Maria Angela S. Cruz-Anacleto, MD

Maria Angela S. Cruz-Anacleto, MD

57/Female Menopausal Non-HTN, non-dm Hypothyroid (s/p RAI 1997) Levothyroxine 100 ug OD

5 Months PTA Chest discomfort Stress Echocardiography

5 Months PTA Chest discomfort Positive Stress Echo Medications ASA 100 mg OD Metoprolol 50 mg OD Trimetazidine 35 mg BID

5 Months PTA 3 Months PTA Thallium myocardial perfusion scan

Exercise ECG Stress Echocardiography Dobutamine Stress Echocardiography Radionuclide Testing

Exercise ECG Stress Echo Dobutamine Stress Echo Radionuclide Testing (Tc) Sensitivity 61% Sensitivity 81% Sensitivity 80% Sensitivity 91% Specificity 70% Specificity 86% Specificity 84% Specificity 86% Circulation 2005; 111:682-696

Stress Echocardiography Dobutamine Stress Echocardiography Radionuclide Testing

5 Months PTA 3 Months PTA Mild stress-induced ischemia on Thallium myocardial perfusion scan Advised coronary angiogram Medications Simvastatin 40 mg OD Losartan 50 mg OD Clopidogrel 75 mg OD ISMN 20 mg OD

5 Months PTA 3 Months PTA 1 Month PTA Chest pain relieved with SL nitrates CA possible PCI

Post NTG Pre NTG

Antegrade LM to LAD Antegrade LM to LCx

Female Typical Angina Abnormal Stress Echocardiogram Perfusion Defect on Thallium Normal Coronary Arteries on Angiogram

Prinzmental Variant Angina Coronary Slow Flow Phenomenon Myocardial Bridging Cardiac Syndrome X

1 Prinzmental Variant Angina 2 Coronary Slow Flow Phenomenon 3 Myocardial Bridging Pain at rest ST Elevation Pain at rest Young male smokers Variable presentation Systolic compression of epicardial a. 1 Circulation. 2007;116:803-877 2 J Am Coll Cardiol, 2010; 56:239-240 3 European Heart Journal 2005; 26: 1159 1168

Diffuse Intimal Thickening 1 Widespread calcification along the vessel wall 1 Atheroma not producing luminal irregularities on angiogram 1 1 Med Hypothesis 2010, doi: 10.1016/j.mehy.2010.0316

Prinzmental Variant Angina Coronary Slow Flow Phenomenon Myocardial Bridging

Typical Angina Stress Induced/ Ischemia Normal Angiogram Circulation. 2007;116:803-877

Abnormal Pain Perception Myocardial Ischemia Psychiatric Morbidity Coronary Microvascular Dysfunction Inflammation Circulation. 2004;109:568-572 Chin Med J 2005; 118(21):1817-1826

Inappropriately Increased Vascular Tone Circulation. 2004;109:568-572 N Engl J Med.2002; 346:1934-1935

Endothelial Dysfunction NO ET-1 Risk Factors Obesity Dyslipidemia Smoking Estrogen Deficiency Circulation. 2004;109:568-572 N Engl J Med.2002; 346:1934-1935

Endothelin Acetylcholine Nitroglycerin Prostacyclin

Endothelin Acetylcholine Prostacyclin

Contrictors Dilators Endothelial Dysfunction in Vascular Disease 2007 Coronary Artery Disease 2001,12:485-491 Interventional Cardiology Secrets 2003

Coronary Flow Reserve 1 Ratio of maximal hyperemia to basal flow Index of microcirculatory function Partly reversible 1 Coronary Angiography + intracoronary doppler 2 NEJM 2007;356:830-840 Circulation. 2010;121:2317-2325

Transthoracic Echocardiographic Doppler Cardiac MR Pulse Amplitude Tonometry All of the above

TTE doppler CBF (peak/rest) < 2.0 Adenosine/Dipyridamole LAD Cardiac MR Segmental & focal perfusion defects Regional and global CBF RH-PAT Automatic Quantitative Practical Circulation. 2010;121:2317-2325 J Am Coll Cardiol 2010;55:1688-96

