Coronary artery calcification and cardiovascular risk prediction

Prevention of cardiovascular events starts with predicting one’s cardiovascular risk, to be used as a solid base for the required level of intensity of preventive measures. Hence, the accuracy of our risk prediction is vital. Risk assessment algorithms, based on traditional risk factors, such as the U.S. Framingham Risk Score1 and its European counterpart SCORE (Systemic COronary Risk Evaluation),2 are widely used to estimate absolute 10-year risk of cardiovascular events. Traditional cardiovascular risk factors like age, gender, blood pressure and cholesterol are clearly related to the severity of atherosclerosis, the underlying mechanism of cardiovascular disease (CVD). However, at every level of risk factor exposure, there is substantial variation in the quantity of atherosclerosis. This variation in disease is probably due to interactions between risk factors, duration of exposure to the specific level of the risk factors, genetic disparity and aspects as biological and laboratory variability in the risk factor. Therefore, measuring the amount of atherosclerosis, representing the end result of risk exposures, might be useful to improve CVD risk prediction

Gynecardiology: Distinct patterns of ischemic heart disease in middle-aged women

Contains fulltext : 155387.pdf (Publisher’s version ) (Closed access)The past 25 years have revealed that distinct patterns of ischemic heart disease exist in women that are importantly different from the male standard. Premenopausal women have a lower risk factor profile resulting in fewer cardiovascular events at younger age, which reverses at older age. First signs of vascular ageing appear in middle-aged women, with a predominance of functional coronary abnormalities over anatomical obstructions. Over 50% of symptomatic middle-aged women have coronary microvascular dysfunction that is often poorly recognized and treated. This microvascular syndrome has different symptomatic characteristics compared to the classic pattern of angina pectoris related with obstructive coronary disease. Vascular dysfunction is also an important contributor to the occurrence of acute coronary syndromes in relatively young women. Female-specific signs and symptoms related to various stages of life are increasingly helpful tools in identifying women at increased risk. This evolving knowledge in 'gynecardiology' is an important challenge for more interaction between gynecologists and cardiologists to further improve accurate prevention in those women at highest need

[Microvascular angina in women: a diagnostic and therapeutic challenge]

Item does not contain fulltextGender differences play an important role in coronary heart disease (CHD). Not only in the presentation of symptoms, but also in their underlying pathophysiology. Women with persistent angina without obstructive coronary artery disease (CAD) pose a diagnostic and therapeutic challenge. Half of these women have microvascular coronary dysfunction (MCD). The 2013 guidelines on management of stable angina now acknowledge this condition, but our understanding of MCD is still limited. In this clinical case presentation we elaborate on contemporary methods of diagnosing and managing microvascular angina based on the cases of two women who attended our outpatient clinic. The availability of non-invasive tools to diagnose MCD is still limited. Current treatment is based on reduction of cardiovascular risk factors but physicians and patients should be aware that although therapy usually reduces symptoms, they do not completely disappear. More research on diagnostic methods and effective therapy for MCD is eagerly awaited

Diagnostic approach in patients with angina and no obstructive coronary artery disease: emphasising the role of the coronary function test

BACKGROUND: Many patients with angina do not have obstructive coronary artery disease (CAD), also referred to as "Ischaemia with No Obstructive Coronary Arteries" (INOCA). Coronary vascular dysfunction is the underlying cause of this ischaemic heart disease in as much as 59-89% of these patients, including the endotypes of coronary microvascular dysfunction and epicardial coronary vasospasm. Currently, a coronary function test (CFT) is the only comprehensive diagnostic modality to evaluate all endotypes of coronary vascular dysfunction in patients with INOCA. OBJECTIVE: In this paper we discuss the relevance of performing a CFT, provide considerations for patient selection, and present an overview of the procedure and its safety. METHODS: We reviewed the latest published data, guidelines and consensus documents, combined with a discussion of novel original data, to present this point of view. RESULTS: The use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and persistent symptoms. The safety of the procedure is comparable to that of a regular coronary angiography with physiological measurements. Non-invasive alternatives have limited diagnostic accuracy for the identification of coronary vascular dysfunction in patients with INOCA, and a regular coronary angiography and/or coronary computed tomography scan cannot establish the diagnosis. CONCLUSIONS: A complete CFT, including acetylcholine and adenosine tests, should be considered in patients with INOCA

Does diastolic dysfunction precede systolic dysfunction in trastuzumab-induced cardiotoxicity? Assessment with multigated radionuclide angiography (MUGA)

Contains fulltext : 165961.pdf (publisher's version ) (Open Access)Trastuzumab is successfully used for the treatment of HER2-positive breast cancer. Because of its association with cardiotoxicity, LVEF is monitored by MUGA, though this is a relatively late measure of cardiac function. Diastolic dysfunction (DD) is believed to be an early predictor of cardiac impairment. We evaluate the merit of MUGA-derived diastolic function parameters in the early detection of trastuzumab-induced cardiotoxicity (TIC).77 trastuzumab-treated patients with normal baseline systolic and diastolic function were retrospectively selected (n = 77). All serial MUGA examinations were re-analyzed for systolic and diastolic function parameters. 36 patients (47\%) developed SD and 45 patients (58\%) DD during treatment. Both systolic and diastolic parameters significantly decreased. Of the patients with SD, 24 (67\%) also developed DD. DD developed prior to systolic impairment in 54\% of cases, in 42\% vice versa, while time to occurrence did not differ significantly (P = .52). This also applied to the subgroup of advanced stage breast cancer patients (P = .1).Trastzumab-induced SD and DD can be detected by MUGA. An impairment of MUGA-derived diastolic parameters does not occur prior to SD and therefore cannot be used as earlier predictors of TIC.9 p

Gender in cardiovascular medicine: chest pain and coronary artery disease

Contains fulltext : 215443.pdf (Publisher’s version ) (Closed access)Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality among women and men yet women are more often underdiagnosed, have a delay in diagnosis, and/or receive suboptimal treatment. An implicit gender-bias with regard to lack of recognition of sex-related differences in presentation of IHD may, in part, explain these differences in women compared with men. Indeed, existing knowledge demonstrates that angina does not commonly relate to obstructive coronary artery disease (CAD). Emerging knowledge supports an inclusive approach to chest pain symptoms in women, as well as a more thoughtful consideration of percutaneous coronary intervention for angina in stable obstructive CAD, to avoid chasing our tails. Emerging knowledge regarding the cardiac autonomic nervous system and visceral pain pathways in patients with and without obstructive CAD offers explanatory mechanisms for angina. Interdisciplinary investigation approaches that involve cardiologists, biobehavioural specialists, and anaesthesia/pain specialists to improve angina treatment should be pursued

Questionnaire survey on cardiologists' view and management of coronary microvascular disease in clinical practice

Contains fulltext : 203601.pdf (publisher's version ) (Open Access