Epicardial Coronary Vasospasm Research Articles

Delayed ventricular septal rupture complicated with ventricular aneurysm in a case of myocardial infarction with non-obstructive coronary arteries

BackgroundMyocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare cause of heart attack, which may not receive sufficient attention from patients during post-discharge treatment, especially among those with normal coronary angiography results.Case presentationWe present the case of a 65-year-old woman who was readmitted to the hospital with ventricular septal rupture (VSR) complicated by ventricular aneurysm, occurring 2 weeks after myocardial infarction. During the initial admission, coronary angiography revealed normal coronary arteries, leading to a diagnosis of MINOCA. Epicardial coronary vasospasm or coronary embolism was considered as potential causes; however, the patient did not adhere to standardized treatment upon initial discharge. The delayed VSR led to a decline in cardiac function but did not result in severe hemodynamic impairment. Following correction of heart failure with medications, the patient underwent percutaneous VSR repair 19 days after diagnosis and was discharged with a favorable recovery.ConclusionsThe occurrence of delayed VSR complicated with ventricular aneurysm in patients with MINOCA is rare, highlighting the possibility of serious complications in MINOCA cases. Both cardioprotective therapies and cause-targeted therapies are essential in the management of patients with MINOCA.

The Relationship between the Systemic Immune-Inflammation Index and Ischemia with Non-Obstructive Coronary Arteries in Patients Undergoing Coronary Angiography.

Ischemia with the non-obstructive coronary artery (INOCA) is an ischemic heart disease that mostly includes coronary microvascular dysfunction and/or epicardial coronary vasospasm due to underlying coronary vascular dysfunction and can be seen more commonly in female patients. The systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery disease (CAD). This study aims to investigate the relationship between INOCA and SII, a new marker associated with inflammation. A total of 424 patients (212 patients with INOCA and 212 normal controls) were included in the study. Peripheral venous blood samples were received from the entire study population prior to coronary angiography to measure SII and other hematological parameters. In our study, the value of p<0.05' was considered statistically significant. The optimal cut-off value of SII for predicting INOCA was 153.8 with a sensitivity of 44.8% and a specificity of 78.77% (Area under the curve [AUC]: 0.651 [95% CI: 0.603-0.696, p=0.0265]). Their ROC curves were compared to assess whether SII had an additional predictive value over components. The AUC value of SII was found to be significantly higher than that of lymphocyte (AUC: 0.607 [95% CI: 0.559-0.654, p = 0.0273]), neutrophil (AUC: 0.559 [95%CI: 0.511-0.607, p=0.028]) and platelet (AUC: 0.590 [95% CI: 0.541-0.637, p = 0.0276]) in INOCA patients. A high SII level was found to be independently associated with the existence of INOCA. The SII value can be used as an indicator to add to the traditional expensive methods commonly used in INOCA prediction.

Evaluation of Ischemia with No Obstructive Coronary Arteries (INOCA) and Contemporary Applications of Cardiac Magnetic Resonance (CMR).

Ischemia with no obstructive coronary arteries (INOCA) is a relatively newly discovered ischemic phenotype that affects patients similarly to obstructive coronary artery disease (CAD) but has a unique pathophysiology and epidemiology. Patients with INOCA present with ischemic signs and symptoms but no obstructive CAD seen on coronary CTA or invasive coronary angiography, which can assess epicardial vessels. The mechanisms of INOCA can be grouped into three endotypes: coronary microvascular dysfunction, epicardial coronary vasospasm, or a combination of both. Accurate and comprehensive assessment of both epicardial and microvascular disease in suspected cases of INOCA is crucial for providing targeted therapy and improving outcomes in this underrepresented population. This review aims to clarify the complex pathophysiology of INOCA, present an overview of invasive and non-invasive diagnostic methods, and examine contemporary approaches for coronary perfusion assessment using cardiac magnetic resonance (CMR). We also explore how recent advancements in quantitative CMR can potentially revolutionize the evaluation of suspected INOCA by offering a rapid, accurate, and non-invasive diagnostic approach, thereby reducing the alarming number of cases that go undetected.

