Women With Chest Pain and Normal Coronary Arteries: Karen
Transcription
Women With Chest Pain and Normal Coronary Arteries: Karen
4/17/2015 Karen Sopko, M.D. NMHI Non-Invasive Cardiologist 1 4/17/2015 Angiogram Review Large vessel spasm Missed lesions Congenital Anomalies Myocardial Bridges 2 4/17/2015 Missed lesions Diffuse disease Eccentric Plaques Flush occlusions Vessel foreshortening aorto-ostial lesions overlapping side branches 3 4/17/2015 4 4/17/2015 Congenital Coronary Anomalies Origin of circumflex arising from the right coronary artery or right sinus of Valsalva Left coronary artery arising the the right sinus of Valsalva RCA arising from the left sinus of Valsalva Large coronary arteriovenous or cardiopulmonary fistulae Myocardial Bridges consist of segments of the LAD that course from their subepicardial surface location into the myocardial tissue and then back out transient systolic constriction occurs 5 4/17/2015 Aortic valvular disease Other cardiac causes of chest Hypertrophic cardiomyopathy pain Dilated cardiomyopathy Hypertension Pericardial disease Takatsubo Cardiomyopathy 6 4/17/2015 Non-cardiac causes of chest pain Gastrointestinal: reflux, esophageal spasm, esophagitis, hiatal hernia, gastritis Musculoskeletal: costochondritis, fibromyalgia, shoulder, cervical/thoracic spine referred pain Cardiac Syndrome X Angina Pectoris (typical chest pain) positive exercise electrocardiogram for myocardial ischemia angiographically smooth coronary arteries 7 4/17/2015 Cardiac Syndrome X Approx. 20-30% of pts undergoing angiography for angina like chest pain have non obstructive CAD It is more common in women than men occurs is perimenopausal and postmenopausal women 8 4/17/2015 Cardiac Syndrome X no definitive conclusions regarding the exact pathogenesis of the condition Patient population is heterogenous and therefore physiological explanation is probably multifactorial. Have a good cardiovascular prognosis Women w/Syndrome X Increased atherosclerotic burden at 10 yr f/u in women who displayed coronary endothelial dysfunction WISE study showed that these patients often have atherosclerosis on IVUS and face a 2.5% annual rate adverse cardiac events. 9 4/17/2015 Theories Impaired coronary flow reserve Microvascular spasm patchy prearteriolar vasoconstriction disease of the small arteries More Theories pain due to excessive adenosine effect w/o ischemia psychological disorders hormonal deficiency abnormal endothelial function 10 4/17/2015 Myocardial ischemia Cannon et al. tested pts w/a vasoconstrictor, ergonovine during atrial pacing pts w/CP during pacing showed significantly lower coronary venous flow, a higher coronary resistance and a higher LVEDP. pts who had a abnormal vasodilator reserve showed reduced EF during exercise compared with pt’s with appropriate vasodilator reserve Conclusion: result of abnormalities of the small coronary arteries or microcirculation. Canon RO III. Bonow RO, Bacharach SL et al. Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation 1985; 71: 21826. 11 4/17/2015 Endothelial Function Egashira et al. tested pts w/Syndrome X vs. pts w/ atypical CP and normal cors w/o ST segment depression. Compared response to intracoronary acetylcholine. noted a marked reduction in response to acetylcholine in pts w/Syndrome X, suggesting impaired endothelium-dependent vasodilation response was limited to the smaller coronary vessels and no difference found in larger coronary arteries gashira K, Inou T, Hirooka Y, Yamada A, Urabe Y, Takeshira A. Evidence of impaired endothelium-dependent coronary vasodilation in patients with angina pectoris and normal coronary angiograms. N Engl J Med 1993; 328: 165964 12 4/17/2015 Pain perception Turiel et al. found that patients with syndrome X had a significantly lower threshold and tolerance for forearm ischemia and electrical skin stimulation than pts w/confirmed CAD. Turiel M, Galassi AR, Glazier JJ, Kaski JC, Maseri A. Pain threshold and tolerance in women with syndrome X and women with stable angina pectoris. Am J Cardiol 1987; 60: 5037. Insulin Resistance Dean et al. found that a glucose tolerance test provoked hyperinsulinemia in patients w/Syndrome X, but not in normal controls. any relationship between insulin resistance and Syndrome X may be incidental; just related to the patient and having independent risk factors themselves. Dean JD, Jones CJ, Hutchison SJ, Peters JR, Henderson AH. Hyperinsulinaemia and microvascular angina (syndrome X). Lancet 1991; 337: 45657. 13 4/17/2015 Menopause and Hormonal Influence most common in postmenopausal women possible link between syndrome and estrogen deficiency based on studies exploring impact of HRT: found that 17B estradiol reduced CP frequency in women w/Syndrome X. need to carefully evaluate risk/benefit ratio of starting HRT, given ovarian/breast CA risk and risk for obstructive CAD. Psychological Factors women w/Syndrome X have higher levels of anxiety and depression than CHD pts and healthy age-matched women. 14 4/17/2015 Treatment No definitive physiological cause, so no effective treatment regimen Anecdotal: nitrates, calcium channel blockers, adenosine triphosphate-sensitive potassium channel openers (nicorandil), theophylline, beta blockers. Imipramine, benzodiazepines Conclusions 20-30% of patients undergoing cardiac angiography will have normal findings. If patients continue to have TYPICAL chest pain despite normal coronary arteries by angiography, will need reassessment by Cardiology once non-cardiac reasons are ruled out. Cardiac Syndrome X is still a condition with no clear cut physiological explanation May need multidisciplinary approach with Pain specialist/Anesthesia and Psychiatrist. 15 4/17/2015 16