RESUMEN
BACKGROUND: Since typical angina has become less frequent, it is unclear if this symptom still has prognostic significance. METHODS: We evaluated 38,383 patients undergoing stress/rest SPECT myocardial perfusion imaging followed for a median of 10.9 years. After dividing patients by clinical symptoms, we evaluated the magnitude of myocardial ischemia and subsequent mortality among medically treated versus revascularized subgroups following testing. RESULTS: Patients with typical angina had more frequent and greater ischemia than other symptom groups, but not higher mortality. Among typical angina patients, those who underwent early revascularization had substantially greater ischemia than the medically treated subgroup, including a far higher proportion with severe ischemia (44.9% vs 4.3%, P < 0.001) and transient ischemic dilation of the LV (31.3% vs 4.7%, P < 0.001). Nevertheless, the revascularized typical angina subgroup had a lower adjusted mortality risk than the medically treated subgroup (HR = 0.72, 95% CI: 0.57-0.92, P = 0.009) CONCLUSIONS: Typical angina is associated with substantially more ischemia than other clinical symptoms. However, the high referral of patients with typical angina patients with ischemia to early revascularization resulted in this group having a lower rather than higher mortality risk versus other symptom groups. These findings illustrate the need to account for "treatment bias" among prognostic studies.
Asunto(s)
Enfermedad de la Arteria Coronaria , Isquemia Miocárdica , Humanos , Pronóstico , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/terapia , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , IsquemiaAsunto(s)
Enfermedad de la Arteria Coronaria , Humanos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/fisiopatología , Angiografía por Tomografía Computarizada/métodos , Prevalencia , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/epidemiología , Angina de Pecho/fisiopatología , Corazón/fisiopatologíaAsunto(s)
Enfermedad de la Arteria Coronaria , Angina Microvascular , Tomografía de Emisión de Positrones , Humanos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/complicaciones , Tomografía de Emisión de Positrones/métodos , Angina Microvascular/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/complicacionesRESUMEN
BACKGROUND: The underlying mechanisms responsible for the clinical benefits following coronary sinus narrowing and pressure elevation remain unclear. The present study aims to investigate whether coronary sinus narrowing improves the indexes of coronary microcirculatory function. METHODS: Patients with refractory angina who had a clinical indication for reducer implantation underwent invasive physiological assessments before and 4 months after the procedure. The primary outcome was the change in the values of the index of microcirculatory resistance. Secondary end points included changes in coronary flow reserve and the resistive resistance ratio values. Angina status was assessed with the Canadian Cardiology Society class and the Seattle Angina Questionnaire. RESULTS: Twenty-four patients with a history of obstructive coronary artery disease and prior coronary revascularization (surgical and percutaneous) treated with reducer implantation were enrolled, and 21 of them (87%) underwent repeated invasive coronary physiological assessment after 4 months. The index of microcirculatory resistance values decreased from 33.35±19.88 at baseline to 15.42±11.36 at 4-month follow-up (P<0.001; mean difference, -17.90 [95% CI, -26.16 to -9.64]). A significant (≥20% from baseline) reduction of the index of microcirculatory resistance was observed in 15 (71.4% [95% CI, 47.8%-88.7%]) patients. The number of patients with abnormal index of microcirculatory resistance (≥25) decreased from 12 (57%) to 4 (19%; P=0.016). Coronary flow reserve increased from 2.46±1.52 to 4.20±2.52 (mean difference, 1.73 [95% CI, 0.51-2.96]). Similar findings were observed for resistive resistance ratio values. Overall, 16 patients (76.1%) had an improvement of 1 Canadian Cardiology Society class. Seattle Angina Questionnaire summary score increase of around 3 points (3.01 [95% CI, 1.39-4.61]). CONCLUSIONS: Coronary sinus reduction implantation is associated with a significant improvement in the parameters of coronary microcirculatory function. These findings provide insights into the improvement of angina symptoms and may have implications for the treatment of coronary microvascular dysfunction. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05174572.
