mechanism and management of coronary microvascular angina dingcheng xiang, md, ph.d cardiovascular...
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Mechanism and Management of Mechanism and Management of Coronary Microvascular Angina Coronary Microvascular Angina
Dingcheng Xiang, MD, Ph.DDingcheng Xiang, MD, Ph.DCardiovascular DepartmentCardiovascular DepartmentLiuhuaqiao HosptialLiuhuaqiao HosptialGuangzhou, ChinaGuangzhou, China
广州军区广州总医院心血管内科广州军区广州总医院心血管内科向定成向定成
DefinitionDefinition
Cardiac Syndrome X (1973, Kemp)Cardiac Syndrome X (1973, Kemp)
Microvascular Angina (1986, Cannon) Microvascular Angina (1986, Cannon) – Effort chest painEffort chest pain
– Evidence of myocardial ischemiaEvidence of myocardial ischemia
– No significant coronary artery stenosisNo significant coronary artery stenosis
Mechanisms of Microvascular AnginaMechanisms of Microvascular Angina
Microvascular dysfunctionMicrovascular dysfunction– Decreased reservation of arteriole dilation– Arteriole spasm
Myocardiac ischemiaMyocardiac ischemia
Effort anginaEffort angina
Mechanisms of Microvascular Mechanisms of Microvascular DysfunctionDysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
Mechanisms of Microvascular Mechanisms of Microvascular DysfunctionDysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
Microvascular endothelial Microvascular endothelial dysfunction (evidence 1)dysfunction (evidence 1)
Coronary sinus Peripheral Venous
ET1 ↑ and/or NO
Microvascular spasm
Blood sample
MVA patients
Microvascular endothelial Microvascular endothelial dysfunction (evidence 2)dysfunction (evidence 2)
Microvascular angina Patients
Flow-Mediated-Dilation
Systemic endothelial dysfunction
Microvascular endothelial Microvascular endothelial dysfunction (evidence 3)dysfunction (evidence 3)
Ergonovine/Acetylcholine Test
Coronary flow resistance ↑(Myocardial perfusion )
No epicardiac artery spasm
Microvascular angina Patients
Mechanisms of Microvascular Mechanisms of Microvascular DysfunctionDysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
Arteriole AtherosclerosisArteriole Atherosclerosis
Lacking in direct evidence Lacking in direct evidence – Limitation of angiographic resolutionLimitation of angiographic resolution
– No autopsy data: benign prognosisNo autopsy data: benign prognosis
– No available animal modelNo available animal model
Arteriole AtherosclerosisArteriole Atherosclerosis
Indirect evidenceIndirect evidence– Angio/IVUS: mild stenosis in ischemia-related Angio/IVUS: mild stenosis in ischemia-related
coronary arteriescoronary arteries– Future PCI candidate vesselFuture PCI candidate vessel– Spotted scar in ischemia-related areaSpotted scar in ischemia-related area– Accompanied by atherosclerotic risk factorsAccompanied by atherosclerotic risk factors– Anti-atherosclerosis therapy improved angina Anti-atherosclerosis therapy improved angina
Am J Cardiol. 2006 Jun 15;97(12):1727-31
Mechanisms of Microvascular Mechanisms of Microvascular DysfunctionDysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
InflammationInflammation
Increased inflammatory factors level Increased inflammatory factors level during episode of anginaduring episode of angina– CRPCRP– InterleukinsInterleukins
Decreased during silenceDecreased during silence
Future Cardiol. 2006 Jan;2(1):63-73
Mechanisms of Microvascular Mechanisms of Microvascular DysfunctionDysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
Autonomic nerves dysfunctionAutonomic nerves dysfunction
spinal cord spinal cord
stimulationstimulation
Reduced Reduced episodeepisode of anginaangina
Cardiac sympathetic nerves
Autogenic training
Sympathetic/paraactivity
Menopause. 2009 Jan-Feb;16(1):60-5
J Nucl Cardiol. 2008 Nov-Dec;15(6):804-10
Mechanisms of Coronary Mechanisms of Coronary Microvascular DysfunctionMicrovascular Dysfunction
Endothelial dysfunctionEndothelial dysfunction
Arteriole atherosclerosisArteriole atherosclerosis
InflammationInflammation
Autonomic nerves dysfunctionAutonomic nerves dysfunction
Diagnosis of coronary Diagnosis of coronary microvascular anginamicrovascular angina
Typic episodic effort chest painTypic episodic effort chest pain
Evidence of myocardial ischemiaEvidence of myocardial ischemia– ST ST during chest pain during chest pain– Positive stress test ( ECG/ECT/UCG)Positive stress test ( ECG/ECT/UCG)
No significant coronary angiographic No significant coronary angiographic stenosisstenosis
Negative ergonovine/acetylcholine testNegative ergonovine/acetylcholine test
Management of coronary Management of coronary microvascular anginamicrovascular angina
Combined therapyCombined therapy–Life-style modificationLife-style modification
–Relieving chest painRelieving chest pain
–Preventing episode of chest painPreventing episode of chest pain
–Improving endothelial functionImproving endothelial function
