RESUMEN
Vasospastic angina (VSA) was first described in 1959 by Myron Prinzmetal as "the variant form of angina pectoris" on the sole basis of medical history and ECG. This condition is currently categorized as an endotype of myocardial infarction without coronary obstruction (Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA)). Diagnostic criteria have been suggested by expert consensus. Provocative testing during coronary angiography is the gold standard test but is rarely used. The clinical presentation is often neglected, and the diagnosis is missed. However, VSA may lead to life-threatening arrhythmias. There are simple and effective therapies that are markedly different from those for the atherosclerotic coronary artery disease.
Le vasospasme coronarien (VC) a été décrit pour la première fois en 1959 par Myron Prinzmetal comme « la forme variante de l'angine de poitrine ¼ sur la seule base de l'anamnèse et de l'ECG. Le VC est actuellement classé comme un endotype de l'infarctus du myocarde sans obstruction coronaire (Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA)). Des critères diagnostiques ont été proposés par des consensus d'experts. Le test de provocation lors de la coronarographie est l'examen de choix mais est rarement employé. La symptomatologie est souvent méconnue et le diagnostic n'est pas suffisamment évoqué. Pourtant, le VC peut conduire à des arythmies potentiellement fatales. Nous disposons de moyens thérapeutiques simples et efficaces, qui diffèrent sensiblement de ceux de la maladie coronarienne athérosclérotique.
Asunto(s)
Vasoespasmo Coronario , Humanos , Vasoespasmo Coronario/diagnóstico , Vasoespasmo Coronario/complicaciones , Angina Pectoris Variable/diagnóstico , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Angiografía Coronaria/métodos , ElectrocardiografíaRESUMEN
Approximately half of all coronary angiograms performed for angina do not show obstructive coronary artery disease, and many of these patients have coronary microvascular dysfunction (CMD). Invasive testing for CMD has increased with the advent and wider availability of thermodilution systems. We review CMD pathophysiology and invasive diagnostic testing using the Doppler and thermodilution systems. We report the results of a PubMed search of invasive microvascular testing and discuss limitations of current diagnostic algorithms in the diagnosis of CMD, including controversies regarding the optimal cutoff value for abnormal coronary flow reserve, use of microvascular resistance indices, and options for increasing sensitivity of testing.
Asunto(s)
Microcirculación , Humanos , Microcirculación/fisiología , Angina de Pecho/fisiopatología , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Termodilución/métodos , Circulación Coronaria/fisiología , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Angiografía Coronaria/métodos , Resistencia Vascular/fisiología , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnósticoRESUMEN
BACKGROUND: Angina pectoris can occur in up to 40% of patients following percutaneous coronary intervention (PCI). There is limited data assessing whether the type of stent implanted during revascularization can predict post-PCI angina symptoms. METHODS: In this study, data regarding revascularization characteristics including the stent type in patients admitted for PCI was collected. Prospective data including occurrence of angina and the presenting class, new onset ST-segment elevation myocardial infarction (STEMI), and other clinical outcomes were collected at 1, 3, and 6-month follow-up intervals. Univariable and multivariable logistic regression models were used to assess the potential predictors of angina symptoms at 6-month follow-up. RESULTS: A total of 787 patients (64.5% males) undergoing PCI with three stent types (Orsiro, Promus, and Xience) were included in the study. The occurrence of post PCI angina pectoris and new STEMI was similar among the stent types (p > 0.05). A linear association was found between the development of new STEMI (p = 0.018) and stroke (p = 0.003) and the worsening of angina class. The stent type was not a predictor of angina during the follow-up period. Other variables including dyslipidemia (odds ratio (OR) (95% CI), 1.51 (1.08; 2.10)), prior coronary artery disease (CAD) (OR (95% CI), 1.63 (1.02; 2.61)), and previous hospitalization (OR (95% CI), 2.10 (1.22; 3.63)) were independent predictors of angina. CONCLUSIONS: Although the type of stent may not have an association with the post-PCI angina, other predictors such as dyslipidemia and previous CAD and hospitalization may predict recurrence of cardiac angina. The class of angina severity may have a linear association with new-onset STEMI and stroke.
Asunto(s)
Angina de Pecho , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Diseño de Prótesis , Infarto del Miocardio con Elevación del ST , Stents , Humanos , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Femenino , Persona de Mediana Edad , Angina de Pecho/terapia , Angina de Pecho/etiología , Angina de Pecho/diagnóstico , Factores de Riesgo , Anciano , Resultado del Tratamiento , Factores de Tiempo , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/diagnóstico , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Medición de Riesgo , Estudios ProspectivosRESUMEN
Coronary sinus reducer implantation is a percutaneous technique creating a narrowing in the coronary sinus through the implantation of an hourglass-shaped endoprosthesis. It is proposed to reduce symptoms in patients suffering from refractory angina pectoris. This innovative treatment is experiencing a major craze among interventional cardiologists. It is associated with very high procedural success rates. Complications are rare and include coronary sinus dissection or perforation and migration of the device. This review exposes the device implantation technique, the potential anatomical difficulties, the tips and tricks to overcome challenging situations. It also focuses on the prevention and management of potential complications.
