This article has been selected as this issue's CME activity, available online at http://www.acc.o... more This article has been selected as this issue's CME activity, available online at http://www.acc.org/jacc-journals-cme by selecting the CME tab on the top navigation bar. CME Objective for This Article: After reading this article the reader should be able to provide an updated review on advances in noninvasive stress imaging and noninvasive coronary angiography in the evaluation of women presenting with stable, suspected ischemic heart disease.
<jats:p> <jats:bold>Background:</jats:bold> Compared with men, women have more ... more <jats:p> <jats:bold>Background:</jats:bold> Compared with men, women have more evidence of myocardial ischemia in the setting of no obstructive coronary artery disease (CAD). While low endogenous estrogen levels are associated with endothelial dysfunction, the role of low dose hormone therapy has not been fully evaluated in women suffering from myocardial ischemia and no obstructive CAD. </jats:p> <jats:p> <jats:bold>Objective:</jats:bold> This WISE ancillary trial evaluated the effect of low dose hormone therapy in postmenopausal women with myocardial ischemia and no obstructive CAD on: </jats:p> <jats:p> <jats:list list-type="order"> <jats:list-item> <jats:p>endothelial dysfunction, assessed by brachial artery reactivity,</jats:p> </jats:list-item> <jats:list-item> <jats:p>physical functional disability assessed by exercise testing, and</jats:p> </jats:list-item> <jats:list-item> <jats:p>quality of life assessed by cardiac symptoms and psychological questionnaires.</jats:p> </jats:list-item> </jats:list> </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> Using a multicenter, randomized, placebo-controlled design, seventy-four participants with normal/minimally diseased epicardial coronary arteries (&lt;50% luminal diameter stenosis) who fulfilled the inclusion criteria were planned to be randomized to receive either 1 mg norethindrone/10 mcg ethinyl estradiol (1/10 NA/EE) or placebo for twelve weeks. Baseline and exit brachial artery reactivity (BART), exercise stress testing, WISE psychosocial questionnaires, SF-36, blood lipids and hormone levels were evaluated. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> Recruitment was closed prematurely due to failure to recruit in the year following publication of the Women's Health Initiative hormone trial results. Of the 37 women randomized, 35 completed the study. While there was no difference in the frequency of chest pain between groups at the baseline visit, at study exit there was less frequent chest pain in the 1/10 NA/EE group compared to the placebo group (p=0.02). Women taking 1/10 NA/EE also showed a trend to improved BART and exercise tolerance, and had significantly fewer hot flashes/night sweats (p=0.003), less avoidance of intimacy (p=0.05), and borderline differences in sexual desire and vaginal dryness (p=0.06). </jats:p> <jats:p> <jats:bold>Conclusion:</jats:bold> Among postmenopausal women with myocardial ischemia and no obstructive CAD, hormone therapy with 1/10 NA/EE is associated with reduced chest pain symptoms, menopausal symptoms and improved quality of life with trends for improved endothelial function and exercise performance. </jats:p>
<jats:p> <jats:bold>Background:</jats:bold> Menstrual cycling irregularity is b... more <jats:p> <jats:bold>Background:</jats:bold> Menstrual cycling irregularity is being associated with greater frequency of diabetes and adverse cardiovascular (CV) events, suggesting a mechanistic link between ovarian dysfunction, CAD risk factors, and CAD. Confirmation of this link and potential explanatory mechanism(s) have not been established. </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> We compared 686 postmenopausal women with and without a history of irregular cycles who were undergoing coronary angiography for suspected ischemia and enrolled in the WISE study. Coronary angiography was assessed by a core laboratory, and the women were prospectively followed for a median of 5.9 years. Chi square and rank sums analyses were used to compare the women on the presence and severity of CAD, CAD risk factors, and CV events. Multivariate Cox regression, adjusting for angiographic CAD and CAD risk factors was used to define time to death, MI, stroke, and angina hospitalization. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> Overall mean age was 62, 18% were non-white, 130 (19%) reported a history of irregular cycles, and 42% had CAD (≥ 50% stenosis). Women with irregular cycles were younger (p=0.01) but did not exhibit more diabetes, obesity, or metabolic syndrome than those with regular cycles. They became menopausal at a younger age (42 ±10 vs 46 ±8, p=0.001) and had more frequent hysterectomy or oophorectomy (both p&lt;0.01). Women with irregular cycles had a similar adjusted prevalence and severity of angiographic CAD compared to those without irregular cycles, yet had a doubled risk for MI (6% vs. 3%, p=0.02) and higher angina hospitalization rate (34% vs. 28%, p=0.01). No differences were found for the incidence of stroke or death. The relationship was maintained in risk-adjusted models controlling for metabolic syndrome, ethnicity and angiographic CAD severity (p=0.01 for MI and p=0.01 for angina hospitalization). </jats:p> <jats:p> <jats:bold>Conclusion:</jats:bold> Although less commonly applied, a history of menstrual cycling irregularity may be an important clinical marker of downstream risk, which is not immediately explained by the presence or severity of CAD risk factors or angiographic CAD. Additional, non-CAD risk factors, such as hormonal, inflammatory and thrombotic variables, may play a role mechanistically in the link between menstrual irregularity and adverse events. </jats:p>
