Anomalous Origin of Coronary Arteries

Coronary arteries supply the heart muscle with blood maintaining myocardial hemostasis and function. Coronary artery anomalies may persist after birth affecting cardiovascular system through haemodynamic impairment caused from shunting, ischaemia, especially in young children or adolescents and young adults. In patients undergoing coronary angiography the incidence of anomalous origination of the left coronary artery from right sinus is 0.15% and the right coronary artery from the left sinus is 0.92%. A recent classification of the coronary anomalies is based on anatomical considerations, recognizing three categories: anomalies of the origin and course, anomalies of the intrinsic coronary artery anatomy, and anomalies of the termination. In the setting of anomalous coronary artery from the opposite sinus, the proximal anomalous CA may run anterior to the pulmonary trunk (prepulmonic), posterior to the aorta (retroaortic), septal (subpulmonic), or between the pulmonary artery and the aorta itself (interarterial). Among them, only those with an interarterial aorta-pulmonary course are regarded as hidden conditions at risk of ischaemia and even sudden death. We presented two cases with anomalous origin of coronary arteries from opposite sinus, and two other cases with anomalous origin of left circumflex artery. The atherosclerotic coronary artery disease leads to the need of coronarography which can find out the presence of coronary artery anomalies. Anomalous origin of coronary artery that is present with atherosclerotic changes continues to exist as a challenge during treatment in interventional cardiology.

Nailfold Capillaroscopy in Rheumatic Diseases

Nailfold capillaroscopy (NFC) has developed into an indispensable tool for rheumatologists in the evaluation of rheumatic diseases. It offers various advantages in being rapid, noninvasive, and inexpensive. With NFC we are able to visualize the microcirculatory changes in the nail beds. These changes are key to the pathogenesis of connective tissue diseases such as systemic sclerosis. Hence NFC helps in early diagnosis of various connective tissue diseases. There is a lack of standardization in the techniques used and various capillary parameters studied, which could lead to variation in the reporting of the parameters studied. In this chapter we shall try to highlight the most common parameters studied in capillaroscopy and its utility in various connective tissue diseases.

Vasculitis and Vasculopathies

Our organism, as complex as it is, needs a giant vascular network to deliver nutrients to all cells, so vasculopathies and vasculitis are diseases present in all medical specialties. The skin and subcutaneous cellular tissue are irrigated by a vast vascular network, with cutaneous involvement related to these frequent pathologies. These can be restricted to the integumentary system or be part of systemic diseases with cutaneous manifestations, which make them of great interest to dermatologists. They can affect any caliber of vessels and present with several dermatological manifestations such as erythema, livedo reticularis, palpable purpura, nodules, ulcers, urticaria, hemorrhagic blisters, gangrene and other manifestations that can be isolated or associated with systemic signs and symptoms. However, there is no worldwide consensus regarding the classification of vasculitis, and the classification proposed in this chapter is based on the International Chapel Hill Conference Nomenclature of Vasculitides 2012, which is based on the size of the vessels. The purpose of this chapter is to compile a review of the most current treatments for these conditions.

Treatment of Vasculitis: Beyond the Basics

Vasculitis is the inflammation of blood vessels in the human body. It causes changes and remodeling in the walls of the vessels that include thickening, narrowing and scarring. As a result, the blood flow to the organs and tissues gets restricted leading to organ damage. The cause of primary vasculitis is not known; however, most cases are thought to be autoimmune. In the present era, it is getting difficult to treat vasculitis with conventional therapies, which includes cyclophosphamide, methotrexate, azathioprine and mycophenolate mofetil, with increasing rates of relapses. Since ever, corticosteroids and cytotoxic agents or immunosuppressants have been the mainstay for treating systemic vasculitis. However, the introduction of newer biological agents have bring about a revolution in the treatment of relapses and in cases where there is failure to induce and sustain remission.

L-Arginine/Nitric Oxide Pathway and KCa Channels in Endothelial Cells: A Mini-Review

The endothelium is an organ with a key role in the maintenance of cardiovascular health through the regulation of vascular tone, vascular resistance, blood flow, and arterial pressure. These functions are related with the synthesis and release of vasoactive molecules, mainly vasodilators like nitric oxide (NO) and endothelium-derived hyperpolarizing factor (EDHF). Both factors are released and diffused from endothelial cells to the smooth muscle cells, where there is a subsequent activation of signaling pathways that finally decrease the intracellular calcium to induce the vascular relaxation. The study of the molecular mechanisms that underlie the endothelial function still is in development, but from the evidence obtained from the endothelial cells in vitro studies are possible to partially describe the pathways to regulate the physiological endothelial function and the disturbances in pathological conditions. In this mini-review, we describe the main mechanisms for NO synthesis and the role of potassium channels related with EDHF. We include schemes and graphical summaries for better understanding of the molecular regulation of vascular tone in the human cardiovascular system.

