Antonio De Vita

Clinical Spectrum and Outcome of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome and No Obstructive Coronary Atherosclerosis.

BACKGROUND Because approximately 10% of patients with no-ST-segment elevation acute coronary syndrome (NSTE-ACS) show no obstructive coronary artery disease (NOCAD) on angiography, we assessed the spectrum of diagnoses and the predictors of outcome of these patients. METHODSANDRESULTS We studied 178 patients admitted to a coronary care unit with an initial diagnosis of NSTE-ACS, based on clinical, ECG and laboratory data, but found to have NOCAD. The final diagnosis in these patients was heterogeneous; true NSTE-ACS (ie, coronary thrombosis on an unstable plaque) was ascertained in 1 patient (0.6%), whereas diagnosis at discharge was microvascular NSTE-ACS in 56.2% of patients, variant angina in 10.1%, myocarditis in 8.9%, takotsubo disease in 7.9%, tachyarrhythmia-related chest pain in 6.7%, and non-cardiac pain in 9.6%. At 24.5-month follow-up, 21 deaths (11.8%) had occurred, 9 (5.1%) from cardiovascular causes, including 2 (1.12%) coronary deaths. By multivariable Cox analysis, age only predicted global (hazard ratio [HR] 1.07 [1.02-1.12]; P=0.006) and cardiovascular (HR 1.08 [1.01-1.16]; P=0.04) mortality; non-coronary vascular disease was the main predictor of cardiovascular death or readmission for cardiovascular disease (HR 3.28 [1.75-6.14]; P<0.001) and coronary death or readmission for angina (HR 3.20 [1.26-8.14]; P=0.014). CONCLUSIONS Patients with an initial diagnosis of NSTE-ACS constitute a heterogeneous population with different final diagnoses. Patients have a rather high rate of fatal events, most of which, however, are not related to coronary causes. (Circ J 2016; 80: 1600-1606).

Primary Stable Microvascular Angina: A Long-Term Clinical Follow-Up Study

Previous studies of patients with primary stable microvascular angina showed excellent prognosis despite frequent recurrence of symptoms.1,2 Recent large studies challenged this view, however, reporting a sizeable rate of major adverse cardiovascular events (MACE) in patients with stable angina and no obstructive coronary artery disease.3,4 To get further insight into this clinical controversy, we performed long-term follow-up of a rather large population of patients with microvascular angina. We included in this study all patients with primary stable microvascular angina who participated in clinical investigations performed at our institute between 1991 and 2011. All patients had exercise-induced angina, positive exercise stress test, angiographically normal coronary arteries, and no other relevant cardiac or systemic disease.5 In suspected cases, coronary spasm was excluded by ergonovine test. Patients were carefully characterized for cardiovascular risk factors and symptoms. All patients gave their informed consent to participate in the study, which was approved by our institutional review board. Follow-up was done by clinical visits or structured telephone interview. In the case of death, its cause …

Association of coronary microvascular dysfunction with restenosis of left anterior descending coronary artery disease treated by percutaneous intervention

BACKGROUND Several patients with successful percutaneous coronary interventions (PCIs) show evidence of coronary microvascular dysfunction (CMVD), which can be responsible for persistent positivity of electrocardiographic exercise stress test (EST). In this study, we assessed whether post-PCI CMVD may predict clinical outcome in patients undergoing successful elective PCI of an isolated stenosis of the left anterior descending (LAD) coronary artery. METHODS We studied 29 patients (age 64±6, 23 M) with stable coronary artery disease and isolated stenosis (>75%) of the LAD coronary artery who underwent successful PCI with stent implantation. Coronary blood flow (CBF) velocity response to adenosine and to cold-pressor test (CPT) was assessed in the LAD coronary artery by transthoracic Doppler echocardiography 24h and 3months after PCI. The primary end-point was a combination of death, admission for acute coronary syndromes (ACS) or target vessel revascularization (TVR). RESULTS No death or ACS occurred during 36months of follow-up, but TVR was performed in 5 patients (17.2%). CBF response to CPT at 3months after PCI was 1.31±0.2 vs. 1.71±0.4 in patients with or without TVR, respectively (p=0.03), whereas CBF response to adenosine at 3months in these two groups was 1.70±0.3 vs. 2.05±0.4 (p=0.059). CONCLUSIONS Our data suggest that, in patients with successful PCI of LAD coronary artery stenosis, lower CBF response to the endothelium-dependent vasodilator stimulus CPT is associated with long-term recurrence of restenosis.

Effect of Remote Ischemic Preconditioning on Coronary Procedure-Related Impairment of Vascular Dilator Function

Remote ischemic preconditioning (RIPC) reduces myocardial damage caused by prolonged ischemia [(1)][1]. Recent studies, however, showed that RIPC has other favorable effects, including a reduction of platelet reactivity during invasive cardiac interventions [(2,3)][2]. In this study we assessed

‘Primary’ Microvascular Angina: Clinical Characteristics, Pathogenesis and Management

Microvascular angina (MVA), i.e. angina caused by abnormalities of the coronary microcirculation, is increasingly recognised in clinical practice. The pathogenetic mechanisms of MVA are heterogeneous and may involve both structural and functional alterations of coronary microcirculation, and functional abnormalities may variably involve an impairment of coronary microvascular dilatation and an increased microvascular constrictor activity. Both invasive and non-invasive diagnostic tools exist to identify patients with MVA in clinical practice. Prognosis has been reported to be good in primary MVA patients, although the prognostic implications of coronary microvascular dysfunction (CMVD) in more heterogeneous populations of angina patients need further assessment. Management of primary MVA can be challenging, but pharmacological and non-pharmacological treatments exist that allow satisfactory control of symptoms in most patients.

