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Myocardial Bridging: Diagnosis, Functional Assessment, and Management: JACC State-of-the-Art Review.Journal of the American College of... Nov 2021Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of the epicardial coronary artery traverses through the myocardium for a portion of its... (Review)
Review
Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of the epicardial coronary artery traverses through the myocardium for a portion of its length. The muscle overlying the artery is termed a myocardial bridge, and the intramyocardial segment is referred to as a tunneled artery. MB can occur in any coronary artery, although is most commonly seen in the left anterior descending artery. Although traditionally considered benign in nature, increasing attention is being given to specific subsets of MB associated with ischemic symptomatology. The advent of contemporary functional and anatomic imaging modalities, both invasive and noninvasive, have dramatically improved our understanding of dynamic pathophysiology associated with MBs. This review provides a contemporary overview of epidemiology, pathobiology, diagnosis, functional assessment, and management of MBs.
Topics: Computed Tomography Angiography; Coronary Angiography; Coronary Circulation; Coronary Vessels; Disease Management; Humans; Myocardial Bridging; Ultrasonography, Interventional
PubMed: 34823663
DOI: 10.1016/j.jacc.2021.09.859 -
Journal of the American College of... Sep 2023Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for... (Review)
Review
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
Topics: Humans; Microcirculation; Myocardial Bridging; Myocardial Ischemia; Angina Pectoris; Coronary Angiography
PubMed: 37704315
DOI: 10.1016/j.jacc.2023.06.043 -
Heart (British Cardiac Society) Feb 2018The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment... (Review)
Review
The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease-INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term 'stable coronary syndromes' (SCS), which aligns with the well-established terminology for 'acute coronary syndromes'. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.
Topics: Angina, Stable; Cardiac Imaging Techniques; Disease Management; Humans; Risk Factors
PubMed: 29030424
DOI: 10.1136/heartjnl-2017-311446 -
Journal of the American College of... Sep 2023Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary... (Review)
Review
Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary arteries (ANOCA). Management leveraging lifestyle, pharmacology, and device-based therapeutic options for ANOCA can improve angina burden and quality of life in affected patients. Multidisciplinary care teams that can tailor and titrate therapies based on individual patient needs are critical to the success of comprehensive programs. As coronary function testing for ANOCA is more widely adopted, collaborative research initiatives will be fundamental to improve ANOCA care. These efforts will require standardized symptom assessments and data collection, which will propel future large-scale clinical trials.
Topics: Humans; Program Development; Quality of Life; Angina Pectoris; Coronary Vessels; Life Style
PubMed: 37704316
DOI: 10.1016/j.jacc.2023.06.044 -
Brazilian Journal of Cardiovascular... Feb 2016Myocardial bridging is rare. Myocardial bridges are most commonly localized in the middle segment of the left anterior descending coronary artery. The anatomic features... (Review)
Review
Myocardial bridging is rare. Myocardial bridges are most commonly localized in the middle segment of the left anterior descending coronary artery. The anatomic features of the bridges vary significantly. Alterations of the endothelial morphology and the vasoactive agents impact on the progression of atherosclerosis of myocardial bridging. Patients may present with chest pain, myocardial infarction, arrhythmia and even sudden death. Patients who respond poorly to the medical treatment with β-blockers warrant a surgical intervention. Myotomy is a preferred surgical procedure for the symptomatic patients. Coronary stent deployment has been in limited use due to the unsatisfactory long-term results.
Topics: Coronary Artery Disease; Humans; Myocardial Bridging; Percutaneous Coronary Intervention; Stents
PubMed: 27074276
DOI: 10.5935/1678-9741.20150082 -
Heart (British Cardiac Society) Dec 2023Myocardial bridging is a common anatomical variant in which a major epicardial coronary artery takes an intramyocardial course, leading to dynamic systolic compression.... (Review)
Review
Myocardial bridging is a common anatomical variant in which a major epicardial coronary artery takes an intramyocardial course, leading to dynamic systolic compression. Because coronary perfusion occurs primarily during diastole, most patients with this anatomical variant have no associated perfusion abnormalities or symptoms. Despite this, there is a subset of patients with myocardial bridging who experience ischaemic symptoms. Determining which anatomical variants are benign and which are clinically relevant remains a challenge. Further complicating the picture, functional factors such as diastolic dysfunction and coronary vasospasm may exacerbate myocardial bridging-related ischaemia. In patients with ischaemic symptoms in the absence of alternative explanations, a detailed assessment of myocardial bridging with invasive physiology should be performed to define the significance of the lesion and guide tailored medical therapy. Patients with refractory symptoms despite maximally tolerated medical therapy should be considered for surgical coronary unroofing.
Topics: Humans; Myocardial Bridging; Heart; Coronary Angiography
PubMed: 37344169
DOI: 10.1136/heartjnl-2022-321586 -
Folia Morphologica 2020Myocardial bridging (MB) is an anatomical variant in which an epicardial coronary artery passes under a bridge of myocardium. The most commonly affected vessel is the...
Myocardial bridging (MB) is an anatomical variant in which an epicardial coronary artery passes under a bridge of myocardium. The most commonly affected vessel is the left anterior descending coronary artery, although other branches such as the marginal branches, diagonal branches and posterior descending right coronary artery may be occasionally involved. Technological advances in radiological techniques have enabled better diagnosis of myocardial bridges especially coronary angiography and coronary computed tomographic angiography (CCTA). During a routine angiography by means of CCTA in a 60-year-old male patient with arrhythmia, a case of MB was found in two segments of the posterior interventricular artery and a small segment of the right coronary artery. Although most cases of myocardial bridges are asymptomatic, knowledge of its pathophysiology is of great clinical importance as some cases of MBs have been associated with acute coronary syndromes, ischaemia, arrhythmias and even sudden death.
Topics: Computed Tomography Angiography; Coronary Angiography; Humans; Male; Middle Aged; Myocardial Bridging
PubMed: 31448810
DOI: 10.5603/FM.a2019.0080 -
The New England Journal of Medicine Feb 2024
Topics: Humans; Coronary Angiography; Myocardial Bridging; Risk Factors
PubMed: 38294977
DOI: 10.1056/NEJMicm2307383 -
Journal of the American College of...
Topics: Humans; Myocardial Bridging
PubMed: 25457408
DOI: 10.1016/j.jacc.2014.07.993 -
Journal of Cardiology Jan 2018
Topics: Coronary Angiography; Humans; Myocardial Bridging; Takotsubo Cardiomyopathy
PubMed: 28754463
DOI: 10.1016/j.jjcc.2017.07.001