Invasive Functional Coronary Assessment in Myocardial Ischemia with Non-Obstructive Coronary Arteries: from Pathophysiological Mechanisms to Clinical Implications.

Despite ischemic heart disease (IHD) has been commonly identified as the consequence of obstructive coronary artery disease (OCAD), a significant percentage of patients undergoing coronary angiography because of signs and/or symptoms of myocardial ischemia do not have any significant coronary artery stenosis. Several mechanisms other than coronary atherosclerosis, including coronary microvascular dysfunction (CMD), coronary endothelial dysfunction and epicardial coronary vasospasm, can determine myocardial ischemia or even myocardial infarction in the absence of flow-limiting epicardial coronary stenosis, highlighting the need of performing adjunctive diagnostic tests at the time of coronary angiography to achieve a correct diagnosis. This review provides updated evidence of the pathophysiologic mechanisms of myocardial ischemia with non-obstructive coronary arteries, focusing on the diagnostic and therapeutic implications of performing a comprehensive invasive functional evaluation consisting of the assessment of both vasodilation and vasoconstriction disorders. Moreover, performing a comprehensive invasive functional assessment may have important prognostic and therapeutic implications both in patients presenting with myocardial ischemia with non-obstructive coronary arteries (INOCA) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as the implementation of a tailored patient management demonstrated to improve patient's symptoms and prognosis. However, given the limited knowledge of myocardial ischaemia with non-obstructive coronary arteries, there are no specific therapeutic interventions for these patients, and further research is warranted aiming to elucidate the underlying mechanisms and risk factors and to develop personalized forms of treatment.

Diagnostic approach in patients with angina and no obstructive coronary artery disease: emphasising the role of the coronary function test.

BackgroundMany patients with angina do not have obstructive coronary artery disease (CAD), also referred to as “Ischaemia with No Obstructive Coronary Arteries“ (INOCA). Coronary vascular dysfunction is the underlying cause of this ischaemic heart disease in as much as 59–89% of these patients, including the endotypes of coronary microvascular dysfunction and epicardial coronary vasospasm. Currently, a coronary function test (CFT) is the only comprehensive diagnostic modality to evaluate all endotypes of coronary vascular dysfunction in patients with INOCA.ObjectiveIn this paper we discuss the relevance of performing a CFT, provide considerations for patient selection, and present an overview of the procedure and its safety.MethodsWe reviewed the latest published data, guidelines and consensus documents, combined with a discussion of novel original data, to present this point of view.ResultsThe use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and persistent symptoms. The safety of the procedure is comparable to that of a regular coronary angiography with physiological measurements. Non-invasive alternatives have limited diagnostic accuracy for the identification of coronary vascular dysfunction in patients with INOCA, and a regular coronary angiography and/or coronary computed tomography scan cannot establish the diagnosis.ConclusionsA complete CFT, including acetylcholine and adenosine tests, should be considered in patients with INOCA.Supplementary InformationThe online version of this article (10.1007/s12471-020-01532-9) contains supplementary material, which is available to authorized users.

