Microvascular Angina and the Continuing Dilemma of Chest Pain With Normal Coronary Angiograms

Translational Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
Journal of the American College of Cardiology (Impact Factor: 15.34). 10/2009; 54(10):877-85. DOI: 10.1016/j.jacc.2009.03.080
Source: PubMed

ABSTRACT Since initial reports over 4 decades ago, cases of patients with angina-like chest pain whose coronary angiograms show no evidence of obstructive coronary artery disease and who have no structural heart disease continue to be a common occurrence for cardiologists. Many features of this patient population have remained constant with successive reports over time: a female predominance, onset of symptoms commonly between 40 and 50 years of age, pain that is severe and disabling, and inconsistent responses to conventional anti-ischemic therapy. Because patients may have had abnormal noninvasive testing that led to performance of coronary angiography, investigators have sought to show an association of this syndrome with myocardial ischemia. Abnormalities in coronary flow and metabolic responses to stress have been reported by several groups, findings consistent with a microvascular etiology for ischemia and symptoms, but others have questioned the presence of ischemia, even in patients selected for abnormal noninvasive testing. Despite considerable efforts by many groups over 4 decades, the syndrome remains controversial with regard to pathophysiology, diagnosis, and management.

    • "In up to 60% of patients undergoing coronary angiography (CAG), no significant obstructive coronary artery disease (CAD) is detected, and these patients with nonobstructive CAD are treated conservatively (Bugiardini and Bairey Merz, 2005; Cannon, 2009; Maddox et al., 2010; Vaccarino et al., 2013). Still, chest pain in patients with normal or near normal coronary arteries is prevalent and recurrent (Jespersen et al., 2013; Mommersteeg et al., 2013), related to increased clinical examinations (Beigel et al., 2013; Rossini et al., 2013), hospitalization (Rossini et al., 2013), major adverse cardiac events (Bugiardini and Bairey Merz, 2005; Jespersen et al., 2012) and mortality (Jespersen et al., 2012; Rossini et al., 2013; Sharaf et al., 2013), which requires further investigation. "
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    ABSTRACT: Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential mediating effects of negative mood states. Any chest pain in the past month was the primary outcome measure reported by 523 patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators. Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain. Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states. © 2015 European Pain Federation - EFIC®
    European journal of pain (London, England) 06/2015; DOI:10.1002/ejp.743 · 3.22 Impact Factor
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    • "We hypothesized that serum adipokines might be involved in the development of CSX. CSX is thought to be characterized by myocardial ischemia, caused by endothelial dysfunction in coronary microcirculation (Cannon et al. 1983) and impaired coronary flow reserve (Cannon 2009). A number of studies have confirmed impairment of both endotheliumdependent and endothelium-independent coronary vasodilation exists in CSX (Cannon 2009; Cannon et al. 1985). "
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    ABSTRACT: Objective: The role of adipokines in the development of cardiac syndrome X (CSX) remains unknown. Methods: Fifty-nine CSX subjects were retrospectively enrolled from our catheterization databank. Another 54 subjects with valvular heart disease or arrhythmia served as controls. Adipokines were measured by ELISA tests. Results: The CSX had lower circulating adiponectin but higher leptin and higher leptin/adiponectin ratio (×1000) (3.78 ± 4.96 vs. 2.14 ± 5.67, p < 0.001) than those of the controls. In a multivariate analysis, a higher leptin/adiponectin ratio was a predictor of CSX, while insulin-resistance index was not. Conclusions: Adipokines may be implicated in the pathogenesis of CSX.
    Biomarkers 10/2012; 18(1). DOI:10.3109/1354750X.2012.730550 · 2.52 Impact Factor
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    ABSTRACT: Myocardial perfusion MRI is acquired with a T1-weighted dynamic MRI sequence. Fully quantitative analysis of myocardial perfusion MRI allows the absolute quantification of myocardial blood flow (MBF) through the use of complex mathematical modeling. There are essentially two main methods for quantification of absolute MBF: the linear time-invariant model and the compartment model. Maximized contrast-to-noise ratio and the reasonable linearity of signal intensity in blood and myocardium are crucial for the accuracy of absolute MBF quantification by MRI. Quantitative assessment of MBF permits an accurate and objective assessment of myocardial perfusion and perfusion reserve in patients. This is of particular significance in patients with coronary artery disease but will also provide a means for investigating globally altered MBF in patients with microvascular disease of the heart. Furthermore, quantification of MBF with magnetic resonance can provides us with an important tool for monitoring disease progression and measuring the response to therapeutic interventions. KeywordsMyocardial perfusion MRI-Quantitative analysis-Myocardial blood flow
    Current Cardiovascular Imaging Reports 04/2010; 3(2):65-73. DOI:10.1007/s12410-010-9013-0
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