Criculation 2008; 117: 2467-2474

Transthoracic Echocardiographic Doppler Cardiac MR Pulse Amplitude Tonometry

Enhanced sensitivity of pain receptors Circulation. 2004;109:568-572 N Engl J Med.2002; 346:1934-1935

Increased Pain Perception Potassium release Adenosine release Mishandling of afferent stimuli by CNS Increased adrenergic activity Impaired parasympathetic activity Enhanced sensitivity of pain receptors Circulation. 2004;109:568-572 N Engl J Med.2002; 346:1934-1935

IL-1 a VCAM-1 b ICAM-1 b Chin Med J 2005; 118(21) :1817-1826 a Am J Cardiol 2004;94: 40-44 b Atherosclerosis 1995;68: 191-197

Clopidogrel Beta-Blockers Calcium Channel Blockers Referral to Cardiac Rehab

Beta-Blockers Calcium Channel Blockers Referral to Cardiac Rehab

Heart 2004;90:457 463

Anti-ischemics Analgesics HRT Psychological Intervention Anti Inflammatory Eur Heart J 2001;22:283-293 Chin Med J 2005; 118(21) :1817-1826

Antiischemics Analgesics HRT Psychological Intervention Anti Inflammatory Nitrates CCB Nicorandil Trimetazidine Beta-Blockers ACE-I Eur Heart J 2001;22:283-293 Chin Med J 2005; 118(21) :1817-1826

Antiischemics Analgesics HRT Psychological Intervention Anti Inflammatory Imipramine Electrostimulation TENS SCS Aminophylline Eur Heart J 2001;22:283-293

Antiischemics Analgesics HRT Psychological Intervention Anti Inflammatory Eur Heart J 2001;22:283-293 Chin Med J 2005; 118(21) :1817-1826

Antiischemics Analgesics HRT Psychological Intervention Anti Inflammatory Eur Heart J 2001;22:283-293 Chin Med J 2005; 118(21) :1817-1826

Antiischemics Analgesics HRT Psychological Intervention Anti Inflammatory ASA Statins Eur Heart J 2001;22:283-293 Chin Med J 2005; 118(21) :1817-1826

Improves exercise tolerance Quality of Life Psychological Morbidity Symptom severity JACC 2000;36:1619-25 Menopause 15;3:454-460

Beta blockers Calcium antagonists Nitrates Imipramine Estrogen Statin therapy Exercise training Cognitive behavioral therapy Circulation 2007;116;803-877

Poor Excellent Uncertain

Poor Uncertain

155 patients with CSX Followed-up for 24-372 months No patients died from cardiovascular causes or developed non-fatal MI Int J Cardiol 2010;140: 197-199

Thallium Scan Cardiac MRI Coronary CT Treadmill Stress Test

Treadmill Stress Test Low sensitivity for detection of CAD 1 CSX have stress induced ischemia 3 Coronary CT Identifies the presence of CAC 1 Anatomic definition of stenosis 1 Accurate in the diagnosis of CAD for CAC < 600 2 No Physiologic significance 1 1Braunwald s Heart Disease 8 th Ed. 2 NEJM 2008;359:2324-36 3 Circulation 2005; 111:682-696 4Circulation. 2007;116:803-877

SPECT Physiologic significance of stenosis 1 Improvement of perfusion with vasodilation 1 Multiple perfusion abnormalities with different levels of severity of CSX 2 Patchy vs clustered hypoperfusion 2 Cardiac MRI Better than SPECT for detection of CAD 1 Visualization of coronaries, assess perfusion, wall motion Accuracy of 87% 3 1Braunwald s Heart Disease 8 th Ed. 2 BMC Nuclear Medicine 2006;6:1 3 JACC Img 2008;1:436-45

SPECT Coronary CT Treadmill Stress Test

Diagnosis Angina Stress Induced Ischemia Normal Coronary Angiogram Pathogenesis is multifactorial Management directed towards symptom control & quality of life Excellent Prognosis