Coronary Artery Spasm Research Articles

Preventing 5-fluorouracil-induced ischemic events in very high-risk cardiac patients: A retrospective cohort analysis (SQCCCRC protocol).

e24112 Background: 5-Fluorouracil (5-FU), a potent chemotherapy agent for various cancers, is linked to cardiotoxicity, particularly in patients with pre-existing ischemic heart disease. The incidence varies, necessitating effective preventive strategies. Among the several mechanisms responsible for 5-FU-induced myocardial ischemia are coronary vasospasm and endothelial injury. Therefore, prevention of ischemic events in very high-risk patients by controlling modifiable cardiac risk factors and good medical treatment including vasodilators are a potential strategy in preventing 5-FU ischemic events. Methods: To assess the effectiveness and safety of a protocol involving Amlodipine and Isosorbide dinitrate in preventing 5-FU-induced ischemic events in very high-risk cardiac patients with documented ischemic heart disease. Nineteen patients underwent 252 cycles of 5-FU chemotherapy, with 12 patients (181 cycles) following the pre-defined protocol (5-FU Protocol Group) and 7 patients (71 cycles) not adhering (Missed 5-FU Protocol Group). The primary outcome measure was the prevention of 5-FU-induced ischemic events, evidenced by the absence of chest pain, elevated Troponin levels, or ECG changes during 5-FU infusion. Results: The 5-FU Protocol Group demonstrated significant reductions in ischemic events, chest pain with p-values of 0.009 for both outcomes. Additionally, the occurrence of ECG changes post-5FU and an increase in Troponin levels was significantly lower in the 5-FU Protocol Group, with p-values of 0.036 for both parameters. Although not statistically significant, there was a lower 5FU-related mortality rate in the 5-FU Protocol Group compared to the missed 5-FU Protocol Group (0% vs. 14.3%, p = 0.37). The incidence of cancer-related mortality did not exhibit a statistically significant difference between the two groups. To evaluate this, we specifically examined and compared the occurrence of ischemic events in both the 5-FU Protocol Group and the Missed 5-FU Protocol Group. The comparison was conducted using the Fisher exact test. Conclusions: The use of vasodilators may be effective in preventing 5-Fluorouracil-Induced ischemic events in very high-risk cardiac patients with documented coronary artery disease. This approach may help reduce the risk of cardiac events and improve the safety of chemotherapy in this vulnerable patient population. Monitoring cardiotoxicity with maximum tolerated medical treatment and dedicated hospital protocols may be a good prophylaxis approach. Further studies are needed to confirm the safety and efficacy of this approach in a larger patient population, and to assess its impact on long-term cardiac outcomes.

Effects of Smoking on Major Adverse Cardiovascular Events in Patients With Coronary Artery Spasm: A Systematic Review and Meta-Analysis

Smoking is an established independent risk factor for coronary artery spasm (CAS), but its effects on major adverse cardiovascular events (MACE) in patients with CAS have not been systematically assessed. This systematic review and meta-analysis of studies published from January 2000 to July 2023 was conducted to examine the relationship between smoking and MACE in patients with CAS. Data on MACE were obtained from both smoking and non-smoking CAS patient groups. The effects of smoking on MACE in patients with CAS were assessed through meta-analysis, utilising Stata 17.0 software for all statistical analyses. Nine studies, encompassing 9,376 patients, from Japan (5 studies), Korea (4 studies) and Spain (1 study) were included in the final analysis. Meta-analysis revealed that smoking significantly impacted MACE in patients with CAS (RR 1.965; 95% CI 1.348-2.865), a finding further validated by sensitivity analyses. Subgroup analyses identified a stronger correlation between smoking and increased MACE endpoints in Japanese patients and in those with >3 years of follow-up. This meta-analysis strongly indicates that smoking escalates the risk of MACE in patients with CAS, with a more pronounced association observed in Japanese patients and those with extended follow-up periods.