Asunto(s)
Seno Coronario , Humanos , Seno Coronario/diagnóstico por imagen , Microcirculación , Estudios Prospectivos , Resultado del Tratamiento , Canadá , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/terapiaRESUMEN
BACKGROUND: Clinical management of patients with angina and no obstructive coronary artery disease (ANOCA) is still challenging. This scenario affects up to 50% of patients undergoing diagnostic coronary angiography due to suspected coronary artery disease. Many patients report a long and debilitating history before adequate diagnostics and management are initiated. OBJECTIVES: This article describes the current recommendations for diagnostic assessments and treatment in patients with ANOCA. Focus is placed on invasive diagnostics in the catheter laboratory, pharmacological/interventional treatment as well as the patient journey. RESULTS: In patients with ANOCA, the current European Society of Cardiology (ESC) guidelines suggest that invasive assessments using acetylcholine and adenosine for the diagnosis of an underlying coronary vasomotor disorder should be considered. Acetylcholine is used to diagnose coronary spasm, whereas adenosine is used in conjunction with a wire-based assessment for the measurement of coronary flow reserve and microvascular resistance. The invasive assessments allow the determination of what are referred to as endotypes (coronary spasm, impaired coronary flow reserve, enhanced microvascular resistance or a combination thereof). Establishing a diagnosis is helpful to: (a) initiate targeted treatment to improve quality of life, (b) reassure the patient that a cardiac cause is found and (c) to assess individual prognosis. CONCLUSIONS: Currently, patients with ANOCA are often not adequately managed. Referral to specialised centres is recommended to prevent long and debilitating patient histories until expertise in diagnosis and treatment becomes more widespread.
Asunto(s)
Angina de Pecho , Angiografía Coronaria , Humanos , Angiografía Coronaria/métodos , Angina de Pecho/terapia , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/diagnóstico , Vasoespasmo Coronario/diagnóstico por imagen , Vasoespasmo Coronario/diagnóstico , Vasoespasmo Coronario/terapia , Acetilcolina , Adenosina/administración & dosificaciónRESUMEN
This case report discusses a 74-year-old man presenting with angina pectoris. Coronary computed tomography angiography suggested only mild stenosis in the mid left anterior descending artery (LAD), with fractional flow reserve based on computed tomography images (FFRct) value of 0.87. However, coronary angiography revealed slit-like stenosis in the mid LAD, and the invasive fractional flow reserve (FFR) was measured at 0.72, demonstrating a deviation from the FFRct value.
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Angina de Pecho , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Estenosis Coronaria , Vasos Coronarios , Reserva del Flujo Fraccional Miocárdico , Valor Predictivo de las Pruebas , Humanos , Anciano , Masculino , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Angina de Pecho/fisiopatología , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/etiología , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Coronary computed tomography angiogram (CCTA) is a crucial tool for diagnosing CAD, but its impact on altering preventive medications is not well-documented. This systematic review aimed to compare changes in aspirin and statin therapy following CCTA and functional stress testing in patients with suspected CAD, and in those underwent CCTA when stratified by the presence/absence of plaque. RESULTS: Eight studies involving 42,812 CCTA patients and 64,118 cardiac stress testing patients were analyzed. Compared to functional testing, CCTA led to 66 â% more changes in statin therapy (pooled RR, 95 â% CI [1.28-2.15]) and a 74 â% increase in aspirin prescriptions (pooled RR, 95 â% CI [1.34-2.26]). For medication modifications based on CCTA results, 13 studies (47,112 patients with statin data) and 11 studies (12,089 patients with aspirin data) were included. Patients with any plaque on CCTA were five times more likely to use or intensify statins compared to those without CAD (pooled RR, 5.40, 95 â% CI [4.16-7.00]). Significant heterogeneity remained, which decreased when stratified by diabetes rates. Aspirin use increased eightfold after plaque detection (pooled RR, 8.94 [95 â% CI, 4.21-19.01]), especially with obstructive plaque findings (pooled RR, 9.41, 95 â% CI [2.80-39.02]). CONCLUSION: In conclusion, CCTA resulted in higher changes in statin and aspirin therapy compared to cardiac stress testing. Detection of plaque by CCTA significantly increased statin and aspirin therapy.