Introduction: Resistant hypertension (RHTN), a blood pressure (BP) ≥140/90 mm Hg despite ≥ 3 anti... more Introduction: Resistant hypertension (RHTN), a blood pressure (BP) ≥140/90 mm Hg despite ≥ 3 antihypertensive drugs or BP < 140/90 mm Hg using ≥ 4 drugs, is associated with increased incidence of adverse cardiovascular outcomes, especially stroke. Hypothesis and objective: We hypothesize common variants exist in the genes regulating BP response and may lead to RHTN in some patients. Methods: A discovery cohort of hypertensive participants were included as cases (as defined above) or controls (N=719; 263 whites, 322 Hispanics, and 134 African Americans) from SPS3-GENES. They were genotyped on the Illumina Omni 5 Exome chip. Multiple logistic regression analysis was conducted separately in each race using an additive genetic model, adjusting for predictors for RHTN, principle components for ancestry and BP target treatment arms. Results from the 3 racial groups were combined using meta-analysis with inverse-variance weighting, with the hypothesis that functional variants are consis...
There has been increasing interest in open artery syndrome, also known as ischemia with non-obstr... more There has been increasing interest in open artery syndrome, also known as ischemia with non-obstructive coronary arteries (INOCA). INOCA has been increasingly recognized as a heterogeneous clinical entity. Diagnostic evaluation of this heterogeneous entity, including invasive assessment, remains key to diagnose this clinical condition and provide the appropriate treatment. Importantly, medical stratification based on the type of INOCA has shown benefit in improving the symptoms in these patients, as illustrated in the CorMicA trial. The Women’s IschemiA Trial to Reduce Events in Non-ObstRuctIve CORonary Artery Disease (WARRIOR) is another promising landmark trial that is currently enrolling patients and will address some of the unanswered questions for management of women with INOCA. In this review, we discuss the pathophysiology, management options, knowledge gaps, and future directions while highlighting the rationale and design of the ongoing WARRIOR trial.
Elevated nighttime blood pressure (BP) and heart rate (HR), increased BP and HR variabili-ty, and... more Elevated nighttime blood pressure (BP) and heart rate (HR), increased BP and HR variabili-ty, and altered diurnal variations of BP and HR (nighttime dipping and morning surge) in pa-tients with systemic hypertension are each associated with increased adverse cardiovascular events. However, there are no reports on the effect of hypertension treat-ment on these important hemodynamic parameters in the growing population of hyperten-sive patients with atherosclerotic coronary artery disease (CAD). This was a pre-specified subgroup analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable patients aged50 years with hypertension and CAD ran-domized to either verapamil SR- or atenolol-based hypertension treatment strategies. The subgroup consisted of 117 patients undergoing 24-hour ambulatory monitoring at baseline
Impact of resting heart rate on outcomes in hypertensive patients with coronary artery disease: f... more Impact of resting heart rate on outcomes in hypertensive patients with coronary artery disease: findings from the INternational
Hypertension is associated with gut bacterial dysbiosis and gut pathology in animal models and pe... more Hypertension is associated with gut bacterial dysbiosis and gut pathology in animal models and people. Butyrate-producing gut bacteria are decreased in hypertension. RNA-seq analysis of gut colonic organoids prepared from spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto (WKY) rats was used to test the hypothesis that impaired interactions between the gut microbiome and gut epithelium are involved and that these would be remediated with butyrate supplementation. Gene expressions in immune responses including antigen presentation and antiviral pathways were decreased in the gut epithelium of the SHR in organoids and confirmed in vivo; these deficits were corrected by butyrate supplementation. Deficits in gene expression driving epithelial proliferation and differentiation were also observed in SHR. These findings highlight the importance of aligned interactions of the gut microbiome and gut immune responses to blood pressure homeostasis.