СТЕНОКАРДИЯ БЕЗ ОБСТРУКТИВНОГО ПОРАЖЕНИЯ КОРОНАРНЫХ АРТЕРИЙ (Часть 1). ПАТОФИЗИОЛОГИЧЕСКИЕ АСПЕКТЫ РАЗВИТИЯ

Angina pectoris is one of the most common symptoms of ischemic heart disease (IHD). Coronary angiography in a significant part of patients with angina pectoris and signs of myocardial ischemia does not reveal obstructive atherosclerotic changes in the coronary arteries. Independent or additional mechanisms of ischemia can be microvascular dysfunction and epicardial coronary vasospasm. The clinical form of ischemic heart disease, which is based on ischemia caused by dysfunction of the coronary vessels in the absence of obstructive changes, has recently received the definition of INOCA (Ischaemia with No Obstructive Coronary Artery Disease). The concept of INOCA comprises two types of angina pectoris – mi- crovascular and vasospastic. The underlying INOCA coronary vasomotor disorders have both different pathophysiological mechanisms and localization in the vascular system of the coronary circulation itself. Clinically the most important vasomotor disorders are epicardial and microvascular vasospasm, impaired microvascular vasodilation. The article provides a brief overview of the mechanisms of regulation of coronary blood flow under physiological conditions and vascular dysfunction in non-obstructive atherosclerotic lesions.

Abstract 12885: Sleepless Nights and Squeamish Days: A Conundrum of Recurrent Myocardial Ischemia

A 63-year old Caucasian female with history of aortic valve replacement and CAD with prior drug-eluting stent placement (DES) to proximal LAD and LCX, presented as a hospital transfer with recurrent episodes of chest pain. Chest discomfort was described as severe chest pressure, radiating to bilateral upper extremities. Episodes were not associated with significant exertion and frequently occurred at night/early morning. Of note, the patient had undergone coronary angiography at the outside hospital, revealing no in-stent restenosis or new coronary lesions. Soon after the patient’s arrival in the CCU, she developed profound chest pressure, accompanied by hypotension, diaphoresis and nausea. Her 12-lead ECG revealed 2-mm ST-elevation in aVR, accompanied by ST-depression in inferior, anterior, and apical leads. Initial high-sensitivity (hs)-troponin T was 26 ng/L. She was given sublingual nitroglycerin and was started on a nitroglycerin and nicardipine infusion, with resolution of symptoms after ~30 minutes, followed by normalization of hs-troponin T. A transthoracic echocardiogram did not reveal focal left ventricular (LV) wall motion abnormalities, mild LV hypertrophy was present. Given the patients’ presentation with no in-stent restenosis or new lesions, frequent episodes of chest pain-not related to exertion with occurrence at nighttime and early morning, her presentation was deemed to be consistent with epicardial coronary vasospasm. Subsequently, the patients’ anti-anginal regimen was uptitrated to include extended-release nitrates, calcium-channel blockade, and I Na blockade. Unfortunately, she continued to have frequent episodes of profound angina, accompanied by hypotension, and significant ischemic ECG changes. This prompted us to pursue bilateral sympathectomy. Subsequently, the patient had resolution of prior symptoms. She was continued on an anti-vasospastic regimen, consisting of extended release nitrates and calcium-channel blockade. This case represents the challenging management of medication-resistant epicardial coronary artery vasospasm. As previously described, sympathectomy remains an effective therapeutic option for management in these difficult and life-threatening situations.

Ischaemia with no obstructive coronary arteries.

Ischaemia with no obstructive coronary arteries (INOCA) is a common ischaemic heart disease with a female preponderance, mostly due to underlying coronary vascular dysfunction comprising coronary microvascular dysfunction and/or epicardial coronary vasospasm. Since standard ischaemia detection tests and coronary angiograms are not suitable to diagnose coronary vascular dysfunction, INOCA is often overlooked in current cardiology practice. Future research, including large outcome trials, is much awaited. Yet, adequate diagnosis is possible and treatment options are available and vital to reduce symptoms and most probably improve cardiovascular prognosis. This review intends to give a brief overview of the clinical presentation, underlying pathophysiology, and the diagnostic and treatment options in patients with suspected INOCA.

78-Year-Old Woman With Intermittent Chest Pain and Palpitations

78-Year-Old Woman With Intermittent Chest Pain and Palpitations

OP-336 Low Adiponectin and High Lipoprotein (A) in Cardiac Syndrome X: Are they the Origin of Pathophysiology?

Cardiac syndrome X (CSX) is usually defined by normal-appearing coronary angiogram associated with typical exertional chest pain, ST-segment changes on the exercise stress test and no evidence of epicardial coronary vasospasm. The cause of CSX is not correctly understood. Lipoprotein a and adiponectin have been accepted the new confounders of the coronary heart disease. We studied the contribution of lipoprotein a ve adiponectin in CSX physiopathology.

