Diagnosis Of Microvascular Angina Research Articles

Long-term outcomes of ischaemia with no obstructive coronary artery disease (INOCA): a systematic review and meta-analysis

BackgroundThe prognosis of myocardial ischaemia with no obstructive coronary artery disease (INOCA) and its underlying vasomotor disorders, vasospastic angina (VSA) and microvascular angina (MVA), is not well defined. The aim...

Myocardial Perfusion Scintigraphy in Diagnosic of Coronary Heart Disease

<i>Introduction: </i>Atherosclerosis plays a key role in the etiopathogenesis of cardiovascular diseases. Atherosclerosis is a generalized chronic inflammatory disease of the vascular wall, which results in anatomical and histological changes that, together with functional changes, lead to endothelial dysfunction, narrowing of the arterial lumen, and insufficient blood supply to the tissues. The shift in the incidence of cardiovascular diseases to younger age groups is alarming. The presence of microvascular changes in the myocardium is significant. The high incidence of cardiovascular diseases, especially ischemic heart disease, requires early diagnosis and modern treatment. <i>Aim: </i>The aim of the paper is to analyse and point out early diagnosis of coronary heart disease using nuclear medicine methods. <i>Set of examined patients and methodology: </i>Using nuclear medicine methods, we try to detect these changes in time and thus prevent the occurrence of acute coronary events. In nuclear cardiology, instead of a large-area scintillation detector, a new type of cardio-gamma camera "Discovery CZT 530c" based on the principle of semiconductor detectors began to be used. The abbreviation CZT stands for semiconductor composition (Cadmium-Zinc-Tellur). The set of respondents consisted of 4270 people examined in the years 2014-2016 by myocardial perfusion scintigraphy. There were 950 diabetic patients in the analysed group of the 4270 examined. <i>Results:</i> In the analysed group of 4270 respondents, 61% had negative findings and 39% had positive findings in terms of the presence of ischemic heart disease. In the group of diabetic patients, there was a negative finding in 28% of respondents and a positive finding in 72% of the respondents in the sense of positive ischemic heart disease. Using myocardial perfusion scintigraphy in the diagnosis of functional changes, we confirmed a great benefit in detecting early changes in coronary heart disease, including in the diagnosis of microvascular angina. <i>Conclusion:</i> Nuclear medicine methods are of great benefit for the diagnosis of small vessel disease, diabetic cardiomyopathy and cardiac autonomic neuropathy in patients with diabetes mellitus. The new type of cardio gamma camera "Discovery CZT 530c" allows more accurate assessment of myocardial perfusion abnormalities and at the same time the reduction of the radiopharmaceutical dose reduces the patient's radiation load by 50%.

The Role of IL-6 and ET-1 in the Diagnosis of Coronary MicroVascular Disease in Women.

Background: Microvascular angina is a common clinical entity, with about a three-fold higher frequency in women. The pathogenesis of microvascular angina has not been much studied, but inflammation and endothelial dysfunction have been incriminated as the main mechanisms of this disease. Methoss: Our purpose was to analyze whether certain inflammatory markers, i.e., interleukin 6 (IL-6) and endothelin 1 (ET-1), can play a role in the diagnosis of microvascular angina in women. Results: Ninety women with ischemic heart disease were divided into two groups, based on their affliction with either microvascular or macrovascular disease. In general, the levels of IL6 and ET1 were similar between the two groups. Analyzing these marker levels according to the number of coronary lesions, we obtained an increased IL6 value that was similar for patients with microvascular angina, one-vessel, and two-vessel coronary disease, but significantly lower than in women with three-vessel coronary lesions. Also, in microvascular angina, IL6 level was correlated with the NYHA IV functional class. Unexpectedly, the level of ET1 was correlated with left ventricular systolic dysfunction. Conclusions: In women with an increased suspicion of microvascular angina, in whom microvascular dysfunction cannot be tested invasively, IL-6 level, unlike the ET-1 level, might be considered a diagnostic marker of this disease.

