Spontaneous Coronary Artery Dissections: A Systematic Review

Myocardial infarction with nonobstructive coronary artery disease due to spontaneous coronary artery dissection (SCAD) accounts for 5–8% of acute coronary syndrome (ACS) presentations. The demographic characteristics, risk factors, and management of patients with SCAD differ from those with atherosclerotic disease. The objective of this review is to provide a contemporary understanding of the epidemiology, pathophysiology, clinical presentation, and management of SCAD.

Biological markers of endothelial dysfunction and fibrosis, macro- and microcirculation alterations in patients with obstructive and nonobstructive coronary artery disease and diabetes mellitus

Aim of the study To analyze the association of biological markers levels of endothelial dysfunction and fibrosis with macro- and microcirculation alterations in patients with obstructive and nonobstructive coronary artery disease (CAD) and type 2 diabetes mellitus (DM). Methods 52 patients with CAD were enrolled and divided into 4 groups: 19 patients with nonobstructive CAD (1–49% stenosis) without DM (1 group: 4 men, age 64.89±7.61, body mass index (BMI) 28.14±3.69 kg/m2); 13 patients with obstructive CAD (≥50% stenosis) without DM (2 group: 9 men, age 66.92±7.02, BMI 30.4±5.91 kg/m2); 10 patients with obstructive CAD (3 group: 4 men, age 63.4±10.37, BMI 31.7±4.81kg/m2) and 10 patients with nonobstructive CAD with DM (4 group: 3 men, age 64.6±5.32, BMI 33.74±3.25 kg/m2). Patients were matched for age, sex and BMI. All patients underwent coronary angiography or coronary computed tomography angiography. Biological markers levels (E-selectin, ng/ml; tissue inhibitor of metalloproteinase 1 (TIMP-1), ng/ml) were measured using ELISA. To determine arterial damage in both macro- and microcirculation, digital reactive hyperemia photoplethysmography were performed. Endothelial function of small (Occlusion Index, OI) and large vessels (Phase Shear, PS, ms) were analyzed. Vascular remodeling of aorta (Stiffness Index, aSI, m/s) and arterioles (Reflection Index, RI, %) were studied. Results The elevation of E-selectin (1 – 21.6 [18.7; 30.4]; 2 – 31.5 [20.1; 36.9]; 3 – 42.25 [29.9; 55.3]; 4 – 42.1 [33.1; 46.5]) and TIMP-1 (1 – 416 [376; 481]; 2 – 478 [381; 539]; 3 – 534 [490; 579]; 4 – 590 [520; 782]) levels were found in all groups. Statistical analysis revealed significant differences between TIMP-1 (p1–3=0.004; p1–4=0.003) and E-Selectin (p1–3=0.013; p1–4=0.01) levels. Remodeling of large vessels was detected only in patients with obstructive CAD without DM and nonobstructive CAD with DM (2 – aSI, 9.05 [7.08; 10.58]; 3 – aSI, 8.2 [7.6; 11]). Patients in all groups had endothelial dysfunction of large vessels (PS, 1 – 5.1 [1.75; 7.75]; 2 – 6.45 [5.53; 9.03]; 3 – 7.65 [13.4; 9.5]; 4 – 4.6 [0.7; 8.1] and arterioles (IO; 1 – 1.5 [1.38; 1.78]; 2 – 1.4 [1.26; 1.53]; 3 – 1.4 [1.2; 1.7]; 4 – 1.3 [1.2; 2.0]). Structural disorders of arterioles were found in all groups, except for patients with obstructive CAD without DM (RI, 1 – 36.95 [23.4; 52.65]; 2 – 28.25 [23.35; 53.75]; 3 – 41.15 [26.5; 55]; 4 – 44.7 [20; 54.5]. The data did not show significant differences between the study groups. Conclusions The data showed that biological markers levels of endothelial dysfunction and fibrosis were increased in all groups. Significant differences revealed between the levels of E-selectin and TIMP-1 in patients with nonobstructive CAD without DM and patients with CAD and DM, regardless of the degree of stenosis. All patients had functional changes of large vessels and arterioles regardless of the severity of coronary artery atherosclerosis and presence of DM. FUNDunding Acknowledgement Type of funding sources: None.

