Obstructive Coronary Arteries Research Articles

Relationship between coronary function testing and migraine: results from the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction project.

Aim:To determine the relationship between coronary vascular dysfunction and history of migraines in women with suspected ischemia and no obstructive coronary arteries (INOCA).Methods:In the Women’s Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction study, 402 women with suspected INOCA answered baseline angina questionnaires, including the Seattle Angina Questionnaire (SAQ). Coronary function testing (CFT) performed in a subgroup of 252 women evaluated for nonendothelial and endothelial-dependent coronary vascular function. Wilcoxon rank sum test, t-test, and linear regression models were performed.Results:Of the 252 women who underwent CFT, 126 (50%) women reported migraine history. Compared to women who reported no migraines, women with migraines were younger and more were premenopausal. They had more angina at rest, with strong emotions, and hot/cold temperatures, as well as angina that wakes them from sleep (P < 0.05 for all). Women with migraines also scored worse on SAQ angina frequency and quality of life P < 0.01 for both). There was no difference in prevalence of coronary vascular dysfunction in the two groups. In addition, linear regression models demonstrated no significant age-adjusted differences in absolute CFT variables.Conclusion:Among women with suspected INOCA, migraine history is prevalent and women with migraines have worse angina compared to those without migraines. Coronary vascular dysfunction diagnosed by CFT does not appear to relate to migraine history.

Coronary Angiography-Derived Index of Microvascular Resistance.

A coronary angiography-derived index of microvascular resistance (caIMR) is proposed for physiological assessment of microvasular diseases in coronary circulation. The aim of the study is to assess diagnostic performance of caIMR, using wire-derived index of microvascular resistance (IMR) as the reference standard. IMR was demonstrated in 56 patients (57 vessels) with stable/unstable angina pectoris and no obstructive coronary arteries in three centers using the Certus pressure wire. Based on the aortic pressure wave and coronary angiograms from two projections, the caIMR was computed and assessed in blinded fashion against the IMR at an independent core laboratory. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the caIMR with a cutoff value of 25 were 84.2% (95% CI: 72.1% to 92.5%), 86.1% (95% CI: 70.5% to 95.3%), 81.0% (95% CI: 58.1% to 94.6%), 88.6% (95% CI: 76.1% to 95.0%), and 77.3% (95% CI: 59.5% to 88.7%) against the IMR with a cutoff value of 25. The receiver-operating curve had area under the curve of 0.919 and the correlation coefficient equaled to 0.746 between caIMR and wire-derived IMR. Hence, caIMR could eliminate the need of a pressure wire, reduce technical error, and potentially increase adoption of physiological assessment of microvascular diseases in patients with ischemic heart disease.

T1 mapping for myocardial tissue evaluation in patients with ischemia and stable coronary artery disease: MASS V-Trial Study Group

Abstract Background T1 mapping is a magnetic resonance imaging (MRI) technique that enables the identification of myocardial structural changes during acute ischemic injury. However, it is not known whether these structural changes are present in patients with chronic effort induced ischemia.Thus, we sought to document the possible T1 mapping changes in chronic coronary artery disease (CAD) patients with documented myocardial ischemia. Methods Multivessel CAD patients from MASS V Trial with indication of myocardial revascularization, were evaluated for the presence of ischemia by myocardial scintigraphy. MRI with T1 mapping was performed in all patients. Based on the results of the scintigraphy, the myocardial segments were identified as ischemic and non-ischemic segments. The corresponding segments of scintigraphy and MRI were compared in relation to native T1 map (NT1), post-contrast T1 (CAT1) and extracellular volume (ECV). Results Of the 720 myocardial segments analyzed, there were 161 ischemic and 559 non-ischemic segments. Comparing ischemic vs non-ischemic segments, respectively, NT1 was 1022.7 (980.0–1052.0) versus 1029.3 (985.0–1066.3), p=0.57, ECV results were 25.4 (24.0–28.1) versus 26.4 (25.3–29.9), p=0.75 and CAT1 results were 492 (461.9–515.4) versus 488 (469.2–521.7), p=0.09. Myocardial segments supplied by obstructive coronary arteries were compared to those supplied by non-obstructive coronary arteries in relation to NT1 and ECV. NT1 values in obstructive and non-obstructive territories were, respectively, 1024.7 (998.5–1043.5) versus 1036.8 (1008.6–1046.9), p=0.30 and ECV results were 26.8 (24.4–29.9) versus 26.8 (24.4–30.0), p=0.90. Conclusion In this study, MRI identified structural similarities between chronic ischemic myocardium compared to the non-ischemic myocardium. This finding supports myocardial tissue stability in the presence of stress induced ischemia. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Zerbini Foundation and also by the FAPESP (2011/ 20876-2)

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.