MICROVASCULAR ANGINA IS ASSOCIATED WITH SYSTEMIC DYSFUNCTION OF PERIPHERAL RESISTANCE ARTERIES

Objective: Microvascular angina (MVA) is characterized by functional and structural alterations of resistance coronary arteries without any significant alterations of epicardial coronary arteries. Whether MVA patients present also dysfunction of peripheral resistance arteries is still a matter of debate. We sought to evaluate whether MVA is associated with parameters of systemic microvascular dysfunction. Design and method: Thirteen patients with MVA and 13 healthy control subjects were enrolled in this study. The diagnosis of MVA was based on the presence of typical symptoms of ischemic heart disease, evidence of myocardial ischemia on exercise stress testing and normal epicardial coronary arteries at angiography. Parameters of peripheral microvascualar alterations, arterial stiffness (Pulse Wave Velocity, PWV), and central blood pressure (cBP) and Subendocardial Viability Ratio (SEVR, and index of subendocardial microvascular dysfunction), were evaluated by applanation tonometry. Results: Patients and controls were similar with respect to metabolic parameters, BMI, and renal function. MVA patients were on therapy with beta-blockers (50%), calcium channel blockers (37%), nitrates (12%), renin-angiotensin-blockers (44%), and statins (25%). MVA patients were slightly older than controls (63.6 ± 1.9 vs 53.1 ± 2.0 years, p < 0.05). Albeit in the normal range, peripheral (pSBP) and central (cSBP) systolic BP were significantly higher in MVA patients as compared to controls (pSBP:134.3 ± 2.9 vs 118.5 ± 3.5 mmHg, p < 0.002; and cSBP:124.8 ± 2.9 vs 109.7 ± 2.9 mmHg, p < 0.001). Diastolic BP was similarly preserved in both groups. SEVR, an index of subendocardial microvascular dysfunction, was lower in MVA patients as compared to controls (139.7 ± 4.1 vs 160.4 ± 8.5 %, p < 0.05). Augmentation index (AI), reflected (RPH), and forward (FPH) pulse height, all parameters of peripheral microvascular dysfunction, were also altered in MVA patients as compared to controls (AI:29.0 ± 1.0 vs 19.9 ± 2.4%, p < 0.003; RPH:22.3 ± 1.4 vs 15.3 ± 0.9 mmHg, p < 0.001; FPH:31.0 ± 1.4 vs 24.2 ± 1.4 mmHg p < 0.005). The index of aortic stiffness PWV was similar in both groups (7.20 ± 07 vs 6.6 ± 0.2 m/sec, NS). Conclusions: Patients with MVA on optimal anti-schemic therapy exhibit alterations of parameters of both subendocardial and peripheral microvascular dysfunction, suggesting that coronary microvascular dysfunction is part of a more generalized disorder also involving peripheral resistance arteries.

Ischemia and No Obstructive Coronary Artery Disease: Prevalence and Correlates of Coronary Vasomotion Disorders.

Determine the prevalence and correlates of microvascular and vasospastic angina in patients with symptoms and signs of ischemia but no obstructive coronary artery disease (INOCA). Three hundred ninety-one patients with angina were enrolled at 2 regional centers over 12 months from November 2016 (NCT03193294). INOCA subjects (n=185; 47%) had more limiting dyspnea (New York Heart Association classification III/IV 54% versus 37%; odds ratio [OR], 2.0 [1.3-3.0]; P=0.001) and were more likely to be female (68% INOCA versus 38% in coronary artery disease; OR, 1.9 [1.5 to 2.5]; P<0.001) but with lower cardiovascular risk scores (ASSIGN score median 20% versus 24%; P=0.003). INOCA subjects had similar burden of angina (Seattle Angina Questionnaire) but reduced quality of life compared with coronary artery disease; subjects (EQ5D-5 L index 0.60 versus 0.65 units; P=0.041). An interventional diagnostic procedure with reference invasive tests including coronary flow reserve, microvascular resistance, and vasomotor responses to intracoronary acetylcholine (vasospasm provocation) was performed in 151 INOCA subjects. Overall, 78 (52%) had isolated microvascular angina, 25 (17%) had isolated vasospastic angina, 31 (20%) had both, and 17 (11%) had noncardiac chest pain. Regression analysis showed inducible ischemia on treadmill testing (OR, 7.5 [95% CI, 1.7-33.0]; P=0.008) and typical angina (OR, 2.7 [1.1-6.6]; P=0.032) were independently associated with microvascular angina. Female sex tended to associate with a diagnosis of microvascular angina although this was not significant (OR, 2.7 [0.9-7.9]; P=0.063). Vasospastic angina was associated with smoking (OR, 9.5 [2.8-32.7]; P<0.001) and age (OR, 1.1 per year, [1.0-1.2]; P=0.032]. Over three quarters of patients with INOCA have identifiable disorders of coronary vasomotion including microvascular and vasospastic angina. These patients have comparable angina burden but reduced quality of life compared to patients with obstructive coronary artery disease. Microvascular angina and vasospastic angina are distinct disorders that may coexist but differ in associated clinical characteristics, symptoms, and angina severity. URL: https://www.clinicaltrials.gov. Unique identifier: NCT03193294.

