Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease — A pilot study

Sheikh, A.; Zeitz, Chris; Rajendran, S; Fiore, David Di; Tavella, Rosanna; Beltrame, John F.

doi:10.1016/j.ijcard.2018.04.077

Cited by 21 publications

(13 citation statements)

References 42 publications

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“…Indeed, anatomic testing (e.g., computed tomographic coronary angiography) may result in false reassurance for patients with no obstructive CAD but underlying MVA and/or VSA. These patients are predominantly women ( 30 ). Discontinuation of therapy by protocol in patients with undiagnosed MVA may be one explanation for why management guided by computed tomographic coronary angiography is associated with more angina and worse health-related quality of life compared with standard care ( 31 ).…”

Section: Discussionmentioning

confidence: 99%

1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA)

Ford

Stanley

Sidik

et al. 2020

JACC: Cardiovascular Interventions

175

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Objectives The aim of this study was to test the hypothesis that invasive coronary function testing at time of angiography could help stratify management of angina patients without obstructive coronary artery disease. Background Medical therapy for angina guided by invasive coronary vascular function testing holds promise, but the longer-term effects on quality of life and clinical events are unknown among patients without obstructive disease. Methods A total of 151 patients with angina with symptoms and/or signs of ischemia and no obstructive coronary artery disease were randomized to stratified medical therapy guided by an interventional diagnostic procedure versus standard care (control group with blinded interventional diagnostic procedure results). The interventional diagnostic procedure–facilitated diagnosis (microvascular angina, vasospastic angina, both, or neither) was linked to guideline-based management. Pre-specified endpoints included 1-year patient-reported outcome measures (Seattle Angina Questionnaire, quality of life [EQ-5D]) and major adverse cardiac events (all-cause mortality, myocardial infarction, unstable angina hospitalization or revascularization, heart failure hospitalization, and cerebrovascular event) at subsequent follow-up. Results Between November 2016 and December 2017, 151 patients with ischemia and no obstructive coronary artery disease were randomized (n = 75 to the intervention group, n = 76 to the control group). At 1 year, overall angina (Seattle Angina Questionnaire summary score) improved in the intervention group by 27% (difference 13.6 units; 95% confidence interval: 7.3 to 19.9; p < 0.001). Quality of life (EQ-5D index) improved in the intervention group relative to the control group (mean difference 0.11 units [18%]; 95% confidence interval: 0.03 to 0.19; p = 0.010). After a median follow-up duration of 19 months (interquartile range: 16 to 22 months), major adverse cardiac events were similar between the groups, occurring in 9 subjects (12%) in the intervention group and 8 (11%) in the control group (p = 0.803). Conclusions Stratified medical therapy in patients with ischemia and no obstructive coronary artery disease leads to marked and sustained angina improvement and better quality of life at 1 year following invasive coronary angiography. (Coronary Microvascular Angina [CorMicA]; NCT03193294 )

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Section: Discussionmentioning

confidence: 99%

1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA)

Ford

Stanley

Sidik

et al. 2020

JACC: Cardiovascular Interventions

175

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“…Minimal MR is calculated as the ratio of distal coronary pressure to distal coronary flow and during maximal coronary vasodilatation and reflects the intrinsic resistance of the coronary microvasculature blood flow as a marker of structural microvascular alterations ( 41 ). Minimal MR is expressed by the hyperemic microvascular resistance (HMR), where HMR >1.9 is considered abnormal and used for diagnosing CMD ( 42 ).…”

Section: Methodsmentioning

confidence: 99%

“…MG is consultant for Circle CVI ( 42 ). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.…”

Section: Conflict Of Interestmentioning

confidence: 99%

Reduced Microvascular Blood Volume as a Driver of Coronary Microvascular Disease in Patients With Non-obstructive Coronary Artery Disease: Rationale and Design of the MICORDIS Study

Vink

Hoef

Götte

et al. 2021

Front. Cardiovasc. Med.

