and diffuse CAD, coronary microvascular dysfunction (CMD), atherosclerotic burden, and left ventricular function. Contemporary evidence demonstrates that this comprehensive approach is one of the most accurate non-invasive tools for diagnosis, risk prediction, and guiding management in patients with CAD. This chapter summarizes the versatility of the integrated PET/CT scan to provide detailed quantitative information tailored to the patient and clinical question. I then review patient-centred clinical applications using case vignettes to illustrate indications of PET/CT and how to present the findings into clinically actionable information for the practising cardiologist. In each case, I review the available data highlighting the diagnostic and prognostic value of the integrated PET/CT protocol.

scholarly journals Coronary Microvascular Dysfunction: An Update

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

Coronary Microcirculation in Heart Failure with Preserved Systolic Function

2018 ◽  
Vol 24 (25) ◽  
pp. 2960-2966
Author(s):  
Zorana Vasiljevic ◽  
Gordana Krljanac ◽  
Marija Zdravkovic ◽  
Ratko Lasica ◽  
Danijela Trifunovic ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Diastolic Dysfunction ◽  
Microvascular Dysfunction ◽  
Left Ventricular ◽  
Coronary Microcirculation ◽  
Left Ventricular Ejection ◽  
Coronary Microvascular Dysfunction ◽  
Fractional Flow ◽  
Flow Reserve

Background: The Heart Failure with Preserved Ejection Fraction (HFpEF) is defined as the preserved left ventricular ejection fraction (LVEF) with the signs of heart failure, elevated natriuretic peptides, and either the evidence of the structural heart disease or diastolic dysfunction. The importance of this form of heart failure was increased after studies where the mortality rates and readmission to the hospital were founded similar as in patients with HF and reduced EF (HFrEF). Coronary microvascular ischemia, cardiomyocyte injury and stiffness could be important factors in the pathophysiology of HFpEF. Methods: The goal of this work is to analyse the relationship of HFpEF and coronary microcirculation in previous studies. Results: The useful diagnostic marker of coronary microcirculation in HFpEF may be the parameters measured by transthoracic echocardiography (TTE), the coronary flow reserve (CFR), as well as fractional flow reserve (FFR) and quantitative myocardial contrast echocardiography (MCE). Cardiac magnetic resonance (CMR) imaging represents the diagnostic gold standard in HFpEF. Coronary microvascular dysfunction in the absence of obstructive coronary artery disease (CAD) is poorly understood and may be more prevalent amongst women than men. Troponin level may be important in risk stratification of HEpEF patients. Conclusion: There are no precise answers with respect to the pathophysiological mechanism, nor are there any precise practical clinical assessment of and diagnostic method for coronary microvascular dysfunction and diastolic dysfunction. In accordance with that, there is no well-established treatment for HFpEF.

scholarly journals Non-invasive assessment of microvascular dysfunction in patients with microvascular angina

2017 ◽  
Vol 248 ◽  
pp. 433-439 ◽  
Author(s):  
Caroline Jaarsma ◽  
Hans Vink ◽  
Judith van Haare ◽  
Sebastiaan C.A.M. Bekkers ◽  
Bart D. van Rooijen ◽  
...  
Keyword(s):  
Microvascular Dysfunction ◽  
Microvascular Angina ◽  
Non Invasive

scholarly journals Clinico-pathophysiological considerations in coronary microvascular disorders

Vessel Plus ◽  
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.

scholarly journals Urinary Orosomucoid (α-1-Acid Glycoprotein) As A Single Potential Biomarker Through PET Assay for Diagnosis of Early Onset Sepsis in Neonates: A Review

2022 ◽  
Vol 3 (1) ◽  
Author(s):  
Alfiani Zukhruful Fitri Rifa’i ◽  
Hanifah Nabilah ◽  
Idznika Nurannisa Wibowo ◽  
Reny I’tishom
Keyword(s):  
Clinical Practice ◽  
Neonatal Sepsis ◽  
Diagnostic Tools ◽  
Routine Laboratory ◽  
Acid Glycoprotein ◽  
Non Invasive ◽  
Early Onset Sepsis ◽  
Potential Biomarker ◽  
Common Causes ◽  
Sterile Body Fluids

Neonatal sepsis is a condition in which bacteria are present in an infant’s sterile body fluids. It is considered one of the most common causes of infant death, with nearly one million deaths per birthday and approximately 2 million deaths in the first week of life. To aid in the early diagnosis of neonatal sepsis, a potential new biomarker for early neonatal sepsis called orosomucoid (ORM) or α1-glycoprotein (α1AGP) in urine is being evaluated because of its greater accuracy than current diagnostic tools. Combined with particle turbidity analysis (PET), neonatal sepsis can be diagnosed in an immediate, sensitive, specific and non-invasive manner. The early local increase in urinary ORM in sepsis suggests that it could be a new promising marker of sepsis and an important part of routine laboratory and clinical practice.

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