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Fourth universal definition of myocardial infarction (2018)

In the late 19th century, post-mortem examinations demonstrated a possible relationship between thrombotic occlusion of a coronary artery and myocardial infarction (MI). However, it was not until the beginning of the 20th century that the first clinical descriptions appeared describing a connection between the formation of a thrombus in a coronary artery and its associated clinical features.

Despite these landmark observations, considerable time elapsed before general clinical acceptance of this entity was achieved, in part due to one autopsy study that showed no thrombi in the coronary arteries of 31% of deceased patients with an MI.

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Research

Coronary microvascular disease: current concepts of pathophysiology, diagnosis and management

Coronary microvascular disease (CMD) is present in 30% of patients with angina and is associated with increased morbidity and mortality. We now have an improved understanding of the pathophysiology of CMD and the invasive and noninvasive tests that can be used to make the diagnosis.

Recent studies have shown that management of CMD guided by physiological testing yields better results than empirical treatment. Despite major advances in diagnosing and stratifying this condition, therapeutic strategies remain limited and poorly defined.

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Research

Clinical characteristics and prognosis of patients with microvascular angina: an...

To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis of patients with microvascular angina (MVA). The Coronary Vasomotor Disorders International Study Group proposed the diagnostic criteria for MVA. We prospectively evaluated the clinical characteristics of patients according to these criteria and their prognosis.

The primary endpoint was the composite of major cardiovascular events (MACE), verified by institutional investigators, which included cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina.

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Research

The Lancet women and cardiovascular disease Commission: reducing the global...

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum.

Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated.

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Research

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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Real Patient Stories

Dima’s story

March 3rd, 2021 was the day that changed everything. At 55, I had a busy counselling practice and a few other projects on the go. The pandemic was causing anxiety for many of my clients and in my private life. I had a lot of stress of my own: there were safety issues in the building where I lived, and I was looking for a new apartment. Despite this, I thought I was handling it well. I was fairly healthy, I walked daily, ate well, meditated and didn’t smoke or drink.

I started to experience heavy fatigue towards the end of 2020 but told myself it was normal considering all that was going on in the world.

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MaryAnn’s story

When I was 39, with zero risk factors for heart disease, I had all the classic symptoms associated with a heart attack. My doctors put me on three blood thinners to dissolve a clot in a minor artery seen in an angiogram. The next day, while the original clot had dissolved, I had a clot in a larger artery. Baffled, the cardiologists put in a stent. As they backed the scope out of the artery, it spasmed in another location.

At that time, I had a 4-year-old, an 8-year-old, and a 12-year-old. My husband traveled extensively for work. I asked myself two questions: 1) How do I feel about dying at age 39? 2) If I don’t die, how do I live?

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Sandra’s story

My story began in January 2010, while sitting at a traffic light returning to the office. I was working as a home health physical therapist. I began having chest pain out of nowhere. I got to my office and my boss, an RN, asked me if I was OK. I told her about the chest pain. By then it was starting to progress down my left arm. She took my blood pressure, normally 98/68. It was 140/90. She called my husband and told him to meet me at the ER. I drove myself there. They ran the normal tests and diagnosed me with costochondritis. Pain meds made the symptoms go away. The pain came back six times in the next 6 months. I asked for a cardiologist referral, but was denied, due to my age (39), lack of family history, and being in shape.

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