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Background: Ischemia with non-obstructive coronary arteries (INOCA) is part of the ischemic heart disease spectrum, and is particularly observed in women. INOCA has various mechanisms, such as coronary vasospasm and coronary microvascular dysfunction (CMD). A decreased coronary flow reserve (CFR) and-or increased myocardial resistance (MR) are commonly used to diagnose CMD. However, CFR and MR do not describe all pathophysiological mechanisms underlying CMD. Increased myocardial oxygen consumption (MVO2) normally increases myocardial blood volume (MBV), independently from myocardial blood flow (MBF). In addition insulin enhances MBV in healthy skeletal muscle, and this effect is impaired in INOCA-related conditions such as diabetes and obesity. Therefore, we propose that MBV is reduced in INOCA patients.Aim: To assess whether myocardial blood volume (MBV) is decreased in INOCA patients, at baseline, during hyperinsulinemia and during stress.Design: The MICORDIS-study is a single-center observational cross-sectional cohort study (identifier NTR7515). The primary outcome is MBV, compared between INOCA patients and matched healthy controls. The patient group will undergo coronary function testing using a Doppler guidewire, intracoronary adenosine and acetylcholine to measure CFR and coronary vasospasm. Both the patient- and the control group will undergo myocardial contrast echocardiography (MCE) to determine MBV at baseline, during hyperinsulinemia and during stress. Subsequently, cardiac magnetic resonance (CMR) will be evaluated as a new and noninvasive diagnostic tool for CMD in INOCA patients. Microvascular endothelial function is a determinant of MBV and will be evaluated by non-invasive microvascular function testing using EndoPAT and by measuring NO production in circulating endothelial cells (ECFCs).

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“…An IMR, calculated as distal coronary pressure at maximal hyperemia multiplied by hyperemic mean index time, greater than or equal to 25 based upon thermodilution is consistent with microvascular dysfunction [ 61 ]. An HMR, calculated by dividing intracoronary pressure by hyperemic flow velocity, greater than 1.9 (odds ratio (OR) 15.6, 95% CI: 2.1–114, p = 0.007) based upon PET and doppler is an independent predictor of recurrent chest pain [ 62 ]. Lastly, flow-limiting CAD can be assessed by FFR, which is the ratio of mean distal coronary pressure to mean aortic pressure at maximal hyperemia; a value of less than or equal to 0.80 is abnormal [ 63 ].…”

Section: Ischemia With Nonobstructive Coronary Artery (Inoca) Disease and Coronary Microvascular Dysfunction (Cmd)mentioning

confidence: 99%

Angiogenic CD34 Stem Cell Therapy in Coronary Microvascular Repair—A Systematic Review

Rai

Shukla

Henry

et al. 2021

Cells

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Ischemia with non-obstructive coronary arteries (INOCA) is an increasingly recognized disease, with a prevalence of 3 to 4 million individuals, and is associated with a higher risk of morbidity, mortality, and a worse quality of life. Persistent angina in many patients with INOCA is due to coronary microvascular dysfunction (CMD), which can be difficult to diagnose and treat. A coronary flow reserve <2.5 is used to diagnose endothelial-independent CMD. Antianginal treatments are often ineffective in endothelial-independent CMD and thus novel treatment modalities are currently being studied for safety and efficacy. CD34+ cell therapy is a promising treatment option for these patients, as it has been shown to promote vascular repair and enhance angiogenesis in the microvasculature. The resulting restoration of the microcirculation improves myocardial tissue perfusion, resulting in the recovery of coronary microvascular function, as evidenced by an improvement in coronary flow reserve. A pilot study in INOCA patients with endothelial-independent CMD and persistent angina, treated with autologous intracoronary CD34+ stem cells, demonstrated a significant improvement in coronary flow reserve, angina frequency, Canadian Cardiovascular Society class, and quality of life (ESCaPE-CMD, NCT03508609). This work is being further evaluated in the ongoing FREEDOM (NCT04614467) placebo-controlled trial.

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Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease — A pilot study

Cited by 21 publications

References 42 publications

1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA)

1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA)

Reduced Microvascular Blood Volume as a Driver of Coronary Microvascular Disease in Patients With Non-obstructive Coronary Artery Disease: Rationale and Design of the MICORDIS Study

Angiogenic CD34 Stem Cell Therapy in Coronary Microvascular Repair—A Systematic Review

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