Expert consensus on blood pressure management in hypertensive disorders of pregnancy (2019)

Objective: To compare the incidence of coronary microvascular disease (CMVD) between patients with non-obstructive and obstructive coronary arteries. Methods: We retrospectively analyzed 97 patients with angina pectoris, who underwent the absolute quantitative PET examination of myocardial perfusion and coronary anatomy examination within 90 days. All patients were divided into two groups: non-obstructive group (72 cases, no stenosis ≥50% in all three coronary arteries) and obstructive group (25 cases, at least one coronary stenosis ≥50%; and at least one coronary stenosis<50%). Quantitative parameters derived from PET including rest myocardial blood flow (RMBF), stress myocardial blood flow (SMBF), coronary flow reserve (CFR) and cardiovascular risk factors were compared between the two groups. CMVD was defined as CFR<2.90 and SMBF<2.17 ml·min(-1)·g(-1). Results: Incidence of CMVD was significant higher in the non-obstructive coronary arteries of the obstructive group than in the non-obstructive coronary arteries of non-obstructive group (47.1% (16/34) vs. 25.5% (55/216), χ(2)=6.738, P=0.009) while incidence of CMVD was similar between non-obstructive and obstructive patients ((44% (11/25) vs. 33.3% (24/72), χ(2)=0.915, P=0.339). RMBF ((0.83±0.14) ml·min(-1)·g(-1) vs. (0.82±0.17) ml·min(-1)·g(-1)), SMBF ((2.13±0.60) ml·min(-1)·g(-1) vs. (1.91±0.50) ml·min(-1)·g(-1)) and CFR (2.59±0.66 vs. 2.36±0.47) were similar between the two groups (all P>0.05). Conclusions: CMVD can occur in non-obstructive coronary arteries in both patients with non-occlusive coronary arteries and patients with obstructive coronary arteries. Prevalence of CMVD is significantly higher in patients with obstructive coronary arteries than in patients with non-obstructive coronary arteries. The CMVD severity is similar between the two groups.目的： 比较非阻塞及阻塞性冠状动脉（冠脉）疾病患者的冠脉微血管疾病（CMVD）发生情况。 方法： 回顾性分析2015年12月至2019年12月在山西医科大学附属第一医院成功完成(13)N-氨水正电子发射计算机断层显像（PET）心肌血流绝对定量检查并在PET检查90 d内完成冠脉造影或CTA的97例疑诊CMVD患者，根据造影及CTA结果将患者分为非阻塞组（72例，3支冠脉均不存在狭窄≥50%的病变）和阻塞组（25例，至少存在1支冠脉狭窄≥50%，且至少存在1支冠脉狭窄<50%），以冠脉血流储备（CFR）<2.90且负荷心肌血流量（SMBF）<2.17 ml·min(-1)·g(-1)为CMVD的判定标准，从血管及患者层面分析两组患者非阻塞性冠脉的CMVD发生情况，并比较两组间发生CMVD的冠脉支配区的静息心肌血流量（RMBF）、SMBF及CFR。 结果： 在血管层面，阻塞组非阻塞性冠脉存在CMVD的比例高于非阻塞组[47.1%（16/34）比25.5%（55/216），χ(2)=6.738，P=0.009]。在患者层面，两组发生CMVD的比例差异无统计学意义[（44%（11/25）比33.3%（24/72），χ(2)=0.915，P=0.339]。两组间发生CMVD的冠脉支配区的RMBF[（0.83±0.14）ml·min(-1)·g(-1)比（0.82±0.17）ml·min(-1)·g(-1)]、SMBF[（2.13±0.60）ml·min(-1)·g(-1)比（1.91±0.50）ml·min(-1)·g(-1)]及CFR（2.59±0.66比2.36±0.47）比较，差异均无统计学意义（P>0.05）。 结论： 非阻塞与阻塞性冠脉疾病患者的非阻塞性冠脉均可存在CMVD，后者的CMVD检出率更高，两者CMVD的严重程度基本一致。.

