Arteriographie anatomy and mechanisms of myocardial ischemia in unstable angina

Ambrose, John A.; Hjemdahl-Monsen, Craig E.

doi:10.1016/s0735-1097(87)80483-7

Cited by 36 publications

(4 citation statements)

References 42 publications

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“…In patients with episodes of chest pain within 24 hours of coronary angiography an incidence of thrombosis of up to 100% has been found. In 2/3 of patients, thrombi ate also present distally to the lesions, possibly as the result of turbulent blood flow, as suggested by Ambrose et al [11].…”

Section: Occiusive or Non-occlusive Thrombus Formationmentioning

confidence: 67%

“…Hemorrhage into the plaque may be extensive and disruptive and may induce significant luminal narrowing [33,34,64]. Intramural hematoma is regarded as the missing tink ( Figure 2) between morphology, atherosclerosis and function (spasm) [11,64]. Using coronary angiography, such lesions can only be detected indirectly.…”

Section: Intramurat Hematomasmentioning

confidence: 99%

“…The prevalence of these signs is depending on the time between start of symptoms and angiography [11,12]. The degree of coronary luminal narrowing is below 50% in the majority of patients, so that a flow reduction due to coronary luminal narrowing cannot explain the onset of ischemic symptoms.…”

Section: Unstable Angina Pectorismentioning

confidence: 99%

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Koronate Mikroembolisierung — Bedeutung bei akuten koronaren Syndromen und bei interventionellen Eingriffen

Erbel¹,

Heusch²

1999

Herz

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The diagnosis coronary artery disease is classically based on patient's symptoms and morphology, as analyzed by angiography. The importance of risk factors for the development of coronary atherosclerosis and disturbance of coronary vasomotion is clearly established. However, microembolization of the coronary circulation has also to be taken into account. Microembolization may occur as a single or as multiple, repetitive events, and it may induce inflammatory responses. Spontaneous microembolization may occur, when the fibrous cap of an atheroma or fibroatheroma (Stary i.v. and Va) ruptures and the lipid pool with or without additional thrombus formation is washed out of the atheroma into the microcirculation. Such events with progressive thrombus formation are known as cyclic flow variations. Plaque rupture occurs more frequently than previously assumed, i.e. in 9% of patients without known heart disease suffering a traffic accident and in 22% of patients with hypertension and diabetes. Also, in patients dying from sudden death microembolization is frequently found. Patients with stable and unstable angina show not only signs of coronary plaque rupture and thrombus formation, but also microemboli and microinfarcts, the only difference between those with stable and unstable angina being the number of events. Appreciation of microembolization may help to better understand the pathogenesis of ischemic cardiomyopathy, diabetic cardiomyopathy and acute coronary syndromes, in particular in patients with normal coronary angiograms, but plaque rupture detected by intravascular ultrasound. Also, the benefit from glycoprotein IIb/IIIa receptor antagonist is better understood, when not only the prevention of thrombus formation in the epicardial atherosclerotic plaque, but also that of microemboli is taken into account. Microembolization also occurs during PTCA, inducing elevations of troponin T and I and elevations of the ST segment in the EKG. Elevated baseline coronary blood flow velocity, as a potential consequence of reactive hyperemia in myocardium surrounding areas of microembolization, is more frequent in patients with high frequency rotablation than in patients with stenting and in patients with PTCA. The hypothesis of iafrogenic microembolization during coronary interventions is now supported by the use of aspiration and filtration devices, where particles with a size of up to 700 microns have been retrieved. In the experiment, microembolization is characterized by perfusion-contraction mismatch, as the proportionate reduction of flow and function seen with an epicardial stenosis is lost and replaced by contractile dysfunction in the absence of reduced flow. The analysis of the coronary microcirculation, in addition to that of the morphology and function of epicardial coronary arteries, and in particular appreciation of the concept of microembolization will further improve the understanding of the pathophysiology and clinical symptoms of coronary artery disease.

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Section: Occiusive or Non-occlusive Thrombus Formationmentioning

confidence: 67%

Section: Intramurat Hematomasmentioning

confidence: 99%

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Koronate Mikroembolisierung — Bedeutung bei akuten koronaren Syndromen und bei interventionellen Eingriffen

Erbel¹,

Heusch²

1999

Herz

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“…Contrary to old conceptualizations linking cardiovascular risk status to degree of luminal obstruction, it is now well established that plaques that produce stenoses that do not limit blood flow are more likely to rupture and provoke thrombosis than are larger plaques producing flow-limiting stenoses. Across studies, sites of high-grade stenosis as identified by preevent coronary angiograms rarely corresponded to [15][16][17][18][19][20][21][22][23] In 48 patients studied by myocardial scintigraphy, for example, a reversible perfusion abnormality was found in only 60% of segments that later were sites of acute myocardial infarction. 23 Rather, lesions causing <50% occlusion of coronary arteries are responsible for approximately two thirds of acute coronary events (Figure 3).…”

Section: Pathophysiology Of Coronary Heart Diseasementioning

confidence: 99%

Cardiovascular Risk Assessment and Triptans

Papademetriou

2004

Headache

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Identifying the patient for whom triptans are contraindicated because of recognized, diagnosed cardiovascular disease is relatively straightforward. Determining whether a patient with potential unrecognized cardiovascular disease is an appropriate candidate for triptan therapy, however, constitutes a difficult challenge, especially in the absence of a framework for workup of patients. This article discusses the pathophysiology of coronary heart disease and issues involved in assessing cardiovascular risk, and it attempts to provide a framework for cardiovascular risk assessment that can be applied to decisions for prescribing triptans. Current guidelines for cardiovascular risk assessment allow stratification of patients to low, intermediate, or high risk of coronary heart disease events. This framework for risk assessment can be applied to decisions for prescribing triptans. Cardiovascular risk-assessment algorithms discussed elsewhere in this supplement suggest that patients at low risk (1 or no risk factors) of coronary heart disease can be prescribed triptans without the need for a more intensive cardiovascular evaluation. Conversely, patients with established coronary heart disease or coronary heart disease risk equivalents should not be prescribed triptans according to the current prescribing recommendations. Patients at intermediate risk (2 or more risk factors) of coronary heart disease require cardiovascular evaluation before triptans can be prescribed. Current understanding suggests that the risk of future acute coronary events is a function of the absolute number of vulnerable plaques present, a variable that cannot be accurately determined using available technology or risk-prediction models. Cardiovascular risk-assessment guidelines should be evaluated in the context of this limitation.

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Thrombosis in Ischemic Heart Disease

Ambrose

Weinrauch²

1996

Arch Intern Med

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Arteriographie anatomy and mechanisms of myocardial ischemia in unstable angina

Cited by 36 publications

References 42 publications

Koronate Mikroembolisierung — Bedeutung bei akuten koronaren Syndromen und bei interventionellen Eingriffen

Koronate Mikroembolisierung — Bedeutung bei akuten koronaren Syndromen und bei interventionellen Eingriffen

Cardiovascular Risk Assessment and Triptans

Thrombosis in Ischemic Heart Disease

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