Long-term effects of bariatric surgery on peripheral endothelial function and coronary microvascular function.

BACKGROUND We previously demonstrated that bariatric surgery (BS) leads to a short-term significant improvement of endothelial function and coronary microvascular function. In this study we assessed whether BS maintains its beneficial effect at long-term follow up. DESIGN We studied 19 morbidly obese patients (age 43±9years, 12 women) without any evidence of cardiovascular disease who underwent BS. Patients were studied before BS, at 3 months and at 4.0±1.5years follow up. METHODS Peripheral vascular function was assessed by flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD), i.e., brachial artery diameter changes in response to post-ischemic forearm hyperhaemia and to nitroglycerin administration, respectively. Coronary microvascular function was assessed by measuring coronary blood flow (CBF) response to intravenous adenosine and to cold pressor test (CPT) in the left anterior descending coronary artery. RESULTS Together with improvement of anthropometric and metabolic profile, at long-term follow-up patients showed a significant improvement of FMD (6.43±2.88 vs. 8.21±1.73%, p=0.018), and CBF response to both adenosine (1.73±0.48 vs. 2.58±0.54; p<0.01) and CPT (1.43±0.30 vs. 2.23±0.48; p<0.01), compared to basal values. No differences in vascular end-points were shown at 3-month and 4-year follow-up after BS. CONCLUSIONS Our data show that, in morbidly obese patients, BS exerts beneficial and long lasting effects on peripheral endothelial function and on coronary microvascular dilator function.

Aggressive management of non-ST-segment elevation acute coronary syndrome: Evidence or faith?

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) that benefits can be expected in high-risk, but not in low-risk patients. is a major clinical presentation of coronary artery disease (CAD) with a sizeable rate of cardiovascular events. Current guidelines recommend early invasive coronary angiography (ICA), followed by coronary revascularization when appropriate, to improve prognosis in highand intermediate-risk patients, suggesting possible benefits also in lowrisk patients [1]. In clinical practice, however, a not negligible proportion of 15–20% of patients are managed with medical therapy only. In an article published in the Journal, Menozzi et al. review clinical characteristics and outcome of this group of patients, suggesting possible strategies for improving their management [2]. Among patients treated conservatively, they identify three main different subgroups. The first group includes patients who not even undergo ICA, usually because of a perceived poor prognosis due to severe clinical conditions. The second group includes patients who show no obstructive CAD (NOCAD). These patients constitute about 10% of those who undergo ICA and, compared to those with obstructive CAD, are at lower risk of cardiac events; yet, they have a high rate of readmission for chest pain, and total mortality can also be high due to the frequent coexistence of severe comorbidities [3]. The third group includes patients with critical stenoses but managed without revascularization because of a very clinical and/or coronary high risk. Menozzi et al. recommend ICA for all patients withNSTE-ACS, as this would allow the detection of high-risk patients due to severe/extensive CAD and help in the choice of subsequent management. Furthermore, for all patients they would also recommend dual antiplatelet therapy (DAPT), unless of contraindications. The authors are to be praised for their excellent review. Some points, however, might be seen under some different perspective. A first point concerns the recommendation of ICA in all NSTE-ACS patients. A careful assessment of valuable randomized clinical trials (RCTs), indeed, shows conflicting results about the benefits of an early invasive strategy compared to a conservative, ischemia-guided strategy in clinically stabilized NSTE-ACS patients (Table 1) [4–8]. Furthermore, favorable data for the invasive approach substantially concerned a reduction of acute myocardial infarction (AMI), with no consistent effects on survival, also at long-term follow-up (Table 1). Finally, subgroup analyses show

Exercise test predictors of severe coronary artery disease: Role of ST‐segment elevation in lead aVR

The role of exercise stress test (EST)‐induced ST‐segment elevation (STE) in electrocardiographic lead aVR in predicting severe coronary artery disease (CAD) is controversial.

Microvascular Angina ― Long-Term Exercise Stress Test Follow-up ―

BACKGROUND A sizeable proportion of patients with primary stable microvascular angina (MVA; exercise-induced angina, positive exercise stress test [EST], normal coronary arteries) have recurrent symptoms during follow-up. There have been no previous studies, however, on the long-term results of EST and their correlation with symptom outcome.Methods and Results:Follow-up EST was performed in 71 MVA patients at an average of 16.2 years (range, 5-25 years) from the first EST. Angina status was assessed on weekly frequency of angina episodes and nitroglycerin consumption and by whether symptoms had worsened, improved, or remained unchanged over time. At follow-up EST, 41 patients (group 1) had exercise-induced ischemia, whereas 30 patients (group 2) had negative EST. Compared to group 2, group 1 patients more frequently had exercise-induced dyspnea, and had a greater maximum ST-segment depression and a lower coronary blood flow response to adenosine and cold pressor test, but group 2 patients had a more frequent history of rest angina. No differences between the 2 groups were found at follow-up in angina status or change in symptom status during follow-up. CONCLUSIONS Electrocardiogram results improve significantly in a sizeable proportion of patients with MVA. Changes in EST results, however, were not associated with clinical outcome.