A Case Report of Korean Medicine Treatment for Chest Pain in Variant Angina

Variant angina causes chest pain due to abnormal coronary vasospasms. A 60-year-old male who was diagnosed with variant angina was admitted to the Oriental Medicine Hospital and treated with herbal medicines, including Pyungjinsujeom-san and Simjeok-hwan. After treatment, the frequency of chest pain and use of nitroglycerin decreased. Subjective symptoms of chest pain measured using a numerical rating scale (NRS) also decreased. These improvements persisted throughout the hospitalization period. In conclusion, Korean medicines, including Pyungjinsujeom-san and Simjeok-hwan, can be effective for patients with chest pain due to variant angina.

A case of early repolarization syndrome in which hyponatremia and coronary vasospasms induced ventricular fibrillation

A 60-year-old man was referred to our hospital presenting with unconsciousness due to severe hyponatremia. The twelve‑lead ECG on admission exhibited prominent J waves in the inferolateral leads. During the treatment for hyponatremia, ventricular fibrillation (VF) occurred and the electrogram (ECG) after the VF incident exhibited marked ST elevation in the inferolateral leads. An Ach provocation test induced vasospasms in the right and left coronary arteries and J wave augmentation, suggesting a high risk for vasospastic angina. Finally, a subcutaneous implantable cardioverter defibrillator was implanted in the patient. We hereby discuss the possible contribution of hyponatremia to VF episodes in early repolarization syndrome based on the present case.

Advanced pulsed field ablation: comprehensive analysis of safety and efficacy in a real-world cohort

Abstract Background Pulsed field ablation (PFA) represents a novel energy modality for catheter ablation of atrial fibrillation (AF). Initial preclinical and clinical studies indicate a higher safety profile with promising efficacy outcomes as well as shorter procedure times. Real world data are sparce and methods to improve clinical success rates are under development. Methods In this observational study 124 patients underwent pulmonary vein isolation with PFA (Farapulse, Boston) for paroxysmal and persistent AF. For anatomical visualization and optimal positioning of the PFA catheter a 3D mapping system was used (Ensite X, Abbott). Patients were followed over a 15-month period to evaluate both efficacy and safety of PFA in a real-world cohort using an advanced mapping technology. Results The patient cohort had a mean age of 67 ± 11 years, 38% females (n= 47), paroxysmal AF 53% (n = 66), persistent AF 47% (n = 58). Acute pulmonary vein isolation (PVI) rate was 100%. After a median FU of 6 months, 17 patients (14%) had a recurrence of AF. In our study population no esophageal complications, pulmonary vein stenosis, or persistent phrenic palsy occurred. Major complications were observed in 2.4% of the cases (3/124), involving two pericardial tamponades (1.6%) and one vascular complication with intervention (0.8%). There were no stroke events and no occurrences of death. Noteworthy was the absence of complications such as coronary arterial spasm or hemolysis-related acute renal failure. The average dose-area product and average procedure time were 9.54 ± 7.68 µGym² and 57.94 ± 18 minutes, respectively. Conclusion PVI with PFA in a real world cohort demonstrates a high safety profile. Furthermore, high clinical success rates can be achieved also in mixed paroxysmal/persistent AF populations. The use of 3D mapping systems might even improve clinical outcomes of PVI with PFA and will also help to guide more complex ablation strategies in the future. These findings pave the way for further exploration into the long-term benefits and broader applicability of PFA in AF ablation.

Preliminary real-world experience on mitral isthmus ablation with a novel catheter that toggles between radiofrequency and pulsed field ablation

