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Journal of the American College of... Sep 2021Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial... (Review)
Review
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
Topics: Animals; Cardiovascular Diseases; Coronary Circulation; Coronary Vessels; Humans; Iatrogenic Disease; Microcirculation; Microvessels
PubMed: 34556322
DOI: 10.1016/j.jacc.2021.07.042 -
Circulation Journal : Official Journal... Aug 2022Ischemic heart disease (IHD) is commonly recognized as the consequence of coronary atherosclerosis and obstructive coronary artery disease (CAD). However, a significant...
Ischemic heart disease (IHD) is commonly recognized as the consequence of coronary atherosclerosis and obstructive coronary artery disease (CAD). However, a significant number of patients may present angina or myocardial infarction even in the absence of any significant coronary artery stenosis and impairment of the coronary microcirculation has been increasingly implicated as a relevant cause of IHD. The term "coronary microvascular dysfunction" (CMD) encompasses several pathogenic mechanisms resulting in functional and/or structural changes in the coronary microcirculation and determining angina and myocardial ischemia in patients with angina without obstructive CAD ("primary" microvascular angina), as well as in several other conditions, including obstructive CAD, cardiomyopathies, Takotsubo syndrome and heart failure, especially the phenotype with preserved ejection fraction. The pathogenesis of CMD is complex and involves the combination of functional and structural alterations leading to impaired coronary blood flow and resulting in myocardial ischemia. In the absence of therapies specifically targeting CMD, attention has been focused on the role of modifiable risk factors. Here, we provide updated evidence regarding the pathophysiological mechanisms underlying CMD, with a particular focus on the role of cardiovascular risk factors and comorbidities. Moreover, we discuss the specific pathogenic mechanisms of CMD across the different cardiovascular diseases, aiming to pave the way for further research and the development of novel strategies for a precision medicine approach.
Topics: Coronary Artery Disease; Coronary Circulation; Coronary Vessels; Humans; Microcirculation; Microvascular Angina; Myocardial Ischemia
PubMed: 34759123
DOI: 10.1253/circj.CJ-21-0848 -
Critical Care (London, England) May 2023The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is... (Review)
Review
The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is happening in the microcirculation of organs, which prevents them from achieving an additional degree of individualization of the hemodynamic resuscitation at tissue level. Indeed, clinicians never know whether optimization of the microcirculation and tissue oxygenation is actually achieved after macrovascular hemodynamic optimization. The challenge for the future is to have noninvasive, easy-to-use equipment that allows reliable assessment and immediate quantitative analysis of the microcirculation at the bedside. There are different methods for assessing the microcirculation at the bedside; all have strengths and challenges. The use of automated analysis and the future possibility of introducing artificial intelligence into analysis software could eliminate observer bias and provide guidance on microvascular-targeted treatment options. In addition, to gain caregiver confidence and support for the need to monitor the microcirculation, it is necessary to demonstrate that incorporating microcirculation analysis into the reasoning guiding hemodynamic resuscitation prevents organ dysfunction and improves the outcome of critically ill patients.
Topics: Critical Care; Microcirculation; Resuscitation; Hemodynamics; Artificial Intelligence
PubMed: 37193993
DOI: 10.1186/s13054-023-04474-x -
Intensive Care Medicine Jun 2023Shock is a life-threatening condition characterized by substantial alterations in the microcirculation. This study tests the hypothesis that considering sublingual... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Shock is a life-threatening condition characterized by substantial alterations in the microcirculation. This study tests the hypothesis that considering sublingual microcirculatory perfusion variables in the therapeutic management reduces 30-day mortality in patients admitted to the intensive care unit (ICU) with shock.
METHODS
This randomized, prospective clinical multicenter trial-recruited patients with an arterial lactate value above two mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of the cause of shock. All patients received sequential sublingual measurements using a sidestream-dark field (SDF) video microscope at admission to the intensive care unit (± 4 h) and 24 (± 4) hours later that was performed blindly to the treatment team. Patients were randomized to usual routine or to integrating sublingual microcirculatory perfusion variables in the therapy plan. The primary endpoint was 30-day mortality, secondary endpoints were length of stay on the ICU and the hospital, and 6-months mortality.
RESULTS
Overall, we included 141 patients with cardiogenic (n = 77), post cardiac surgery (n = 27), or septic shock (n = 22). 69 patients were randomized to the intervention and 72 to routine care. No serious adverse events (SAEs) occurred. In the interventional group, significantly more patients received an adjustment (increase or decrease) in vasoactive drugs or fluids (66.7% vs. 41.8%, p = 0.009) within the next hour. Microcirculatory values 24 h after admission and 30-day mortality did not differ [crude: 32 (47.1%) patients versus 25 (34.7%), relative risk (RR) 1.39 (0.91-1.97); Cox-regression: hazard ratio (HR) 1.54 (95% confidence interval (CI) 0.90-2.66, p = 0.118)].
CONCLUSION
Integrating sublingual microcirculatory perfusion variables in the therapy plan resulted in treatment changes that do not improve survival at all.
