63 yo woman with chest pain

Transcription

1 63 yo woman with chest pain Coronary Microvascular Disease: Does It Exist? EA Amsterdam, MD Distinguished Professor Cardiology and Internal Medicine UC Davis School of Medicine and Medical Center Sacramento, CA Exertional CP 3-4x/wk, +/- response to meds Normal baseline ECG. Pos ETT, Neg ESE Several visits to ED with CP Nonspecific ST-T during CP, negative troponins 1 Admission: Neg eval for ACS Coronary angio: 10-20% stenoses in LAD/RCA, LVEF 60%. On multiple antianginal meds, RF reduction GI, pulmonary, musculoskeletal w/u NEG. Counseling for psychosocial stress 1

2 Terms Applied to Syndrome of Chest Pain without Obstructive CAD Cardiac syndrome X Coronary microvascular dysfunction (CMD) Microvascular angina Endothelial dysfunction Impaired coronary vasodilator capacity Impaired coronary flow reserve Abnormal pain perception ( sensitive heart ) Somatoform disorder Type of MVD TYPE 1 absence of myocardial disease and obstructive CAD Type 2 myocardial diseases Type 3 obstructive CAD Classification of Coronary Microvascular Dysfunction Clinical Setting Risk factors Microvascular angina TR HCM, DCM, amyloid Stable CAD, ACS Type 4 iatrogenic PCI, CABG Pathogenetic Mechanisms Endothelial dysfunction SMC dysfunction Vascular remodeling Vascular remodeling Endothelial dysfunction Smooth muscle dysfunction Autonomic dysfunction Impaired arteriolar function F. Crea et al. European Heart Journal 2014;35, Type of MVD TYPE 1 absence of myocardial disease and obstructive CAD Type 2 myocardial diseases Type 3 obstructive CAD Classification of Coronary Microvascular Dysfunction Clinical Setting Risk factors Microvascular angina TR HCM, DCM, amyloid Stable CAD, ACS Type 4 iatrogenic PCI, CABG Pathogenetic Mechanisms Endothelial dysfunction SMC dysfunction Vascular remodeling Impaired arteriolar fxn Vascular remodeling Endothelial dysfunction Smooth muscle dysfunction Autonomic dysfunction Impaired arteriolar function Classification of Coronary Microvascular Dysfunction F. Crea et al. European Heart Journal 2014;35, F. Crea et al. European Heart Journal 2014;35,

3 Coronary Arteries and Arterioles RCA 3

4 RCA Coronary Artery Size and Distribution BLUSH Coronary Artery Physiology: Endothelium-Derived/Other Vasoactive Agents Coronary Artery Physiology: Endothelium-Derived/Other Vasoactive Agents VASCULAR LUMEN VASCULAR LUMEN Adenosine The coronary arterioles are normally in a relatively dilated state Adenosine The coronary arterioles are normally in a relatively dilated state 4

5 CMD Demographics 20-30% of patients with anginal-type CP have no obstructive CAD (normal or <50% stenosis) Usually have objective evidence of ischemia Women: ~3-5 X more frequent than in men Exclude other etiologies of CP Coronary spasm, myocardial bridging, pericarditis, GI/Pul/MS/Psychosocial stress Clinical Presentation - CMD Exercise Treadmill All pts CP and nonobstructive or NL coronary arteries But broad continuum of Sx, RFs, ischemia test results Group A) Typical angina, +RFs, ischemia on noninvasive tests ETT, stress imaging, Ambulatory ECG Group B) Atypical CP, +/- RFs, +/- ischemia stress tests Group C) Variable data from groups A and B Sx, RFs, Tests 5

6 Exercise Treadmill 7 min Impression of by Myocardial Blush Impression of by Myocardial Blush 6

7 The Physiologic Angiogram Intracoronary Acetylcholine Tests integrity of microvascular endothelium Normal: increase CBF >50% above control Intracoronary Adenosine Tests direct response of microvascular dilatation Normal: increase in CBF 2.5 X over control Imaging Methods Positron Emission Tomography (PET) Rubidium Images transmyocardial distribution of CBF, detects impaired rise in subendocardial CBF indicative of CMD Coronary Microvascular Function in Patients with Suspected CAD: Relation to Gender Murthy, JACC 2012;59:E women, 97 men Cardiac MRI Detects inadequate subendocardial distribution of CBF, thereby identifying CMD by inadequate increase in response to stress (adenosine) Frequency/magnitude of coronary microvascular dysfunction are similar in both genders Copyright 2012 American College of Cardiology Foundation. Restrictions may apply. 7

8 Reduced subendocardial perfusion providing evidence for coronary MVD Cardiac Syndrome X NEJM 2002;346:1948 STRESS-INDUCED MICROVASCULAR ISCHEMIA Berman et al. JACC 4/16 Normal stress perfusion MRI Uniform contrast enhancement of lv myocardium 8

9 41 yo runner with chest pain and normal coronary angio Stress perfusion MRI with Gadoliniunm Reduced subendocardial enhancement during Gadolinium infusion (dark area, arrow) Prognosis Initially felt to be relatively benign Recent findings: CMD associated with adverse clinical outcomes (Murthy, Circ 2014, 129:2518) CFR <2.0, n=641 pts, 61 yo, 1.3 yr interval 8.6% MACE, 5% mortality CMD: Prevalence/outcomes similar in the sexes 9

10 Management Antianginal meds (incl. ranolazione), Risk factor modification Statins, ACEI/ARB Enhanced endothelial function Cardiac Rehab Comprehensive, exercise-centered Hormone replacement therapy Beneficial effect on endothelium(?), give for shortest possible interval.... Counseling Psychosocial stress reduction, sx may be related to somatoform disorder Imipramine Effective in some pts with Dx sensitive heart Our Patient MRI: No stress-induced subendocardial ischemia No obstructive CAD, negative stress imaging tests Consider Somatoform Disorder or Sensitive Heart Imipramine was added to her therapy. Coronary Microvascular Function in Patients with Suspected CAD: Relation to Gender Murthy, JACC 2012;59:E women, 97 men Summary Coronary microvascular disease: real, multiple etiologies, can occur as isolated abnormality Dx requires rigorous evaluation More women than men with MVD (but rate similar in W/M) Adverse prognostic effect has been documented Diagnostic approach favors MRI or PET rubidium scan.. not yet specific, multiple approaches Consider somatoform disorder, sensitive heart Copyright 2012 American College of Cardiology Foundation. Restrictions may apply. 10