Asunto(s)
Aspirina , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Inhibidores de Agregación Plaquetaria , Valor Predictivo de las Pruebas , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Angina de Pecho/diagnóstico por imagen , Aspirina/uso terapéutico , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Prueba de Esfuerzo , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Placa Aterosclerótica , Inhibidores de Agregación Plaquetaria/uso terapéutico , Pautas de la Práctica en Medicina , Factores de Riesgo , Resultado del TratamientoRESUMEN
AIMS: Myocardial perfusion imaging (MPI) using [15O]H2O positron emission tomography (PET) is used to guide the selection of patients with angina for invasive angiography and possible revascularization. Our study evaluated (i) whether atrial fibrillation (AF) reduces global hyperaemic myocardial blood flow (MBF) and (ii) whether [15O]H2O PET MPI effectively guides revascularization procedures for patients with ongoing AF. METHODS AND RESULTS: We prospectively recruited 346 patients with angina and persistent or paroxysmal AF referred for baseline/hyperaemic [15O]H2O PET MPI. The primary outcome was revascularization within 3 months of MPI. In the analyses, patients were divided into four groups based on whether they had ongoing AF or sinus rhythm (SR) and whether they had previously documented coronary artery disease (CAD) or not. Thus, four groups were compared: SR-noCAD, AF-noCAD, SR-CAD, and AF-CAD. Hyperaemic MBF was affected by both ongoing AF and prior CAD [MBF (mL/min/g): 2.82 (SR-noCAD) vs. 2.12 (AF-noCAD) vs. 2.22 (SR-CAD) vs. 1.80 (AF-CAD), two-way analysis of variance P < 0.0001]. In multiple linear regression, ongoing AF was independently associated with reduced hyperaemic MBF. Every 0.1â mL/min/g decrease in hyperaemic MBF was associated with a 23% increase in odds of early revascularization. Receiver operating characteristic (ROC) analysis of vessel-specific hyperaemic MBF to predict early revascularization yielded the following areas under the ROC curve: SR-noCAD: 0.95 (P < 0.0001); AF-noCAD: 0.79 (P < 0.0001); SR-CAD: 0.78 (P < 0.0001); and AF-CAD: 0.88 (P < 0.0001). CONCLUSION: Ongoing AF is associated with 19-25% reduced global hyperaemic MBF as measured by [15O]H2O MPI PET. Regardless, vessel-specific hyperaemic MBF still predicts early revascularization in patients with AF.
Asunto(s)
Fibrilación Atrial , Imagen de Perfusión Miocárdica , Revascularización Miocárdica , Radioisótopos de Oxígeno , Tomografía de Emisión de Positrones , Humanos , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Femenino , Masculino , Imagen de Perfusión Miocárdica/métodos , Estudios Prospectivos , Tomografía de Emisión de Positrones/métodos , Persona de Mediana Edad , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Angina de Pecho/diagnóstico por imagen , Estudios de Cohortes , Angiografía Coronaria/métodos , Curva ROC , Índice de Severidad de la Enfermedad , Medición de RiesgoRESUMEN
AIMS: Women with angina and non-obstructive coronary artery disease (ANOCA) have a heightened risk for cardiovascular events, and the pathophysiology for ischaemic symptoms may be related to alterations in microvascular structure and function. We examined the use of breathing-enhanced oxygenation-sensitive cardiac magnetic resonance imaging (OS-CMR) using vasoactive breathing manoeuvres to assess myocardial oxygenation in women with ANOCA. METHODS AND RESULTS: We recruited women (aged 40-65 years) from two sites in Canada who presented to healthcare with persistent retrosternal chest pain and found to have ANOCA, or without a history of cardiovascular disease. All participants were scanned using a clinical 3T MRI scanner, and OS-CMR images were acquired over a breath hold following paced hyperventilation to measure global and regional measurements of heterogeneity. Fifty-four women with ANOCA (age: 55 ± 6.2 years) and 48 healthy controls (age: 51.2 ± 4.8 years) were recruited. There was no significant difference in volume, function, mass, or global myocardial oxygenation between the two groups [mean %Δ in signal intensity (SI): 4.9 (±7.3) vs. 4.5 (±10.1), P = 0.82]. Women with ANOCA had higher regional variations in myocardial oxygenation in circumferential [median %Δ in SI: 5.1 (2.0-7.6) vs. 2.2 (1.4-3.5), P = 0.0004] and longitudinal directions [median %Δ in SI: 11.4 (5.4-16.7) vs. 6.0 (3.0-7.0), P = 0.001], which remained present in a multivariate model. CONCLUSION: Heterogeneous myocardial oxygenation may explain ischaemic symptoms without any associated epicardial obstructive coronary artery disease. Regional variations in myocardial oxygenation on OS-CMR could serve as an important diagnostic marker for microvascular dysfunction in women with ANOCA.
