Despite their low-risk profile, nearly one half of symptomatic and mostly obese emergency department patients without evidence of myocardial infarction or coronary artery disease had CMD. The results could explain the high rates of return visits associated with chest pain, although their application to the general emergency department population require validation.
Aims
We explored the relationship between inflammation, renalase an anti-inflammatory protein, and acute chest pain with coronary microvascular dysfunction (CMD).
Methods and Results
We used cardiac Rb-82 PET/CT imaging to diagnose coronary artery disease (CAD/CALC) (defect or coronary calcification) and CMD (depressed coronary flow reserve without CAD) in patients with chest pain in an emergency department (ED). Blood samples were collected pre-imaging within 24 hours of ED presentation and were analyzed for renalase and inflammatory markers including C-reactive protein, interleukins, interferon gamma, tumor necrosis factor, vascular endothelial growth factor, and metalloproteinases. Exclusions were age ≤30 years, myocardial infarction, hemodynamic instability, hypertensive crisis, heart failure or dialysis.
Between 6/2014-11/2015, 80 patients undergoing PET/CT provided blood and were categorized as normal (18%), CAD/CALC (27%) and CMD (55%). Median renalase values were highest in patients with CMD (5503 ng/ml; IQR 3070) compared to patients with normal flows (4266 ng/ml; IQR 1503; p = 0.02) or CAD/CALC (4069 ng/ml IQR 1850; p =0.004). CMD patients had similar median values for inflammatory markers as normal patients (p > 0.05). Renalase remained an independent predictor of CMD (OR 1.34; 95% CI= 1.1-1.7, per 1,000 ng/ml) after adjustment for smoking, family history, obesity and Framingham risk score. In a model for CMD diagnosis with Framingham risk score, typical angina history and CRP, renalase improved discrimination from C-statistic=0.60 (95% CI 0.47, 0.73) to 0.70 (95% CI, 0.59-0.82).
Conclusion
We found elevated renalase in response to ischemia from acute CMD. Its role as a biomarker needs validation in larger trials.
The emergency department offers a unique venue to diagnose CMD with acute symptoms. In an exploratory randomized controlled trial of symptomatic patients with CMD and no coronary artery disease, promising results were seem with ranolazine and CFR improving at 30 days. Large robust clinical trials are needed to verify improvement of CMD in a sex-specific model. ClinicalTrials.gov identifier NCT02052011.
Community-based interventions (CBI) have been targeted as a potential means of tackling cardiovascular disease in women. However, there have been mixed results in terms of their impact on health, with at least some of this being attributed to high attrition rates. This study explores factors that may be contributing to the low retention of women in cardiovascular CBIs. In 2009, Sister to Sister, a national organization that sponsors community health fairs, provided free cardiovascular health screenings for a total of 9,443 women nationwide. All participants were invited to enroll in a 1 year, survey-based observational study to assess the effectiveness of these community health screenings. Of these 9,443 women, 5.9 % actively participated in the follow-up study. Participants were more likely to have health insurance (75.5 vs. 65.3 %, p < 0.001), have an annual income above 75,000 dollars (26.7 vs. 19.7 %, p < 0.001), and identify themselves as white (50.0 vs. 31.5 %, p < 0.001). They were also more likely to have hypertension (32.1 vs. 27.4 %, p = 0.018) and metabolic syndrome (35.7 vs. 20.4 %, p < 0.001). Our results suggest that white, affluent women with health insurance and cardiovascular risk factors are more likely to engage in CBIs that require longitudinal assessment. This study gives insight into the demographics, socioeconomic status, and cardiovascular comorbidities of women who participate in cardiovascular CBIs. The results may prove to be useful in understanding the biopsychosocial barriers to participation in CBIs in order to develop more effective interventions in the future.
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