Asunto(s)
Seno Coronario , Humanos , Angina de Pecho/terapia , Angina de Pecho/prevención & control , Angina de Pecho/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
BACKGROUND: Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes. METHOD: Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing. RESULTS: This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007). CONCLUSIONS: Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.
Asunto(s)
Angiografía Coronaria , Vasos Coronarios , Humanos , Femenino , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Vasoespasmo Coronario/fisiopatología , Vasoespasmo Coronario/epidemiología , Vasoespasmo Coronario/diagnóstico , Australia/epidemiología , Angina de Pecho/epidemiología , Angina de Pecho/fisiopatología , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Anciano , Sistema Vasomotor/fisiopatologíaAsunto(s)
Calor , Humanos , Calor/efectos adversos , Masculino , Hemorragia/etiología , Angina de Pecho/etiología , Vesícula/etiologíaRESUMEN
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
INTRODUCTION: In this study, we aimed to evaluate the most common causes of recurrent angina after coronary artery bypass grafting (CABG) and our treatment approaches applied in these patients. METHODS: We included all patients who underwent CABG, with or without percutaneous coronary intervention after CABG, at our hospital from September 2013 to December 2019. Patients were divided into two groups according to the time of onset of anginal pain after CABG. Forty-five patients (58.16 ± 8.78 years) had recurrent angina in the first postoperative year after CABG and were specified as group I (early recurrence). Group II (late recurrence) comprised 82 patients (58.05 ± 8.95 years) with angina after the first year of CABG. RESULTS: The mean preoperative left ventricular ejection fraction was 53.22 ± 8.87% in group I, and 54.7 ± 8.58% in group II (P=0.38). No significant difference was registered between groups I and II regarding preoperative angiographic findings (P>0.05). Failed grafts were found in 27.7% (n=28/101) of the grafts in group I as compared to 26.8% (n=51/190) in group II (P>0.05). Twenty-four (53.3%) patients were treated medically in group I, compared with 54 (65.8%) patients in group II (P=0.098). There was a need for intervention in 46.6% (n=21) of group I patients, and in 34.1% (n=28) of group II patients. CONCLUSION: Recurrent angina is a complaint that should not be neglected because most of the patients with recurrent angina are diagnosed with either native coronary or graft pathology in coronary angiography performed.
Asunto(s)
Angina de Pecho , Puente de Arteria Coronaria , Recurrencia , Humanos , Puente de Arteria Coronaria/efectos adversos , Persona de Mediana Edad , Masculino , Femenino , Angina de Pecho/etiología , Angina de Pecho/cirugía , Anciano , Estudios Retrospectivos , Angiografía Coronaria , Complicaciones Posoperatorias/etiología , Intervención Coronaria Percutánea , Resultado del Tratamiento , Factores de Tiempo , Volumen Sistólico/fisiologíaRESUMEN
BACKGROUND: Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield. OBJECTIVES: The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA). METHODS: Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 µg) and right (20 to 80µg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels. RESULTS: This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486). CONCLUSIONS: Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.
Asunto(s)
Acetilcolina , Angina de Pecho , Enfermedad de la Arteria Coronaria , Circulación Coronaria , Vasoespasmo Coronario , Vasos Coronarios , Valor Predictivo de las Pruebas , Vasodilatadores , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Vasos Coronarios/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Vasodilatadores/administración & dosificación , Vasoespasmo Coronario/fisiopatología , Vasoespasmo Coronario/diagnóstico , Acetilcolina/administración & dosificación , Angina de Pecho/fisiopatología , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Cateterismo Cardíaco , Angiografía Coronaria , Reproducibilidad de los Resultados , Vasodilatación , VasoconstricciónRESUMEN
A 67-year-old woman with no known risk factors for coronary artery disease presented to the outpatient department with complaints of exertional fatigue and angina New York Heart Association class III.
Asunto(s)
Angina de Pecho , Humanos , Femenino , Anciano , Angina de Pecho/etiología , Angina de Pecho/diagnóstico , Angiografía Coronaria/métodosRESUMEN
BACKGROUND: Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly which can be congenital or acquired. Patients with SVA are commonly asymptomatic when the occupying effect of SVA is insignificant, while ruptured SVA usually causes severe symptoms including heart failure and myocardial ischemia. CASE PRESENTATION: We present an unusual case of a 64-year-old female manifesting with exertional dyspnea as well as angina pectoris for three months. Echocardiography and cardiac computed tomographic angiography confirmed unruptured left-coronary and non-coronary SVAs. The left anterior descending artery and left circumflex artery were stretched and compressed by the SVA which causing myocardial ischemia. The patient finally received aortic root replacement (Bentall procedure) and got symptom relieved. CONCLUSIONS: Giant unruptured SVA originating from left coronary sinus is extremely rare. Our case highlights that giant SVA should be considered in cases with angina pectoris. Echocardiography and coronary computed tomographic angiography are useful and important for diagnosis. Surgery is highly recommended in patients with SVA.