A Case of Recurrent Chest Pain With Reversible Left Ventricular Dysfunction and ST Segment Elevation on Electrocardiogram

There is a syndrome consisting of acute infarction-like symptoms and ECG findings, and transient left ventricular apical ballooning without epicardial coronary artery obstruction. A 67-year-old female admitted to our hospital because of severe anterior chest pain was diagnosed as having this syndrome. Since stenotic, spastic, or occlusive sites were not found in epicardial coronary arteries by emergency cardiac catheterization, we speculated coronary microvasculature involvement in the pathophysiology of the event. Four weeks later in a drug-free condition, there was no significant epicardial coronary vasospasm by intracoronary acetylcholine administration (IC-ACh). The average peak flow velocity (APFV) of the left coronary artery (LCA) was measured using the Doppler flow wire method. Under maximal dilatation of the epicardial LCA by intracoronary nitroglycerin administration, IC-ACh was again performed taking into consideration that the change in APFV in response to IC-ACh reflects a coronary microvascular response to it. In the nonischemic control subjects, basal APFV increased to 296+/-29% (n = 24) of the basal value after IC-ACh. In this patient, although IC-ACh did not cause vasospasm in epicardial LCA, APFV was decreased to 54% of its basal value. After administration of a Ca antagonist and KATP opener, she had no chest symptoms and was discharged from the hospital. In 2003, she forgot to take her medication for 3 days and then experienced a sudden recurrence of the same type of attack. She started her medication again and her symptoms disappeared. Three weeks later, she underwent an assessment of the coronary microvascular response to ACh with medicine. Her APFV after ACh increased to 177% of the basal value.

Rho-kinase inhibition with intracoronary fasudil prevents myocardial ischemia in patients with coronary microvascular spasm

ObjectivesWe sought to determine whether a potent Rho-kinase inhibitor fasudil prevents the occurrence of myocardial ischemia in patients with microvascular angina attributable to coronary microvascular spasm. BackgroundEffective treatment of patients with angina who have normal coronary arteriograms (microvascular angina) has not yet been established. Rho-kinase–mediated calcium sensitization of the myosin light chain in smooth muscle cells has been implicated as substantially contributing to vascular hyperconstriction. MethodsWe studied consecutive 18 patients with angina and normal epicardial coronaries in whom intracoronary acetylcholine (ACh) induced myocardial ischemia (ischemic electrocardiographic changes, myocardial lactate production, or both) without angiographically demonstrable epicardial coronary vasospasm. All patients underwent a second ACh challenge test after pretreatment with either saline (n = 5) or fasudil (4.5 mg intracoronarily, n = 13). ResultsMyocardial ischemia was reproducibly induced by ACh in the saline group. In contrast, 11 of the 13 patients pretreated with fasudil had no evidence of myocardial ischemia during the second infusion of ACh (p < 0.01). The lactate extraction ratio (median value [interquartile range]) during ACh infusion was improved by fasudil pretreatment, from −0.16 (−0.25 to 0.04) to 0.09 (0.05 to 0.18) (p = 0.0125). ConclusionsFasudil ameliorated myocardial ischemia in patients who were most likely having coronary microvascular spasm. The inhibition of Rho-kinase may be a novel therapeutic strategy for this group of patients with microvascular angina.

Transient ST Elevation and Left Ventricular Asynergy Associated With Normal Coronary Artery in Aneurysmal Subarachnoid Hemorrhage

A 62-year-old woman presented with transient ST segment elevation and left ventricular asynergy in an acute phase of subarachnoid hemorrhage (SAH). A coronary arteriogram during ongoing ST elevation showed no fixed stenoses or spasm. These findings refute epicardial coronary vasospasm as a cause of transient ST elevation and left ventricular asynergy in patients with SAH.