P6434Evaluation of the nociceptive flexor reflex, as a new method for the diagnosis of microvascular angina

Abstract The purpose of this study was to study the diagnostic value of the nociceptive flexor reflex (NFR) method in patients with microvascular angina. Materials and methods The study included 49 patients with MVA (main group), 40 patients with classical angina II-III f.c. (comparison group 1), 42 patients with silent myocardial ischemia (comparison group 2) and 32 healthy volunteers (control group). Criteria for inclusion in the group with MVA: chest pain, positive stress test, unchanged coronary arteries according to coronary angiography, the presence of myocardial perfusion disturbance and reduction of the coronary reserve according to positiron-emission tomography of the myocardium at rest, with adenosine and cold one test. Chest pain syndrome was observed in all 49 patients. All subjects studied the functional activity of nociceptive and antinociceptive systems using the nociceptive flexor reflex method on the equipment of expert class electromyography system, the pain threshold (Pb) values, the reflex threshold (Pr) were calculated and the ratio of pain and reflex threshold was calculated to calculate the pain threshold / threshold reflex (Pb/Pr), which in healthy people is about 0.9–1.0. Results and discussion In te study of NFR in patients with MVA in the group as a whole, a decrease in the pain threshold, reflex threshold and Pb/Pr ratio compared with normal values were found. The pain threshold in patients in the group was lower (statistically significantly) when compared with the group 1, the group 2 and the control group (p&lt;0.0001; p&lt;0.0001; p&lt;0.0001, respectively). The reflex threshold in patients of the MCC group was also significantly lower when compared with the group 1, the group 2 and the control group (p&lt;0.001; p&lt;0.0001; p&lt;0.001, respectively). Due to the fact that the low pain threshold was found in 84.4% of the examined patients with MVA who had microvascular dysfunction according to positron-emission tomography, we evaluated the prognostic value of the NFR method for diagnosing the disease. To do this, an assessment was made of the odds ratio (OR) of identifying MVA in groups of patients with different levels of index K (the ratio of the pain threshold value to the reflex threshold value). We have chosen the value of index K with the highest specificity and high sensitivity equal to 0.8892. Based on the data obtained, the diagnostic value of the NFR method was calculated during the verification of the MVA. When conducting a mathematical analysis, it was found that this technique has high sensitivity (84.4%), specificity (95.12%), positive (90.48%) and negative predictive value (91.76%). We have not found information in the literature on the use of the NFR assessment method and its diagnostic value in MVA. Findings Due to the high diagnostic value of determining the NFR, we propose to include this method in the MVA diagnostic algorithm as an additional one.

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

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.

CURRENT ISSUES OF CHD DIAGNOSIS IN MATERIALS OF THE RUSSIAN CARDIOLOGY CONGRESS (EKATERINBURG, 20-23 September 2016)

Currently, one of the problems of diagnosis of CHD is a significant percentage of detection of non-obstructive lesions of coronary arteries (CA) for invasive coronary angiography (CAG). In register trials intact CA rate reaches 42%, in the analysis of our clinical data - 37.9%. In the materials of the past of the Russian Cardiology Congress, solutions to this problem were considered from different points of view, both by improving the diagnostic algorithms in primary care, and using high-tech methods of diagnosis. A number of breakout sessions was devoted to the modern possibilities and prospects of development of MSCT-angiography, stress echocardiography in the diagnosis of coronary atherosclerosis; clinical value assessment of left ventricular mechanics (LV) in CHD; modern trends radionuclide diagnosis of CHD; methods of contrast enhancement in radiation pathophysiological assessment of coronary atherosclerosis and myocardial viability; as well as the characteristics of non-invasive diagnosis of stable coronary artery disease in Russia. In addition, in one of the workshops reminded us that in the absence of stenosis of large CA do not forget about the possible presence of a particular form of ischemic heart disease - microvascular angina (MVA). The reports of the current understanding of the pathogenesis and diagnosis of MVA were recorded, especially pain and determination of nociceptive disorders in patients with MVA, new opportunities in drug therapy MVA. Participation in the Congress allowed us to compare our views on ways to reduce the frequency of intact CA detection with the position of the leading Russian experts. This review will help clinicians to better navigate the current state of the real problem.