Asunto(s)
Aneurisma de la Aorta , Seno Aórtico , Femenino , Humanos , Persona de Mediana Edad , Seno Aórtico/diagnóstico por imagen , Seno Aórtico/cirugía , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Ecocardiografía , Tomografía Computarizada por Rayos X , Angina de Pecho/etiología , Angina de Pecho/cirugíaRESUMEN
BACKGROUND: ST-elevation myocardial infarction (STEMI) systems of care have reduced inter-hospital transfer times and facilitated timely reperfusion goals. Helicopters may be an option when land transportation is not feasible; however, the safety of air transport in patients with acute coronary syndrome (ACS) is a factor to consider. OBJETIVES: The aim of this study was to evaluate the safety of helicopter transport for patients with ACS. METHODS: Prospective, observational, and descriptive study including patients diagnosed with ACS within the STEMI network of a metropolitan city transferred by helicopter to a large cardiovascular center to undergo percutaneous coronary intervention. The primary outcome of the study was the incidence of air-travel-related complications defined as IV dislodgement, hypoxia, arrhythmia, angina, anxiety, bleeding, and hypothermia. Secondary outcomes included the individual components of the primary outcome. RESULTS: A total of 106 patients were included in the study; the mean age was 54 years and 84.9% were male. The most frequent diagnosis was STEMI after successful fibrinolysis (51.8%), followed by STEMI with failed fibrinolysis (23.7%) and non-reperfused STEMI (9.4%). Five patients (4.7%) developed at least one complication: IV dislodgement (1.8%) and hypoxemia (1.8%) in two patients and an episode of angina during flight (0.9%). A flight altitude of > 10,000 ft was not associated with complications. CONCLUSIONS: The results of this study suggest that helicopter transportation is safe in patients undergoing acute coronary syndrome, despite the altitude of a metropolitan area.
ANTECEDENTES: Los sistemas de atención de IAMCEST han reducido los tiempos de transferencia interhospitalaria y han facilitado las metas de reperfusión oportuna. Los helicópteros pueden ser una opción cuando el transporte terrestre no es factible; sin embargo, la seguridad del transporte aéreo en pacientes con síndrome coronario agudo (SICA) es un factor a considerar. OBJETIVOS: Evaluar la seguridad del transporte en helicóptero para pacientes con SICA. MÉTODOS: Estudio prospectivo, observacional, descriptivo. Se incluyeron pacientes con diagnóstico de SICA dentro de la red IAMCEST en metrópolis extensa, trasladados en helicóptero a un centro cardiovascular. El resultado primario del estudio fue la incidencia de complicaciones relacionadas con los viajes aéreos definidas cómo desalojo de catéter intravenoso, hipoxia, arritmia, angina, ansiedad, sangrado e hipotermia. RESULTADOS: Total de 106 pacientes; la edad media fue de 54 años y 84,9% eran hombres. La altitud media de vuelo fue de 10,100 pies y la distancia media de vuelo fue de 50,0 km. El diagnóstico más frecuente fue IAMCEST tras fibrinolisis exitosa (51,8%), seguido de IAMCEST con fibrinolisis fallida (23,7%). Cinco pacientes (4,7%) desarrollaron una complicación: desalojo IV (1,8%) e hipoxemia (1,8%) en dos pacientes y un episodio de angina durante el vuelo (0,9%). Una altitud de vuelo mayor de 10,000 pies no se asoció a complicaciones. CONCLUSIONES: Los resultados de este estudio sugieren que el transporte en helicóptero es seguro en pacientes con SICA, incluso en altitudes > 10,000 pies.
Asunto(s)
Síndrome Coronario Agudo , Infarto del Miocardio , Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Masculino , Persona de Mediana Edad , Femenino , Síndrome Coronario Agudo/terapia , Infarto del Miocardio con Elevación del ST/etiología , Infarto del Miocardio/etiología , Estudios Prospectivos , Viaje , Enfermedad Relacionada con los Viajes , Aeronaves , Intervención Coronaria Percutánea/métodos , Angina de Pecho/etiologíaRESUMEN
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.
Asunto(s)
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
We report the case of a 79-year-old male patient who benefited from the implantation of a coronary sinus reducer (CSR) (Reducer; Neovasc, Inc.) in the management of typical angina with mild exertion with optimal medical treatment.
Asunto(s)
Seno Coronario , Arteria Pulmonar , Masculino , Humanos , Anciano , Seno Coronario/diagnóstico por imagen , Seno Coronario/cirugía , Angina de Pecho/diagnóstico , Angina de Pecho/etiología , Angina de Pecho/terapiaRESUMEN
Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.