Resting coronary velocity and myocardial performance in women with impaired coronary flow reserve: Results from the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study

BackgroundWomen with evidence of ischemia and no obstructive coronary arteries (INOCA) often have coronary microvascular dysfunction (CMD) indicated by impaired coronary flow reserve (CFR) to adenosine. Low CFR is associated with an adverse prognosis, including incident heart failure. Because the CFR calculation relies on the baseline intrinsic coronary vasomotor flow velocity, a major determinate of CFR and the degree of variation in baseline flow alone may be an important contributor to risk of adverse outcomes in women with CMD. A better understanding of baseline blood flow in the setting of low CFR and its association with myocardial performance would be helpful. MethodsWe evaluated 74 women who underwent invasive coronary reactivity testing in the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study and had impaired CFR (<2.32). We assessed the relationship between coronary artery baseline average peak velocity (bAPV) at rest and cardiac magnetic resonance imaging measures of left ventricular (LV) structure and function. ResultsWhen stratified as low (<22 cm/s) versus high (≥22 cm/s) bAPV, there were no differences in cardiovascular risk factors, coronary plaque burden, or LV structure. However, low bAPV was associated with higher LV end-diastolic filling pressure (P = 0.04), lower LV ejection fraction (P = 0.001), and differences in late systolic and diastolic strain rates (P = 0.01 to 0.05). ConclusionsIn women with impaired CFR, low resting coronary flow velocity is associated with more adverse myocardial performance, which may contribute to risk for adverse outcomes and particularly heart failure in women with CMD.

318 Diagnostic Utility of Cardiac Magnetic Resonance (CMRI) in Patients with Myocardial Infarction without Obstructive Coronary Arteries (MINOCA)

318 Diagnostic Utility of Cardiac Magnetic Resonance (CMRI) in Patients with Myocardial Infarction without Obstructive Coronary Arteries (MINOCA)

Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): aposition paper from the Dutch ACS working group.

Patients with myocardial infarction and non-obstructive coronary arteries (MINOCA), defined as angiographic stenosis <50%, represent a conundrum given the many potential underlying aetiologies. Possible causes of MINOCA can be subdivided into coronary, myocardial and non-cardiac disorders. MINOCA is found in up to 14% of patients presenting with an acute coronary syndrome. Clinical outcomes including mortality, and functional and psychosocial status, are comparable to those of patients with myocardial infarction and obstructive coronary arteries. However, many uncertainties remain regarding the definition, clinical features and management of these patients. This position paper of the Dutch ACS working group of the Netherlands Society of Cardiology aims to stress the importance of considering MINOCA as a dynamic working diagnosis and to guide the clinician in the management of patients with MINOCA by proposing a clinical diagnostic algorithm.

P612Multimodal cardiac imaging in patients with suspected ST-elevation myocardial infarction and no obstructive coronary arteries

Abstract Background Patients with suspected ST-elevation myocardial infarction (STEMI) and normal coronary arteries comprise a heterogeneous group with various underlying causes of disease. Purpose To study pathophysiology and underlying diagnoses in patients with suspected STEMI and normal coronary arteries using multimodal cardiac imaging. Methods We consecutively included patients with suspected STEMI, normal coronary arteries on acute coronary angiography, and elevated troponin T levels at a tertiary heart center (2012–14). Patients were examined with echocardiography, cardiac magnetic resonance imaging, and 13NH3/82Rb and 18F-FDG positron emission tomography within one week from symptom onset. Results We included 42 patients (60% male, median age 58 (IQR 50–65) years. Median troponin T levels were 783 (IQR 566–1208) ng/l. Multimodal cardiac imaging findings are presented in Table 1. Multimodal cardiac imaging showed signs of cardiac involvement in all but one patient (98%). Underlying diagnoses were acute myocardial infarction (36%), Takotsubo cardiomyopathy (29%), perimyocarditis (10%), and cardiomyopathy (7%). The diagnosis was unclear in 19% of patients. Echocardiography Left ventricular ejection fraction &lt;40%, n (%) 12 (29) Moderate to severe left ventricular hypertrophy, n (%) 3 (7) Moderate to severe valvular disease, n (%) 3 (7) Pericardial effusion, n (%) 5 (12) Apical thrombus, n (%) 1 (2) Magnetic resonance imaging Left ventricular end diastolic volume, ml (IQR) 157 (125–185) Left ventricular end systolic volume, ml (IQR) 75 (63–88) Left ventricular stroke volume, ml (IQR) 73 (57–93) Edema, n (%) 38 (91) Late gadolinium enhancement, n (%) 22 (52) 13NH3/82Rb and 18F-FDG positron emission computer tomography Myocardial perfusion defect, n (%) 29 (69) Myocardial perfusion-metabolism mismatch, n (%) 12/30 (40) Reduced myocardial viability, n (%) 6/30 (20) Conclusion The majority of patients with suspected STEMI and normal coronary arteries had signs of cardiac involvement by multimodal cardiac imaging and were diagnosed with cardiac disease. Acknowledgement/Funding The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation

Es la miocardiopatía hipertrófica apical la evolución de un infarto de miocardio sin lesiones coronarias obstructivas (minoca)?

Es la miocardiopatía hipertrófica apical la evolución de un infarto de miocardio sin lesiones coronarias obstructivas (minoca)?

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.

Factors Associated with Sub-intimal Coronary Artery Dissection in MINOCA Patients with Delayed Washout at Coronary Angiography – Protocol for an Observational, OCT-based Study

Abstract Background: Myocardial infarction (MI) with no obstructive coronary arteries (MINOCA) is a special form of the acute coronary syndrome. The heterogeneous pathophysiology of MINOCA is not well elucidated and includes cardiac and non-cardiac causes. Slow flow phenomenon on coronary angiography can be associated with several possible causes of MINOCA confirmed by optical coherence tomography (OCT). Therefore, the aim of this study is to assess the underlying mechanism of the delayed washout phenomenon on coronary angiography and the potential role of subintimal coronary artery dissection (SD) in the setting of an acute MI. Methods and design: This clinical prospective, descriptive research will enroll patients diagnosed with acute MI (STEMI or NSTEMI) identified by coronary angiography, followed by OCT imaging of the coronary arteries at the Emergency Clinical County Hospital of Târgu Mureş, Romania. The enrolled patients will be separated into two groups based on OCT examination, patients with SD and patients with no SD. Conclusion: The underlying mechanisms of MINOCA with delayed washout phenomenon on coronary angiography is still poorly understood. Modern invasive imaging techniques are capable to assess the microstructure of the coronary artery wall and are able to offer the much needed information to elucidate the pathophysiological changes which ultimately cause the acute event. The current study offers a new, complex – clinical, invasive and noninvasive imaging, as well as biomarker-based – approach, which may lead to a better understanding and treatment of this pathology.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) in Chinese patients: Clinical features, treatment and 1 year follow-up

BackgroundMyocardial infarction with non-obstructive coronary arteries (MINOCA) is characterised by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography (stenosis<50%). We investigated clinical features among Chinese MINOCA patients and one-year follow-up on medication management and cardiovascular events. MethodsThe data of 2029 patients with acute myocardial infarction were consecutively collected. MINOCA patients were identified with coronary angiography (<50% stenosis). Clinical features, medication management and cardiovascular events were assessed. ResultsOne hundred and twenty-eight patients (6.3%) were diagnosed as MINOCA. Compared with the myocardial infarction with obstructive coronary arteries (MI-CAD) patients, the prevalence of traditional risk factors of CAD was lower in MINOCA patients. The levels of TG, LDL-C, cTnT, CK-MB and myoglobin in the MINOCA group were significantly lower, whereas LVEF was higher. MINOCA patients are less likely to receive secondary prevention medication for MI, and use of all recommended drugs decreased at one-year follow-up. MACE in the MINOCA group was lower. After adjusting related risk factors, logistic analysis showed MINOCA was independently associated with lower risk of MACE. Independent predictors for MACE in MINOCA patients were older age (≥60 years), females, atrial fibrillation and reduced LVEF. ConclusionCompared with MI-CAD, MINOCA was accompanied by fewer traditional risk factors of CAD, less likely to be discharged upon secondary prevention medication of MI and the occurrence of MACE during 1 year follow-up was lower. Older age (≥60 years), females, atrial fibrillation and reduced LVEF were independent risk factors for MACE in MINOCA patients within one year.