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Angina de Pecho , Enfermedad de la Arteria Coronaria , Imagen por Resonancia Cinemagnética , Humanos , Femenino , Persona de Mediana Edad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Adulto , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/fisiopatología , Anciano , Imagen por Resonancia Cinemagnética/métodos , Estudios de Casos y Controles , Canadá , Consumo de Oxígeno/fisiología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Circulación Coronaria/fisiologíaRESUMEN
We present the case of a 60-year-old male, with active smoking and cocaine use disorder, who reported progressive chest pain. Various anatomical and functional cardiac imaging, performed to further evaluate chest pain etiology, revealed changing severity and distribution of left main artery (LMA) stenosis, raising suspicion for vasospasm. Intracoronary nitroglycerin relieved the vasospasm, with resolution of the LMA pseudostenosis. A diagnosis of vasospastic angina (VA) led to starting appropriate medical therapy with lifestyle modification counselling. This case highlights VA, a frequently underdiagnosed etiology of angina pectoris. We discuss when to suspect VA, its appropriate work-up, and management.
Asunto(s)
Angiografía Coronaria , Estenosis Coronaria , Vasoespasmo Coronario , Nitroglicerina , Vasodilatadores , Humanos , Masculino , Persona de Mediana Edad , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Estenosis Coronaria/fisiopatología , Vasoespasmo Coronario/diagnóstico por imagen , Vasoespasmo Coronario/fisiopatología , Vasoespasmo Coronario/tratamiento farmacológico , Vasoespasmo Coronario/terapia , Vasoespasmo Coronario/diagnóstico , Nitroglicerina/administración & dosificación , Resultado del Tratamiento , Vasodilatadores/uso terapéutico , Vasodilatadores/administración & dosificación , Valor Predictivo de las Pruebas , Trastornos Relacionados con Cocaína/complicaciones , Índice de Severidad de la Enfermedad , Angina de Pecho/etiología , Angina de Pecho/diagnóstico por imagen , Diagnóstico Diferencial , Fumar/efectos adversosRESUMEN
Cardiovascular disease (CVD) is the main cause of death worldwide, including in Brazil. Angina pectoris is a challenging disease because its clinical manifestation is not always related to the degree of obstruction. Visceral pain fromany source can be totally disabling. It influences all aspects of the life of a patient and it can be one of the main causes of absence from work and of family disruption. Spinal cord electrical stimulation (SCES) has been traditionally applied for the treatment of neuropathic pain, with good to excellent results. Visceral pain syndrome can be as debilitating and disabling as somatic or neuropathic pain; however, there seems to be a lack of consensus on the appropriate treatment and strategies for these disorders. Themajor difference of SCES for visceral pain, compared to postlaminectomy syndrome or to regional complex syndrome, is the number of stimulated dermatomes. In most viscera, the somatotopic arrangement has two to four medullar levels, sometimes requiring laterality. After reviewing the literature, we have concluded that SCES is now a viable, low-risk option with satisfactory results for the treatment of neuropathic and visceral pain; therefore, it can be used in refractory angina after the failure of standard therapy. However, further studies are required to increase the application and efficacy of this procedure in the clinical practice.
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Humanos , Masculino , Persona de Mediana Edad , Médula Espinal , Estimulación Eléctrica Transcutánea del Nervio/métodos , Dolor Visceral/terapia , Angina de Pecho/terapia , Resultado del Tratamiento , Dolor Visceral/etiología , Angina de Pecho/diagnóstico por imagenRESUMEN
No disponible
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Humanos , Masculino , Anciano , Soplos Cardíacos/diagnóstico por imagen , Aneurisma Ilíaco/complicaciones , Aneurisma Roto/diagnóstico por imagen , Angina de Pecho/diagnóstico por imagen , Troponina/análisisRESUMEN
Abstract The lateral costal artery has sometimes been identified as the culprit for the "steal phenomenon" after coronary artery bypass grafting, besides being occasionally used for myocardial revascularization. Its branches make anastomoses with the internal thoracic artery through lateral intercostal arteries. We aim to report, on three cases, the clinical significance of a well-developed lateral costal artery after coronary artery bypass grafting. Two out of three patients who underwent coronary artery bypass graft surgery in our center between June 2010 and August 2017, applied to us with stable angina pectoris, while the third one was diagnosed with acute coronary syndrome after applying to the emergency department. In coronary cineangiography, in all three cases, a well-developed accessory vessel arising from the proximal 2.5 cm segment of the left internal thoracic artery coursed as far as the 6th rib was detected, and it was confirmed to be the lateral costal artery. A stable angina pectoris in two of the patients was thought to be the result of steal phenomenon caused by the well-developed lateral costal artery. In the two cases with stable angina pectoris the lateral costal artery was obliterated via coil embolization. In the other case with the proximal left anterior descending artery stenosis, before percutaneous coronary intervention, the lateral costal artery was obliterated via coil embolization and the occluded subclavian artery was stented. Routine visualization in cineangiography and satisfactory surgical exploration of the left internal thoracic artery could be very helpful to identify any possible accessory branch of the left internal thoracic artery like the lateral costal artery.