Abstract Background The mitral isthmus (MI) is frequently targeted during the ablation of persistent atrial fibrillation (AF). Nevertheless, achieving a complete bidirectional MI block using radiofrequency (RF) is often technically challenging and time-consuming1,2. Previously, we described a fluoroscopy-guided technique to achieve MI block using a penta-spline pulsed field ablation (PFA) catheter3. Recently, a new catheter was introduced, which toggles between RF and PFA and is integrated into a 3D mapping system, thus supposedly facilitating its use for the ablation of extra-pulmonary vein structures4. Purpose To describe the acute efficacy and procedural features of the first cases of posterior MI ablation performed with the toggling catheter at two centers. Methods We collected and reviewed demographic, clinical and procedural features of all patients who underwent ablation of the posterior MI at our centers between September and October 2023. Ablation of the MI was performed with either RF or PFA according to operator’s discretion. Bidirectional MI block was validated through activation mapping and differential pacing. Results During the study period, 44 patients were treated with the toggling catheter. Out of them, 16 patients (aged 68.3±10.1 years; 29% females) underwent posterior MI ablation for persistent AF, in addition to PVI and posterior wall isolation. Mean history of AF was 29.8±34.5 months and mean LA volume 135.6±54.9 ml. Skin-to-skin procedural time (93 minutes, IQR 64-112), LA mapping time (9.0 min, IQR 7.3-12.1) and time required for MI ablation (4.0 min, IQR 3.3-6.5) were remarkably short. In PFA-treated patients (10 cases), first-pass MI block was achieved in 8 (80%), with 16 (IQR 12-22) applications; none of these patients required RF touch-up. In the remaining 6 RF-treated patients, first-pass MI block was achieved in 3 (50%) patients with 8 (IQR 6-13) applications. Additional PFA applications (median 3, IQR 2-5) on the most venous portion of the MI were required in all RF-treated patients. In the 5 patients in whom bidirectional block could not be achieved at first-pass, remapping and touch-up application time were 2.6 (IQR 2.6- 6.3) and 2.0 (IQR 0.8-5.2) minutes, respectively. Eventually, bidirectional MI block was achieved in 16/16 (100%) patients by the end of the procedure. Importantly, no patients in the entire cohort experienced complications such as coronary artery spasm or clinically significant pericardial effusion. Conclusions Several observations can be made on this first real-world experience on posterior MI ablation with the toggling catheter: first, acute safety and efficacy in achieving a bidirectional MI block are high with both PFA and RF; secondly, patients undergoing RF ablation often require additional PFA applications on the venous segment of the MI; lastly, the time required to achieve MI block is remarkably short even when remapping and touch-up applications are needed.Figure 1Figure 2

Type 1 Kounis syndrome: recurrent myocardial infarctions in a patient with aspirin-exacerbated respiratory disease: a case report

Introduction. We present a case of type 1 Kounis syndrome in a patient with recurrent myocardial infarction with non-obstructive coronary arteries (MINOCA) due to allergic coronary vasospasm. Awareness of doctors about this pathology will allow identifying the MINOCA causes and prescribing pathogenetic treatment.Brief description. A 51-year-old woman with aspirin-exacerbated respiratory disease (asthma, rhinosinusitis with nasal polyposis, aspirin hypersensitivity, eosinophilia) without cardiovascular risk factors developed three recurrent myocardial infarctions against the background of vasospastic angina over a 6-month period. Despite the typical clinical performance, stable ST segment elevation, unchanged coronary arteries on coronary angiography, the vasospastic MI was not immediately established. The patient received long-term treatment for type 1 MI, including beta-blockers. Recurrent MI occurred against the background of an asthma attack. During the second and third hospitalization for MI, coronary angiography revealed a spasm of the right coronary artery, which completely resolved with the nitroglycerin administration. Intracoronary ultrasound made it possible to rule out atherosclerotic involvement of the infarct-related artery. Subsequently, microvascular angina developed, which was confirmed by positron emission tomography. Vasospastic angina in combination with microvascular angina, MIBOCA with asthma attacks, were regarded as type 1 Kounis syndrome. Over the next 2 years, the patient received pathogenetic treatment, and no recurrent cardiovascular events were observed.Discussion. Lack of awareness about Kounis syndrome led to incomplete examination of the patient with MIBOCA and the prescription of pathogenetically unreasonable tehrapy, which could contribute to recurrent MI within 6 months.

VASOSPASTIC INFARCTION STARTED WITH PULSELESS ELECTRICAL ACTIVITY CARDIAC ARREST

Abstract We report the case of a 48–year–old female with a special history of ischemic heart disease. It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged. She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022. During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose. In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates. No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed. Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero–septal and inferior wall in toto, suggesting recent ischemia; EF was 31%. During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose. The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting. In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.

Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers.

Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.