A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found ... more A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.
OBJECTIVES To assess the prognostic value of a left ventricular energy-model in women with suspec... more OBJECTIVES To assess the prognostic value of a left ventricular energy-model in women with suspected myocardial ischemia. BACKGROUND The prognostic value of internal energy utilization (IEU) of the left ventricle in women with suspected myocardial ischemia is unknown. METHODS Women (n=227, mean age 59±12 years, range 31-86), with symptoms of myocardial ischemia, underwent myocardial perfusion imaging (MPI) assessment for regional perfusion defects along with measurement of ventricular volumes separately by gated Single Photon Emission Computed Tomography (SPECT) (n= 207) and magnetic resonance imaging (MRI) (n=203). During follow-up (40±17 months), time to first major adverse cardiovascular event (MACE, death, myocardial infarction or hospitalization for congestive heart failure) was analyzed using MRI and gated SPECT variables. RESULTS Adverse events occurred in 31 (14%). Multivariable Cox models were formed for each modality: IEU and wall thickness by MRI (Chi-squared 34, p<0.0...
Cardiovascular disease (CVD) prevalence remains elevated globally. We have previously shown that ... more Cardiovascular disease (CVD) prevalence remains elevated globally. We have previously shown that a one-week lifestyle “immersion program” leads to clinical improvements and sustained improvements in quality of life in moderate to high atherosclerotic CVD (ASCVD) risk individuals. In a subsequent year of this similarly modeled immersion program, we again collected markers of cardiovascular health and, additionally, evaluated intestinal microbiome composition. ASCVD risk volunteers (n = 73) completed the one-week “immersion program” involving nutrition (100% plant-based foods), stress management education, and exercise. Anthropometric measurements and CVD risk factors were compared at baseline and post intervention. A subgroup (n = 22) provided stool, which we analyzed with 16S rRNA sequencing. We assessed abundance changes within-person, correlated the abundance shifts with clinical changes, and inferred functional pathways using PICRUSt. Reductions in blood pressure, total cholester...
Aims To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis o... more Aims To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis of patients with microvascular angina (MVA). Methods and results The Coronary Vasomotor Disorders International Study Group proposed the diagnostic criteria for MVA. We prospectively evaluated the clinical characteristics of patients according to these criteria and their prognosis. The primary endpoint was the composite of major cardiovascular events (MACE), verified by institutional investigators, which included cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina. During the period from 1 July 2015 to 31 December 2018, 686 patients with MVA were registered from 14 institutes in 7 countries from 4 continents. Among them, 64% were female and the main ethnic groups were Caucasians (61%) and Asians (29%). During follow-up of a median of 398 days (IQR 365–744), 78 MACE occurred (6.4% in men vs. 8.6% in women, P =...
This article has been selected as this issue's CME activity, available online at http://www.acc.o... more This article has been selected as this issue's CME activity, available online at http://www.acc.org/jacc-journals-cme by selecting the CME tab on the top navigation bar. CME Objective for This Article: After reading this article the reader should be able to provide an updated review on advances in noninvasive stress imaging and noninvasive coronary angiography in the evaluation of women presenting with stable, suspected ischemic heart disease.