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Humanos , Femenino , Persona de Mediana Edad , Anciano , Arterias Torácicas/anomalías , Síndrome de Robo Coronario-Subclavio/complicaciones , Anastomosis Interna Mamario-Coronaria , Angina de Pecho/etiología , Costillas/irrigación sanguínea , Arterias Torácicas/cirugía , Cineangiografía , Síndrome de Robo Coronario-Subclavio/cirugía , Síndrome de Robo Coronario-Subclavio/diagnóstico por imagen , Angina de Pecho/cirugía , Angina de Pecho/diagnóstico por imagen , Revascularización MiocárdicaRESUMEN
No disponible
Asunto(s)
Humanos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Angina de Pecho/complicaciones , Angina de Pecho/diagnóstico por imagen , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Angiografía/métodos , Imagen de Perfusión Miocárdica/métodosRESUMEN
Anomalies of the origin of coronary arteries are detected in 0.5-1.5% of all angiographies. Anomalous origin of the left main trunk is the most uncommon and its origin from pulmonary artery in adults is exceptional, usually because it is associated with a short survival. We report a 49-year-old female, presenting with a two months history of angina. The exercise electrocardiogram suggested ischemia. A coronary angiography was performed, showing the absence of the left main trunk in the left coronary sinus, a dilated right coronary artery, with no lesions and extensive collateral circulation to the anterior descending and circumflex arteries, with inverted flow and the left main trunk draining to the pulmonary artery. The left ventricle was mildly dilated with middle and apical anterior hypokinesia. Global systolic function was conserved. A surgical correction was decided, occluding the left main anomalous origin and performing a coronary artery bypass grafting from the left internal thoracic artery. The patient was discharged with no complications. At two years of follow-up she is symptom free and has a normal physical capacity.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Arteria Pulmonar/anomalías , Enfermedad de la Arteria Coronaria/complicaciones , Anomalías de los Vasos Coronarios/complicaciones , Angina de Pecho/etiología , Arteria Pulmonar/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Angina de Pecho/diagnóstico por imagenRESUMEN
OBJECTIVE: We aimed to describe the imaging findings of multidetector CT coronary angiography (MDCTA) in cases of vasospastic angina (VA) and to determine the accuracy of MDCTA in the identification of VA as compared with invasive coronary angiography with an ergonovine provocation test (CAG with an EG test). MATERIALS AND METHODS: Fifty-three patients with clinically suspected VA were enrolled in this study. Two radiologists analyzed the stenosis degree, presence or absence of plaque, plaque composition, and a remodeling index of the related-segment in CAG with an EG test, which were used as a gold standard. We evaluated the diagnostic performances of MDCTA by comparing the MDCTA findings with those of CAG with an EG test. RESULTS: Among the 25 patients with positive CAG with an EG test, all 12 patients with significant stenosis showed no definite plaque with the negative arterial remodeling. Of the six patients with insignificant stenosis, three (50%) had non-calcified plaque (NCP), two (33%) had mixed plaque, and one (17%) had calcified plaque. When the criteria for significant stenosis with negative remodeling but no definite evidence of plaque as a characteristic finding of MDCTA were used, results showed sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) of 48%, 100%, 100%, and 68%, respectively. CONCLUSION: Significant stenosis with negative remodeling, but no definite evidence of plaque, is the characteristic finding on MDCTA of VA. Cardiac MDCTA shows good diagnostic performance with high specificity and PPV as compared with CAG with an EG test.