Comparison of myocardial infarction with non-obstructive coronary arteries (MINOCA) versus type 2 MI with NSTEMI presentation; an Italian observation study

Abstract Funding Acknowledgements None. Background In the last decades, NSTEMI, is the predominant phenotype of myocardial infarction (MI) and many NSTEMI patients(pts) have a non-obstructive CAD. NSTEMI, represents an umbrella for many different conditions with distinct underlying pathogenesis and exhibits significant gender discrepancies and survival differences. Further, in absence of non-obstructive CAD, pts could be wrongly comforted about their prognosis. Purpose In this study, we compared the characteristics and the prognosis of pts with MINOCA and type 2 MI with non-obstructive CAD. The primary outcome was a composite of all-cause mortality, non-fatal MI, hospitalization for heart failure (HF) and transitory ischemic attack or non-fatal stroke. Methods Were screened 18223 pts with MI, who underwent coronary angiography between 2005 and 2022. Among them, 7815 pts had NSTEMI presentation, of which 693 pts (9%) had a non-obstructive CAD. After reviewing the angiographic data and clinical presentation, 155 pts were excluded because they belonged to one of the categories known as "MINOCA mimichers" (Fig 1). Five hundred and thirty eight pts with MI, NSTEMI presentation and with non-obstructive CAD were included in the final cohort: 301 (56%) had MINOCA and 237 pts (44%) had type 2 MI (Fig 1). Results The mean age of the population was 68 years, and females were predominant in both groups. MINOCA pts were younger, more frequently had adverse events during pregnancy and endocrine disorders. Pts with type 2 MI were more likely to have typical CV risk factors and comorbidities such as CKD and HF. Pts with type 2 MI had a worse diastolic function, a more dilated left atrium and left ventricle(LV), and non-coronary distribution of regional LV wall-motion abnormalities. At initial clinical presentation, the MINOCA group had typical chest pain upon awakening or at night, responsive to nitrates, while type 2 MI were more often to present with dyspnea, palpitations, and with higher blood pressure. Coronary vasospasm and embolization were the most common identified aetiologies in MINOCA pts while tachyarrhythmias were the most common trigger of type 2 MI, followed by hypertensive crisis. The final model of the predictors of MINOCA at multivariate logistic regression analysis listed in Fig 2, yielded an AUC of 0.865, p<0.01 at ROC analysis(Fig 2a). These variables were used for the generation of nomogram for MINOCA prediction(Fig 2b). During the median follow-up of 61 months (IQR 34.2-100.35), pts with MINOCA had a significantly better survival rate; 135 of 538 pts (25.1%) reached the primary combined endpoint(Fig 3a). The primary end-point was mainly driven by the all-cause mortality, followed by HF hospitalization, non-fatal stroke, non-fatal MI recurrence. Results of Cox multivariable analysis are presented in Fig 3b. Conclusions MINOCA cohort was associated with unconventional risk factors and had a better prognosis compared to T2 MI, which is closer to the classical AMI-CAD.

Perioperative multivessel coronary artery spasm and cardiac arrest after cardiac surgery.

Postoperative coronary artery spasm, a rare but potentially fatal complication following cardiac surgery, warrants significant attention. This report discusses a 64-year-old male who suffered a severe coronary artery spasm leading to cardiac arrest following surgery. Initially stable, the patient rapidly developed critical ventricular arrhythmias and hypotension, resulting in cardiac arrest 4 h post-surgery. Emergency coronary angiography revealed extensive spasms, successfully managed with intracoronary nitroglycerine. This case stresses prompt recognition and management of coronary artery spasm after non-coronary cardiac procedures, underscoring coronary angiography's vital role in diagnosis and treatment.

Dual energy for pulmonary vein isolation using dual-energy focal ablation technology integrated with a three-dimensional mapping system: SmartfIRE 3-month results.

