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Coronary Artery Spasm: The Interplay Between Endothelial Dysfunction and Vascular...

Patients with angina pectoris, the cardinal symptom of myocardial ischaemia, yet without significant flow-limiting epicardial artery stenosis represent a diagnostic and therapeutic challenge. Coronary artery spasm (CAS) is an established cause for anginal chest pain in patients with angiographically unobstructed coronary arteries. CAS may occur at the epicardial level and/or in the microvasculature.

Although the underlying pathophysiological mechanisms of CAS are still largely unclear, endothelial dysfunction and vascular smooth muscle cell (VSMC) hyperreactivity seem to be involved as major players, although their contribution to induce CAS is still seen as controversial.

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Research

Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA)

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is clinically defined by the presence of the universal acute myocardial infarction (AMI) criteria, absence of obstructive coronary artery disease (≥50% stenosis), and no overt cause for the clinical presentation at the time of angiography (eg, classic features for takotsubo cardiomyopathy).

With the more frequent contemporary use of coronary angiography in AMI, clinicians have been regularly confronted with this puzzling problem and seeking guidance in its management. An article by Lindahl et al in this issue of Circulation represents a major step forward in MINOCA and thereby warrants taking stock of the past, present, and future management strategies of this intriguing condition.

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Research

2019 ESC Guidelines for the diagnosis and management of chronic...

Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

A great number of guidelines have been issued in recent years by the European Society of Cardiology (ESC), as well as by other societies and organizations. Because of their impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user.

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Research

Ischemia and No Obstructive Coronary Artery Disease

Determine the prevalence and correlates of microvascular and vasospastic angina in patients with symptoms and signs of ischemia but no obstructive coronary artery disease (INOCA).

Three hundred ninety-one patients with angina were enrolled at 2 regional centers over 12 months from November 2016 (NCT03193294). INOCA subjects (n=185; 47%) had more limiting dyspnea (New York Heart Association classification III/IV 54% versus 37%; odds ratio [OR], 2.0 [1.3–3.0]; P=0.001) and were more likely to be female (68% INOCA versus 38% in coronary artery disease; OR, 1.9 [1.5 to 2.5]; P<0.001) but with lower cardiovascular risk scores (ASSIGN score median 20% versus 24%; P=0.003).

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News

Twenty-Five Worldwide Renowned Cardiologists Give their Support to the IHSA

International Heart Spasms Alliance (IHSA) is a global initiative lead by experts through experience. These are patients who are living with coronary vasospasms and microvascular angina, while also working in a collaborative equal partnership with clinicians.

We have invited healthcare professionals from around the world to our alliance to work with us in an equal partnership. These are expert cardiologists and healthcare professionals who are interested in learning more about and further researching these NOCAD conditions. Together, we are looking to spread worldwide awareness to help further research and bring faster diagnoses to patients suffering from these often-overlooked heart conditions.

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Research

Diagnosis of patients with angina and non-obstructive coronary disease in...

Around 40% of all patients undergoing angiography are found to have normal coronary arteries or non-obstructive coronary artery disease (NOCAD). Despite the high prevalence, this is a group who rarely receive a definitive diagnosis, are frequently labelled and managed inappropriately and by and large, continue to remain symptomatic.

Half of this group will have coronary microvascular dysfunction (CMD), associated with a higher rate of major adverse cardiovascular events; identifying CMD represents a therapeutic target of unmet need. As the pressure wire has revolutionised our ability to interrogate epicardial coronary disease during the time of angiography, measuring flow can similarly classify NOCAD during a single procedure.

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Research

Angina: contemporary diagnosis and management

Around one half of angina patients have no obstructive coronary disease; many of these patients have microvascular and/or vasospastic angina. Tests of coronary artery function empower clinicians to make a correct diagnosis (rule-in/rule-out), complementing coronary angiography. Physician and patient education, lifestyle, medications and revascularisation are key aspects of management.

Ischaemic heart disease (IHD) remains the leading global cause of death and lost life years in adults, notably in younger (<55 years) women. Angina pectoris (derived from the Latin verb ‘angere’ to strangle) is chest discomfort of cardiac origin. It is a common clinical manifestation of IHD with an estimated prevalence of 3%–4% in UK adults. There are over 250 000 invasive coronary angiograms performed each year with over 20 000 new cases of angina.

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Research

Assessment of Vascular Dysfunction in Patients Without Obstructive Coronary Artery...

Ischemic heart disease secondary to coronary vascular dysfunction causes angina and impairs quality of life and prognosis. About one-half of patients with symptoms and signs of ischemia turn out not to have obstructive coronary artery disease, and coronary vascular dysfunction may be relevant.

Adjunctive tests of coronary vasomotion include guidewire-based techniques with adenosine and reactivity testing, typically by intracoronary infusion of acetylcholine. The CorMicA (Coronary Microvascular Angina) trial provided evidence that routine management guided by an interventional diagnostic procedure and stratified therapy improves angina and quality of life in patients with angina but no obstructive coronary artery disease.

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Research

Prognostic Links Between OCT-Delineated Coronary Morphologies and Coronary Functional Abnormalities...

Whether there are prognostic links between coronary morphologies and coronary functional abnormalities was examined in ischemia and nonobstructive coronary artery disease (INOCA) patients.

Although INOCA has attracted much attention, little is known about the prognostic impact of coronary morphologies in this disorder.

A total of 329 consecutive INOCA patients were enrolled and underwent spasm provocation testing combined with lactate sampling for diagnosis of epicardial and microvascular spasm (MVS).

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Research

International standardization of diagnostic criteria for vasospastic angina

Standardization of diagnostic criteria for ischemic symptoms due to coronary microvascular dysfunction (CMD) is needed for further investigation of patients presenting with anginal chest pain consistent with “microvascular angina” (MVA).

At the annual Coronary Vasomotion Disorders International Study Group (COVADIS) Summits held in August 2014 and 2015, the following criteria were agreed upon for the investigative diagnosis of microvascular angina…

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Around The World

Real Patient Stories

Arthur’s story

My name is Arthur. I am a Scot but have lived in London for nearly forty years.

In 2014, I had my first heart attack. In the following six years, I went to A&E at least twice a year. Every time, I was sent home and was told it was reflux.

My own doctor in about 2015/16 put me on half an angina pill. When I was in hospital, I was told by the cardiology doctors that I did not need it as I never had angina at all.

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Barbara’s story

I am a 62-year-old retired physician. My story began at age 47.

I was a very busy practicing OB/Gyn physician who was otherwise healthy.

I was on call at the hospital, and it was turning out to be one of the busiest days I had ever experienced as a physician. I was in a medical group that took call for 24 hours straight, most of the time working the entire 24 hours.

Halfway through that 24-hour call, I was in the operating room doing a C/Section on a patient. Halfway through the surgery I began to feel crushing chest pain.

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Charlotte’s story

While at work in September 2014, I lost vision of my left eye and had terrible feeling of “heat” all over the left side of my body.

The ER ophthalmologist directed me to cardiology for a vascular problem.

A week later, I could not walk 100 meters (325 feet) without crushing chest pain and shortness of breath.

I was no longer functional. Making my bed was all I could do in a whole day. I was no longer an active 54-year-old.

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