Basic Principles in Microvascular Anastomosis and Free Tissue Transfer

Free tissue transfer pursues the best functional and aesthetic results in reconstructive surgery. As these techniques completely maximise the donor tissues’ disposability, these treatments have become a first-line option in many situations. When the donor site is taken form the same patient, these surgeries are often referred to as autotransplants. Free tissue transfer sustains in microvascular anastomosis, which are defined by a vessel lumen diameter inferior to 3 mm. Particular attention to some details is important in these techniques, as, for example, to preclude any damage to the vessel walls or any leakage in the microvascular anastomosis. But the success of these techniques does not only depend on an adequate vascular suture, but also on a constellation of details that must be taken into account. These go from the availability of a trained team, to the ergonomics of the surgeon, through the scrupulous cleanliness of the surgical field.

Nitric Oxide and Oxidative Stress-Mediated Cardiovascular Functionality: From Molecular Mechanism to Cardiovascular Disease

The underlying pathology of most cardiovascular diseases (CVDs) such as coronary artery disease, high blood pressure, and stroke involves decreased cardiovascular contractility and anatomic alterations in cardiovascular structures. Nitric oxide (NO) regulates vascular tone and contractile function of myocardium and maintains blood vessel homeostasis. Interestingly, the effect of NO is like a double-edged sword in the body. Insufficient NO causes hypertension and atherosclerosis, while an overproduction of NO may foster inflammation and cause heart infarction and shock. In addition, growing evidences have shown that oxidative stress plays pivotal roles in the initiation and progression of CVDs. This chapter will discuss in detail the roles NO plays in the cardiovascular system under both physiological and pathological conditions. We will focus on: (1) the molecular mechanism of cardiovascular contraction, (2) NO/Ca2+-induced muscle relaxation, (3) NO-related structural change in blood vessels, and (4) redox balance in the cardiovascular system. The relationships between these molecular mechanisms and the characteristics of CVDs will be highlighted.

The Impact of Nailfold Capillaroscopy in the Approach of Microcirculation

Nailfold capillaroscopy (NFC) is a simple, validated, and noninvasive method to assess the microcirculation, through direct visualization of the capillaries. Main patterns are classified, according to Cutolo et al., as scleroderma, further divided into early, active, or late patterns, or nonscleroderma. NFC findings include dilated loops, tortuosities, meandering or bushy capillaries, hemorrhage, or architectural distortion. NFC use has been indicated for the evaluation of Raynaud’s phenomenon (RP), once it permits the distinction between primary and secondary RP. NFC results accounts for diagnostic criteria of systemic sclerosis, but they can also be useful in staging other connective tissue autoimmune diseases, like systemic lupus erythematosus, inflammatory myositis, or vasculitis. The CSURI index uses NFC for prediction of digital ulcer relapse. Recent evidence revealed NFC can also be applied in systemic disorders with vascular involvement.

Giant Cell Arteritis: Current Advances in Pathogenesis and Treatment

Giant cell arteritis (GCA) is the most common vasculitis in adults, with the incidence increasing with the advancing age. The aorta and its branches, especially the carotid extracranial branches, are the classic targets of inflammation in GCA. Visual loss, upper limb ischemia, and stroke are complications described. Suspicion of GCA is a medical emergency, and patients need to be quickly diagnosed/treated to prevent irreversible damage. Headache is the most common symptom, and a new-onset headache in older adults should always raise the suspicion of GCA. Patients may also present with scalp tenderness or tongue/jaw pain. GCA is often found to be the cause of an obscure-origin fever in older patients. A positive temporal artery biopsy is considered the gold standard for the diagnosis, but imaging techniques enable the assessment of cranial and extracranial arteries and the aorta. Ultrasound of temporal arteries is recommended and noncompressible “halo” sign is the typical finding. PET, MRI, or CT may be useful for the detection of the disease in the aorta and other vessels. The treatment must be started promptly with prednisone 1 mg/kg/day. When visual symptoms/unilateral visual loss is present, methylprednisolone pulse is recommended. Methotrexate, leflunomide and tocilizumab may be effective and well-tolerated glucocorticoid-sparing agents in GCA. Cardiovascular diseases are the leading causes of death in patients.

The Role of Physical Activity on Insulin Resistance-Associated Endothelial Dysfunction

Enhanced physical activity and cardiorespiratory fitness significantly impact morbidity and mortality across the spectrum of noncommunicative chronic illnesses experienced by modern lifestyles. Physical activity itself prompts an intricate interplay of physiological responses across vital organ systems including microvascular adaptations to optimize nutrient, oxygen, and hormone delivery, some of which involves insulin-mediated regulation. Insulin has been known to act on the vasculature in multiple ways by its effects on endothelium and skeletal muscle blood flow. This is important to understand as it has implications for conditions associated with insulin resistance (IR) such as obesity, metabolic syndrome, prediabetes, diabetes, and polycystic ovarian syndrome among others. These conditions are associated with increased morbidity and mortality contributed by endothelial dysfunction via increased atherosclerosis, hypertension, and increased free fatty acid levels. In this chapter, we will discuss the effects of insulin on the vasculature, IR on the endothelium, and lastly, what impact physical activity may have on such processes.