Contact force (CF)-sensing radiofrequency (RF) catheters with an ablation index have shown reproducible outcomes for the treatment of atrial fibrillation (AF) in large multicentre studies. A dual-energy (DE) focal CF catheter to deliver RF and unipolar/biphasic pulsed field ablation (PFA), integrated with a three-dimensional (3D) mapping system, can provide operators with additional flexibility. The SmartfIRE study assessed the safety and efficacy of this novel technology for the treatment of drug-refractory, symptomatic paroxysmal AF. Results at 3 months post-ablation are presented here. Pulmonary vein isolation (PVI) was performed using a DE focal, irrigated CF-sensing catheter with the recommendation of PFA at posterior/inferior and RF ablation at the anterior/ridge/carina segments. Irrespective of energy, a tag size of 3 mm; an inter-tag distance ≤6 mm; a target index of 550 for anterior, roof, ridge, and carina; and a target index of 400 for posterior and inferior were recommended. Cavotricuspid isthmus ablation was permitted in patients with documented typical atrial flutter. The primary effectiveness endpoint was acute procedural success. The primary safety endpoint was the rate of primary adverse events (PAEs) within 7 days of the procedure. A prespecified patient subset underwent oesophageal endoscopy (EE; 72 h post-procedure), neurological assessment (NA; pre-procedure and discharge), and cardiac computed tomography (CT)/magnetic resonance angiogram (MRA) imaging (pre-procedure and 3 months post-procedure) for additional safety evaluation, and a mandatory remapping procedure (Day 75 ± 15) for PVI durability assessment. Of 149 patients enrolled between February and June 2023, 140 had the study catheter inserted (safety analysis set) and 137 had ablation energy delivered (per-protocol analysis set). The median (Q1/Q3) total procedure and fluoroscopy times were 108.0 (91.0/126.0) and 4.2 (2.3/7.7) min (n = 137). The acute procedural success rate was 100%. First-pass isolation was achieved in 89.1% of patients and 96.8% of veins. Cavotricuspid isthmus ablations were successfully performed in 12 patients [pulsed field (PF) only: 6, RF only: 5, and RF/PF: 1]. The PAE rate was 4.4% [6/137 patients; 2 pulmonary vein (PV) stenoses, 2 cardiac tamponades/perforations, 1 stroke, and 1 pericarditis]. No coronary artery spasm was reported. No oesophageal lesion was seen in the EE subset (0/31, 0%). In the NA subset (n = 30), microemboli lesions were identified in 2 patients (2/30, 6.7%), both of which were resolved at follow-up; only 1 was symptomatic (silent cerebral lesion, 3.3%). In the CT/MRA subset (n = 30), severe PV narrowing (of >70%) was detected in 2 patients (2/30, 6.7%; vein level 2/128, 1.6%), of whom 1 underwent dilatation and stenting and 1 was asymptomatic; both were associated with high index values and a small inter-tag distance. In the PV durability subset (n = 30), 100/115 treated PVs (87%) were durably isolated and 18/30 patients (60.0%) had all PVs durably isolated. A DE focal CF catheter with 3D mapping integration showed a 100% acute success rate with an acceptable safety profile in the treatment of paroxysmal AF. Prespecified 3-month remapping showed notable PVI durability. ClinicalTrials.gov Identifier: NCT05752487.

Assessment of Residual Vasospasm in Patients with Plaque Rupture or Plaque Erosion using Optical Coherence Tomography.

Coronary vasospasm is associated with acute coronary syndrome (ACS) and may persist during primary percutaneous coronary intervention (PCI). We aimed to elucidate the incidence, morphological characteristics, and prognostic impact of residual vasospasm in plaque rupture (PR) and plaque erosion (PE) lesions using optical coherence tomography (OCT). We enrolled 142 patients with ACS who underwent OCT-guided primary PCI. All patients received intracoronary vasodilators before OCT examination. Residual vasospasm was identified as intimal gathering and categorised as polygonal- or wavy- patterned depending on the luminal shape. A wavy pattern was defined as a curved intimal surface line. A polygonal pattern was defined as a lumen with multiple angles. The incidence of major cardiovascular events, defined as death, non-fatal myocardial infarction, stroke, and any revascularization, within 1-year of PCI was identified. The prevalence of residual vasospasm in PR and PE was 15.1% (13 of 86) and 21.4% (12 of 56), respectively. Wavy pattern was the major shape of the residual vasospasm. Polygonal-patterned lumen was more frequently observed in PR than in PE (38.5 vs. 8.3 %). The polygonal-patterned lumens had significantly larger lipid arcs (257.9 vs. 78.0 °; P＜0.01), and significantly smaller areas (1.27 vs. 1.88 mm2; P=0.05) than wavy-patterned lumens. Residual vasospasm had a prognostic impact on PR but not PE at 1-year of successful primary PCI. Considerable proportion of ACS including both PR and PE had residual vasospasm with variable morphological feature and different prognostic impact.