Prevalence of myocardial infarction with non-obstructive coronary arteries (MINOCA) amongst acute coronary syndrome in patients with antiphospholipid syndrome

Antiphospholipid antibody syndrome (APLS) is well known to cause thrombotic events and premature atherosclerosis leading to coronary artery occlusion. The association of non-thrombotic acute myocardial infarctions (AMI) with APLS is not as clearly delineated. The objective of this study was to determine the relative prevalence of myocardial infarction with non obstructive coronary arteries (MINOCA) compared to MI from vaso-occlusive disease amongst patients with known APLS at our institution. Out of 575 patients with positive antiphospholipid antibodies, cardiac catheterizations were performed in 40 patients presented with AMI and had cardiac catheterizations. MINOCA was found in 8 patients. We found that MINOCA is common in patients with APLS presenting with ACS and that spasm may also play a role in AMI in patients with APLS.

Kobieta w wieku 58 lat z bólem w klatce piersiowej

We present the case of a 58-year-old woman with suspected myocardial infarction. Coronarography did not reveal changes in coronary arteries. Laboratory tests revealed increases in troponin and inflammation parameters, and therefore MRI was performed. This showed subendocardial ischaemic necrosis with organ viability preservation in the heart muscle. As a result, myocardial infarction with non obstructive coronary arteries (MINOCA) was diagnosed.

MYOCARDIAL SCAR PATTERNS IN WOMEN WITH SUSPECTED CORONARY VASOMOTOR DYSFUNCTION: A REPORT FROM THE WOMEN’S ISCHEMIA SYNDROME EVALUATION

Women with suspected ischemia and no obstructive coronary arteries (INOCA) have an 8% prevalence of myocardial scar. However scar patterns are not well described in relation to coronary vasomotor function. 367 symptomatic women with suspected INOCA underwent cardiac magnetic resonance imaging with

Incremental Diagnostic Role of Cardiac Magnetic Resonance in Myocardial Infarction with Non–Obstructive Coronary Arteries: Regional Far North Queensland Experience

Background: Myocardial infarction with non–obstructive coronary arteries (MINOCA) is increasingly diagnosed in clinical practice. The mechanism may be due to small-vessel occlusion, thromboembolism, or plaque disruption. There are other causes for troponin-positive chest pain, including Takotsubo cardiomyopathy, pulmonary embolism, and myocarditis, for which treatments differ. Recent clinical guidelines suggest cardiac magnetic resonance (CMR) is essential to facilitate accurate diagnosis and treatment. We evaluated the additional CMR value in Far North Queensland patients.

Frequency of Non Obstructive Epicardial Coronary Arteries in Patients with Typical Cardiac Chest Pain

Frequency of Non Obstructive Epicardial Coronary Arteries in Patients with Typical Cardiac Chest Pain

Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing Evidence-Based Therapies and Research Agenda for the Next Decade.

The Cardiovascular Disease in Women Committee of the American College of Cardiology, in conjunction with interested parties (from the National Heart, Lung, and Blood Institute, American Heart Association, and European Society of Cardiology), convened a working group to develop a consensus on the syndrome of myocardial ischemia with no obstructive coronary arteries. In general, these patients have elevated risk for a cardiovascular event (including acute coronary syndrome, heart failure hospitalization, stroke, and repeat cardiovascular procedures) compared with reference subjects and appear to be at higher risk for development of heart failure with preserved ejection fraction. A subgroup of these patients also has coronary microvascular dysfunction and evidence of inflammation. This document provides a summary of findings and recommendations for the development of an integrated approach for identifying and managing patients with ischemia with no obstructive coronary arteries and outlines knowledge gaps in the area. Working group members critically reviewed available literature and current practices for risk assessment and state-of-the-science techniques in multiple areas, with a focus on next steps needed to develop evidence-based therapies. This report presents highlights of this working group review and a summary of suggested research directions to advance this field in the next decade.

Optical coherence tomography-based diagnosis in a patient with ST-elevation myocardial infarction and no obstructive coronary arteries

Optical coherence tomography-based diagnosis in a patient with ST-elevation myocardial infarction and no obstructive coronary arteries