Management of coronary Management of coronary microvascular anginamicrovascular angina
Combined therapyCombined therapy–Life-style modificationLife-style modification
–Relieving chest painRelieving chest pain
–Preventing episode of chest painPreventing episode of chest pain
–Improving endothelial functionImproving endothelial function
Life-style modificationLife-style modification
Same risk factors of CHDSame risk factors of CHD
Same life-style modificationSame life-style modification
Management of coronary Management of coronary microvascular anginamicrovascular angina
Combined therapyCombined therapy–Life-style modificationLife-style modification
–Relieving chest painRelieving chest pain
–Preventing episode of chest painPreventing episode of chest pain
–Improving endothelial functionImproving endothelial function
Relieving chest painRelieving chest pain
Discontinue inducementDiscontinue inducement
NitratesNitrates
Spinal cord stimulationSpinal cord stimulation– Refractory chest painRefractory chest pain
Am J Med. 2006 Jul;119(7):560-6
J Nucl Cardiol. 2008 Nov-Dec;15(6):804-10
Management of coronary Management of coronary microvascular anginamicrovascular angina
Combined therapyCombined therapy–Life-style modificationLife-style modification
–Relieving chest painRelieving chest pain
–Preventing episode of chest painPreventing episode of chest pain
–Improving endothelial functionImproving endothelial function
Preventing episode of anginaPreventing episode of angina
Nitrates + Nitrates + -blockers -blockers reduce 80% of reduce 80% of episodesepisodes
-blockers-blockers– Not as effective as in stenotic effort anginaNot as effective as in stenotic effort angina– nebivolol better than atenololnebivolol better than atenolol
Am J Med. 2006 Jul;119(7):560-6
Preventing episode of anginaPreventing episode of angina
CCBs: ControversialCCBs: Controversial
NicorandilNicorandil
Aminophylline or adenosine precursorAminophylline or adenosine precursor– Effective but side-effectEffective but side-effect
Preventing episode of anginaPreventing episode of angina
External counterpulsationExternal counterpulsation– Reducing 87% of chest painReducing 87% of chest pain– MechanismMechanism
increasing myocardial perfusion increasing myocardial perfusion
Improving endothelial functionImproving endothelial function
Autogenic trainingAutogenic training
Int J Cardiol. 2009 Jun 26;135(2):256-7
Menopause. 2009 Jan-Feb;16(1):60-5
Management of coronary Management of coronary microvascular anginamicrovascular angina
Combined therapyCombined therapy–Life-style modificationLife-style modification
–Relieving chest painRelieving chest pain
–Preventing episode of chest painPreventing episode of chest pain
–Improving endothelial functionImproving endothelial function
Improving endothelial functionImproving endothelial function
StatinsStatins–Simvastatin & XuezhikangSimvastatin & Xuezhikang
–Decrease IL6,CRP,ET1Decrease IL6,CRP,ET1
–Improve exercise-induced ischemia Improve exercise-induced ischemia
Cardiology. 2008;110(1):39-44
Int J Cardiol. 2007 Oct 31;122(1):82-4
Improving endothelial functionImproving endothelial function
ACEIACEI– Hypertension & microvascular anginaHypertension & microvascular angina– Enalapril: decrease blood pressure & improve Enalapril: decrease blood pressure & improve
endothelial functionendothelial function– Reduced episode of chest pain Reduced episode of chest pain
Am J Cardiol, 1995, 76: 31D
Improving endothelial functionImproving endothelial function
ARBARB– Irbesartan vs placebo:24 patients with 3wIrbesartan vs placebo:24 patients with 3w– No statistical improvement in ischemia and No statistical improvement in ischemia and
exercise toleranceexercise tolerance
Heart. 2007 February; 93(2): 253–254.
Summary of managementSummary of management
Life-style modificationLife-style modification
Nitrates+Nitrates+-blockers+CCBs+ nicorandil-blockers+CCBs+ nicorandil
StatinsStatins
AspirinAspirin
ACEI/ARB: hypertension ?ACEI/ARB: hypertension ?
Refractory: EEP or spinal cord stimulationRefractory: EEP or spinal cord stimulation
PrognosisPrognosis
Depends on the left ventricular functionDepends on the left ventricular function
Majority undergoes benign prognosis but Majority undergoes benign prognosis but poor life quality.poor life quality.
ConclusionsConclusions
Since initial report over 4 decades ago, Since initial report over 4 decades ago, microvascular angina continues to be a microvascular angina continues to be a common occurrence for cardiologists. common occurrence for cardiologists.
Despite considerable efforts over 4 Despite considerable efforts over 4 decades, the syndrome remains decades, the syndrome remains controversial with regard to mechanism controversial with regard to mechanism and management. and management.