Coronary Artery Spasm—Risk Factors and Pathophysiological Mechanisms

Coronary Artery Spasm—Risk Factors and Pathophysiological Mechanisms

Kounis Syndrome: A Comprehensive Review of Pathophysiology, Clinical Manifestations, Diagnostic Challenges, and Therapeutic Strategies

Kounis syndrome, also known as allergic angina or allergic myocardial infarction, is a rare but potentially life-threatening condition characterized by the acute onset of chest pain, myocardial infarction, or sudden cardiac death in the setting of allergic or hypersensitivity reactions. The syndrome encompasses a spectrum of acute coronary syndromes triggered by various allergic insults, including medications, insect stings, food allergens, and environmental exposures. The pathophysiology involves the activation of mast cells and platelets, leading to coronary artery spasm, atheromatous plaque erosion or rupture, and subsequent myocardial ischemia or infarction. Diagnosis can be challenging due to the diverse clinical presentations and the need for a high index of suspicion. Management includes the identification and avoidance of triggers, along with the use of standard therapies for acute coronary syndromes. This review aims to provide a comprehensive overview of Kounis syndrome, focusing on its pathophysiology, clinical manifestations, diagnostic considerations, and therapeutic strategies.

Role of Personalized Medicine in Myocardial Infarction With Nonobstructive Coronary Artery Disease (MINOCA): An Updated Review

Cardiovascular diseases, notably myocardial infarction (MI), contribute significantly to global mortality. While traditional MIs are often associated with notable coronary artery blockages, a subgroup experiences MI without such blockages, termed myocardial infarction with nonobstructive coronary arteries (MINOCA). Current diagnostic methods, like invasive coronary angiograms, are inadequate in diagnosing MINOCA due to the absence of visible vessel blockages. Personalized medicine endeavors to introduce novel diagnostic tools for early identification and tailored management of MINOCA. Unlike percutaneous coronary intervention, which lacks efficacy in MINOCA, personalized medical management aligned with the specific underlying pathophysiological cause is essential. Treatments may include statins, agents modulating the renin-angiotensin system, and antiplatelet therapies if linked to plaque disruption. At the same time, calcium channel blockers may be pivotal if coronary artery spasm is the primary cause. Research is ongoing to refine tailored therapies and discover new biomarkers, highlighting the crucial need for individualized approaches in managing MINOCA.

The role of microvascular obstruction and intramyocardial hemorrhage in reperfusion injury to the heart

Microvascular obstruction (MVO) of coronary arteries promotes an increase in mortality and major adverse cardiac events in patients with acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI). Intramyocardial hemorrhage (IMH) is observed in 41–50 % of patients with ST-segment elevation myocardial infarction and PCI and is accompanied by inflammation. There is evidence that microthrombi are not involved in the development of MVO, which is associated with infarct size, the duration of ischemia, and myocardial edema. However, there is no conclusive evidence that the latter plays an important role in the development of MVO. There is evidence that platelets, inflammation, Ca2+ overload, neuropeptide Y, and endothelin-1 could be involved in the pathogenesis of MVO. The role of endothelial cell dysfunction in MVO formation in patients with AMI and PCI remains under question. It is unclear whether nitric oxide production is decreased in patients with MVO. It was obtained only indirect evidence on the involvement of inflammation in the development of MVO. The role of reactive oxygen species, necroptosis and pyroptosis in the pathogenesis of MVO is also not studied. The participation of thromboxane A2, vasopressin, and prostacyclin in the formation of MVO is unknown. It was not obtained conclusive evidence on the involvement of coronary artery spasm in the development of MVO. Dual antiplatelet therapy improves the efficacy of PCI in prevention of MVO. It is unknown whether epinephrine or L-type Ca2+-channel blockers improves coronary blood flow in patients with MVO.