Topics: Humans; Microcirculation; Prospective Studies; Shock, Septic; Resuscitation; Intensive Care Units
PubMed: 37278760
DOI: 10.1007/s00134-023-07098-5 -
Medical Science Monitor : International... Mar 2023Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a reversible syndrome commonly found among patients presenting for acute coronary syndromes,... (Review)
Review
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a reversible syndrome commonly found among patients presenting for acute coronary syndromes, especially women. With the COVID-19 pandemic, the incidence of takotsubo cardiomyopathy was dramatically increased. However, this clinical cardiac entity remains underdiagnosed, largely due to the interplay with acute coronary syndrome. The pathophysiology of takotsubo cardiomyopathy is miscellaneous, including coronary vasospasm, microcirculatory dysfunction, catecholamine surge, and sympathetic overdrive. Diagnosing takotsubo cardiomyopathy requires a high index of clinical suspicion and multimodality tests. To date, there are no guidelines for the management of takotsubo cardiomyopathy. Thus, available data are derived from case series, retrospective analyses, and experts' opinions. Heart failure medicines were investigated in takotsubo cardiomyopathy patients. Evidence supports the benefits of angiotensin-converting enzyme inhibitors and angiotensin receptors blockers use on mortality and recurrence rates, while results from use of beta-blockers are controversial. In complicated cases, inotropes are preferred over vasopressors, except in the presence of left ventricular outflow tract obstruction, in which medical therapy is limited to fluids administration and beta-blockers. Use of oral vitamin K antagonist can benefit patients at high thrombo-embolic risk for up to 3 months. Mechanical supports are reserved for refractory hemodynamically unstable cases. This review aims to provide an update on the epidemiology, diagnosis, and outcomes of takotsubo cardiomyopathy, and an extended discussion on the management of complicated and non-complicated cases.
Topics: Humans; Female; Takotsubo Cardiomyopathy; COVID-19; Microcirculation; Pandemics; Retrospective Studies; Acute Coronary Syndrome; COVID-19 Testing
PubMed: 36872594
DOI: 10.12659/MSM.939020 -
European Heart Journal Oct 2020This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises...
An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group.
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
Topics: Cardiology; Consensus; Coronary Vessels; Female; Humans; Ischemia; Male; Microcirculation; Quality of Life
PubMed: 32626906
DOI: 10.1093/eurheartj/ehaa503 -
Neurobiology of Disease Aug 2022Cerebral small vessel disease (CSVD) is a generic term used for intracranial vascular disorders caused by the structural changes of cerebral microvessels, including the... (Review)
Review
Cerebral small vessel disease (CSVD) is a generic term used for intracranial vascular disorders caused by the structural changes of cerebral microvessels, including the small arteries, arterioles, capillaries and venules. CSVD exhibits various neuroimaging features and is associated clinical characteristics. Although CSVD is recognized as the leading cause of vascular cognitive impairment (VCI), the underlying mechanism(s) remains elusive. Growing evidence indicates a significant association between altered neurovascular unit (NVU) functioning and the pathophysiology of evolving CSVD-induced VCI. Therefore, research is required to understand how NVU dysregulation contributes to cognitive impairment due to CSVD. In this review, we describe the link between the neuroimaging focal lesions and cognitive alterations. We also discuss the potential pathological role of NVU dysregulation in the entry of pathogens from the blood into the parenchyma by altering the blood-brain barrier (BBB), affecting the cerebral microvascular and consequently cause VCI. Next, we review the coupling of neural activity with cerebral blood flow to control the microvascular perfusion; and the disrupted clearance of metabolic byproducts with CSF-ISF exchange via perivascular pathways and glymphatic system. Finally, we discussed the possible therapeutic interventions in CSVD.
Topics: Cerebral Small Vessel Diseases; Cognitive Dysfunction; Glymphatic System; Humans; Microcirculation; Neuroimaging
PubMed: 35580816
DOI: 10.1016/j.nbd.2022.105750 -
EuroIntervention : Journal of EuroPCR... Jan 2021This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises...
An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group.
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
Topics: Cardiology; Consensus; Female; Humans; Ischemia; Male; Microcirculation; Quality of Life
PubMed: 32624456
DOI: 10.4244/EIJY20M07_01 -
Microcirculation (New York, N.Y. : 1994) Oct 2022
Topics: Microcirculation
PubMed: 36125801
DOI: 10.1111/micc.12785 -
Journal of Alternative and... Feb 2020Tecar therapy (TT) is an endogenous thermotherapy used to generate warming up of superficial and deep tissues. TT capability to affect the blood flow is commonly... (Randomized Controlled Trial)
Randomized Controlled Trial
Tecar therapy (TT) is an endogenous thermotherapy used to generate warming up of superficial and deep tissues. TT capability to affect the blood flow is commonly considered to be the primary mechanism to promote tissue healing processes. Despite some preliminary evidence about its clinical efficacy, knowledge on the physiologic responses induced by TT is lacking. The aim of this quantitative randomized pilot study was to determinate if TT, delivered in two modes (resistive and capacitive), affects the perfusion of the skin microcirculation (PSMC) and intramuscular blood flow (IMBF). A randomized controlled pilot feasibility study. Ten healthy volunteers ( = 4 females, = 6 males; mean age 35.9 ± 10.7 years) from a university population were recruited and completed the study. All subjects received three different TT applications (resistive, capacitive, and placebo) for a period of 8 min. PSMC, IMBF, and the skin temperature (ST) were measured pre- and post-TT application using power Doppler sonography, laser speckle contrast imaging (LSCI), and infrared thermography. Compared with placebo application, statistically significant differences in PSMC resulted after both the resistive ( = 0.0001) and the capacitive ( = 0.0001) TT applications, while only the resistive modality compared with the placebo was capable to induce a significant change of IMBF ( = 0.013) and ST ( = 0.0001). The use of power Doppler sonography and LSCI enabled us to evaluate differences in PSMC and IMBF induced by TT application.
Topics: Adult; Diathermy; Electric Stimulation Therapy; Feasibility Studies; Female; Forearm; Humans; Laser-Doppler Flowmetry; Male; Microcirculation; Middle Aged; Muscle, Skeletal; Perfusion Imaging; Physical Therapy Modalities; Pilot Projects; Regional Blood Flow; Skin; Skin Temperature
PubMed: 31580698
DOI: 10.1089/acm.2019.0165