Anxiety Disorders Are Associated With Coronary Endothelial Dysfunction in Women With Chest Pain and Nonobstructive Coronary Artery Disease

Background Anxiety disorders are the most prevalent mental disorders and are an emerging risk factor for coronary artery disease and its complications. We determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED) using invasive coronary reactivity testing across both sexes. Methods and Results Patients presenting with chest pain and nonobstructive coronary artery disease (stenosis <40%) at coronary angiography underwent an invasive assessment of CED. Patients were categorized as having a clinical diagnosis of an anxiety disorder at the time of coronary angiography by chart review. The frequency of CED was compared between patients with versus without an anxiety disorder and after stratifying patients by sex. Between 1992 and 2020, 1974 patients (mean age, 51.3 years; 66.2% women) underwent invasive coronary reactivity testing, of which 550 (27.9%) had a documented anxiety disorder at the time of angiography. There was a significantly higher proportion of patients with any type of CED in those with an anxiety disorder in all patients (343 [62.7%] versus 790 [56.4%]; P =0.011) that persisted in women but not in men. After adjusting for covariables, anxiety was significantly associated with any CED among all patients (odds ratio [95% CI], 1.36 [1.10–1.68]; P =0.004), and after stratifying by sex in women but not in men. Conclusions Anxiety disorders are significantly associated with CED in women presenting with chest pain and nonobstructive coronary artery disease. Thus, CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events.

Atrial fibrillation is a predictor of nonobstructive coronary artery disease in elective angiography in old age: a cross-sectional study in Poland and Russia

Background Significant changes in the coronary vessels are not confirmed in a large proportion of patients undergoing cardiac catheterization. Aims The present study aimed to determine correlates and independent predictors of nonobstructive coronary artery disease (CAD) in older adults referred for elective coronary angiography. Methods A cross-sectional study was conducted involving 2,214 patients referred to two medical centers (in Poland and Russia) between 2014 and 2016 for elective coronary angiography due to exacerbated angina, despite undergoing optimal therapy for CAD. The median age was 72 years (IQR: 68–76), and 49.5% patients were women. Results Significant stenosis (defined as stenosis of 50% or more of the diameter of the left main coronary artery stem or stenosis of 70% or more of the diameter of the remaining major epicardial vessels) was diagnosed only in 1135 (51.3%) patients. Female sex (odds ratio [OR], 3.01; 95% confidence interval [CI], 2.44–3.72; p < 0.001) and atrial fibrillation (OR, 1.87; 95% CI 1.45–2.40; p < 0.001) were the main independent predictors of nonobstructive CAD. Significantly lower ORs were observed for diabetes (OR, 0.75; 95% CI 0.59–0.95; p = 0.02), chronic kidney disease (OR, 0.76; 95% CI 0.61–0.96; p = 0.02), and anemia (OR, 0.69; 95% CI 0.50–0.95; p = 0.02) after controlling for age, chronic heart failure, BMI, and study center. Discussion and conclusions The results confirmed that nonobstructive CAD occurs in a high percentage of older patients referred for elective coronary angiography. This suggests the need to improve patient stratification for invasive diagnosis of CAD, especially for older women and patients with atrial fibrillation. Trial registration number and date of registration: NCT04537507, September 3, 2020.

Prognostic Value of Atherosclerotic Extent in Diabetic Patients with Nonobstructive Coronary Artery Disease

Background and Objective. Atherosclerotic extent was proved to be associated with adverse cardiac events. Risk scores derived by coronary computed tomography angiography (CCTA) could identify high-risk group among patients with nonobstructive coronary artery disease (CAD), but the ability is still uncertain in the presence of diabetes mellitus (DM). The purpose of this study was to investigate the prognostic value of the atherosclerotic extent shown by CCTA in diabetic patients with nonobstructive CAD. Methods and Results. 813 DM patients (mean age 58.9 ± 9.9 years, 48.1% male) referred for CCTA due to suspected CAD in 2015-2017 were consecutively included. During a median follow-up of 31.77 months, 50 major adverse cardiovascular events (MACEs) (6.15%) were experienced, including 2 cardiovascular deaths, 14 nonfatal myocardial infarctions, 27 unstable anginas requiring hospitalization, and 7 strokes. Three groups were defined based on coronary stenosis combined with Leiden score as normal, nonobstructive Leiden < 5 , and nonobstructive Leiden ≥ 5 . Cox models were used to assess the prognosis of plaque burden within these groups. An incremental incidence of MACE rates was observed. After adjustment for age, gender, and presence of high-risk plaque, the group of Leiden ≥ 5 showed a higher risk than Leiden < 5 (HR: 1.88, 95% CI: 1.03-3.42, p = 0.039 ). Similar results were observed when segment involvement score (SIS) was used for sensitivity analysis. Conclusion. Atherosclerotic extent was associated with the prognosis of DM patients with nonobstructive coronary artery disease, highlighting the importance of better risk stratification and management.