The parallel tales of microvascular angina and heart failure with preserved ejection fraction: a paradigm shift.

An increasing number of studies clearly demonstrate that coronary microvascular dysfunction (CMD) plays a pivotal role in several cardiovascular diseases.1 In particular, emerging evidence suggests that CMD is the main contributor to myocardial ischaemia in a large subset of patients with chronic stable angina. Indeed, non-obstructive coronary atherosclerosis is observed in up to 50% of patients with angina and positive stress test results undergoing diagnostic coronary angiography.2 Thus, the prevalence of microvascular angina (MVA) is higher than previously thought and associated with worse clinical outcomes than those observed in asymptomatic subjects with similar risk factor burden.3 The diagnosis of MVA is based on the following criteria: (i) symptoms of myocardial ischaemia; (ii) absence of obstructive epicardial coronary artery disease; (iii) evidence of myocardial ischaemia on non-invasive stress testing; and (iv) evidence of impaired coronary microvascular function. The clinical relevance of MVA has historically been overlooked since the diagnostic tools required for the evaluation of the coronary microcirculation are infrequently utilized. A parallel ‘tale’ could be proposed for heart failure (HF) with preserved ejection fraction (HFpEF). Indeed, HFpEF is observed in about 50% of patients presenting with HF symptoms and is characterized by the absence of a relevant reduction of left ventricular ejection fraction (LVEF).4 As with MVA, patients with HFpEF have poorer clinical outcomes compared with asymptomatic subjects exhibiting a similar burden of risk factors. The diagnosis of HFpEF is based on the following: (i) symptoms with or without signs of HF; (ii) normal or only mildy reduced LVEF; (iii) elevated levels of natriuretic peptides; (iv) relevant structural heart disease (i.e. left ventricular hypertrophy, left atrial enlargement) and/or diastolic dysfunction. In both MVA and HFpEF, no therapeutic intervention has hitherto been proven to improve patient outcome; similarly, symptomatic treatment is largely empirical. A key shared characteristic …

Evolving strategies for the treatment of microvascular angina in women

Microvascular angina, also known as cardiac syndrome X, is characterized by anginal chest pain, at least one cardiovascular risk factor, an abnormal stress test and normal coronary arteries on angiography. It is significantly more common in women than in men. A definitive diagnosis of microvascular angina can be made by invasive or noninvasive methods; a presumptive diagnosis can also be made based on fulfillment of diagnostic criteria. Effective treatment of microvascular angina requires aggressive risk factor modification; exercise is one of the most effective treatment modalities. Several other treatment strategies have been shown to relieve anginal symptoms as well as improve vascular function; these include b-blockers, angiotensin-converting enzyme inhibitors, ranolazine, l-arginine, statin drugs and potentially estrogen replacement therapy. Nitrates may be effective for symptom relief. Further studies are required to determine whether specific treatments are associated with improved survival as well as decreased symptoms.

Resultados de la gammagrafía de perfusión miocárdica con 99mTc-tetrofosmina y estímulo con dipiridamol en pacientes diagnosticados de angina microvascular

The objective of the study was to evaluate the results of the myocardial scintigraphy with 99mTc-tetrofosmin (Tc-Tf) and pharmacological stimulation with dipyridamole in patients diagnosed of microvascular angina. The study population is made up of 50 patients discharged with the diagnosis of microvascular angina who had undergone Tc-Tf-dipyridamole. Clinical and electrical positivity appeared in 40% and 12% of the patients, respectively. Myocardial perfusion defects were found in 35 patients (70%), and were reversible in 21 (60%), fixed in 11 (21%), and combined in 3 (9%). Abnormalities were inferior, anteroseptal and lateral in 21, 18, and 2 patients, respectively. Patients with a positive exercise treadmill test, compared with those with a negative one, had more frequent perfusion abnormalities (91% vs 50%, p = 0.0327) and myocardial ischemia (64% vs 20%, p = 0.392). Women, in comparison with men, had angina (56% vs 22%, p = 0.013), and anteroseptal perfusion abnormalities (26% vs 4%, p = 0.028) more frequently. On the contrary, men had inferior perfusion abnormalities more frequently (57% vs 30%, p = 0.057). Thus, Tc-Tf-dipyridamole shows perfusion abnormalities in 70% of patients with microvascular angina (91% in patients with a positive exercise treadmill test). Scintigraphic pattern may be partially conditioned by gender in these patients.