An Unusual Case of Cardiogenic Shock: Coronary Artery Vasospasms

An Unusual Case of Cardiogenic Shock: Coronary Artery Vasospasms

Genetic associations of cardiovascular risk genes in European patients with coronary artery spasm.

Coronary artery spasm (CAS) is a frequent finding in patients presenting with angina pectoris. Although the pathogenesis of CAS is incompletely understood, previous studies suggested a genetic contribution. Our study aimed to elucidate genetic variants in a cohort of European patients with angina and unobstructed coronary arteries who underwent acetylcholine (ACh) provocation testing. A candidate association analysis of 208 genes previously associated with cardiovascular conditions was performed using genotyped and imputed variants in patients grouped in epicardial (focal, diffuse) CAS (n = 119) and microvascular CAS (n = 87). Patients with a negative ACh test result (n = 45) served as controls. We found no association below the genome-wide significance threshold of p < 5 × 10-8, thus not confirming variants in ALDH2, NOS3, and ROCK2 previously reported in CAS patients of Asian ancestry. However, the analysis identified suggestive associations (p < 10-05) for the groups of focal epicardial CAS (CDH13) and diffuse epicardial CAS (HDAC9, EDN1). Downstream analysis of the potential EDN1 risk locus showed that CAS patients have significantly increased plasma endothelin-1 levels (ET-1) compared to controls. An EDN1 haplotype comprising rs9349379 and rs2070698 was significantly associated to ET-1 levels (p = 0.01). In summary, we suggest EDN1 as potential genetic risk loci for patients with diffuse epicardial CAS, and European ancestry. Plasma ET-1 levels may serve as a potential cardiac marker.

Comparison of Baseline and Post-Nitrate Exercise Testing in Patients with Angina but Non-Obstructed Coronary Arteries with Different Acetylcholine Test Results.

Background: Intracoronary acetylcholine testing may induce epicardial coronary artery spasm (CAS) or coronary microvascular spasm (CMVS) in patients with angina syndromes but non-obstructive coronary artery disease, but their causal role in individual patients is not always clear. In this prospective, observational single-center study, we aimed to assess whether (1) the induction of myocardial ischemia/angina by electrocardiogram (ECG) exercise stress test (EST) differs between patients showing different results in response to acetylcholine testing (i.e., CAS, CMVS, or no spasm); (2) the preventive administration of short-acting nitrates has any different effects on the EST of those patients who showed a positive basal EST. We expected that if exercise-induced angina and/or ischemic ECG changes are related to CAS, they should improve after nitrates administration, whereas they should not significantly improve if they are caused by CMVS. Methods: We enrolled 81 patients with angina syndromes and non-obstructive coronary artery disease, who were divided into three groups according to acetylcholine testing: 40 patients with CAS (CAS-group), 14 with CMVS (CMVS-groups), and 27 with a negative test (NEG-group). All patients underwent a basal EST (B-EST). Patients with a positive B-EST repeated the test 24-48 h later, 5 min after the administration of short-acting nitrates (N-EST). Results: There were no significant differences among the groups in terms of the B-EST results. B-EST was positive in eight (20%) patients in the CAS-group, seven (50%) in the CMVS-group, and six (22%) in the NEG-group (p = 0.076). N-EST, performed in eight, six, and five of these patients, also showed similar results in the three groups. Furthermore, the N-EST results also did not significantly differ compared to B-EST in any group, remaining positive in seven (87.5%), four (66.7%), and four (80%) patients in the CAS-group, CMVS-group, and NEG-group, respectively (p = 0.78). Conclusions: Our data show that patients with angina and non-obstructive coronary artery disease show largely comparable results of the ECG exercise stress test and similar poor effects of short-acting nitrates on abnormal ECG exercise stress test results. On the whole, our findings suggest caution in attributing to the results of Ach testing a definite causal role for the clinical syndrome in individual patients.