<jats:p> <jats:bold>Background:</jats:bold> Compared with men, women have more ... more <jats:p> <jats:bold>Background:</jats:bold> Compared with men, women have more evidence of myocardial ischemia in the setting of no obstructive coronary artery disease (CAD). While low endogenous estrogen levels are associated with endothelial dysfunction, the role of low dose hormone therapy has not been fully evaluated in women suffering from myocardial ischemia and no obstructive CAD. </jats:p> <jats:p> <jats:bold>Objective:</jats:bold> This WISE ancillary trial evaluated the effect of low dose hormone therapy in postmenopausal women with myocardial ischemia and no obstructive CAD on: </jats:p> <jats:p> <jats:list list-type="order"> <jats:list-item> <jats:p>endothelial dysfunction, assessed by brachial artery reactivity,</jats:p> </jats:list-item> <jats:list-item> <jats:p>physical functional disability assessed by exercise testing, and</jats:p> </jats:list-item> <jats:list-item> <jats:p>quality of life assessed by cardiac symptoms and psychological questionnaires.</jats:p> </jats:list-item> </jats:list> </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> Using a multicenter, randomized, placebo-controlled design, seventy-four participants with normal/minimally diseased epicardial coronary arteries (&lt;50% luminal diameter stenosis) who fulfilled the inclusion criteria were planned to be randomized to receive either 1 mg norethindrone/10 mcg ethinyl estradiol (1/10 NA/EE) or placebo for twelve weeks. Baseline and exit brachial artery reactivity (BART), exercise stress testing, WISE psychosocial questionnaires, SF-36, blood lipids and hormone levels were evaluated. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> Recruitment was closed prematurely due to failure to recruit in the year following publication of the Women's Health Initiative hormone trial results. Of the 37 women randomized, 35 completed the study. While there was no difference in the frequency of chest pain between groups at the baseline visit, at study exit there was less frequent chest pain in the 1/10 NA/EE group compared to the placebo group (p=0.02). Women taking 1/10 NA/EE also showed a trend to improved BART and exercise tolerance, and had significantly fewer hot flashes/night sweats (p=0.003), less avoidance of intimacy (p=0.05), and borderline differences in sexual desire and vaginal dryness (p=0.06). </jats:p> <jats:p> <jats:bold>Conclusion:</jats:bold> Among postmenopausal women with myocardial ischemia and no obstructive CAD, hormone therapy with 1/10 NA/EE is associated with reduced chest pain symptoms, menopausal symptoms and improved quality of life with trends for improved endothelial function and exercise performance. </jats:p>
<jats:p> <jats:bold>Background:</jats:bold> Menstrual cycling irregularity is b... more <jats:p> <jats:bold>Background:</jats:bold> Menstrual cycling irregularity is being associated with greater frequency of diabetes and adverse cardiovascular (CV) events, suggesting a mechanistic link between ovarian dysfunction, CAD risk factors, and CAD. Confirmation of this link and potential explanatory mechanism(s) have not been established. </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> We compared 686 postmenopausal women with and without a history of irregular cycles who were undergoing coronary angiography for suspected ischemia and enrolled in the WISE study. Coronary angiography was assessed by a core laboratory, and the women were prospectively followed for a median of 5.9 years. Chi square and rank sums analyses were used to compare the women on the presence and severity of CAD, CAD risk factors, and CV events. Multivariate Cox regression, adjusting for angiographic CAD and CAD risk factors was used to define time to death, MI, stroke, and angina hospitalization. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> Overall mean age was 62, 18% were non-white, 130 (19%) reported a history of irregular cycles, and 42% had CAD (≥ 50% stenosis). Women with irregular cycles were younger (p=0.01) but did not exhibit more diabetes, obesity, or metabolic syndrome than those with regular cycles. They became menopausal at a younger age (42 ±10 vs 46 ±8, p=0.001) and had more frequent hysterectomy or oophorectomy (both p&lt;0.01). Women with irregular cycles had a similar adjusted prevalence and severity of angiographic CAD compared to those without irregular cycles, yet had a doubled risk for MI (6% vs. 3%, p=0.02) and higher angina hospitalization rate (34% vs. 28%, p=0.01). No differences were found for the incidence of stroke or death. The relationship was maintained in risk-adjusted models controlling for metabolic syndrome, ethnicity and angiographic CAD severity (p=0.01 for MI and p=0.01 for angina hospitalization). </jats:p> <jats:p> <jats:bold>Conclusion:</jats:bold> Although less commonly applied, a history of menstrual cycling irregularity may be an important clinical marker of downstream risk, which is not immediately explained by the presence or severity of CAD risk factors or angiographic CAD. Additional, non-CAD risk factors, such as hormonal, inflammatory and thrombotic variables, may play a role mechanistically in the link between menstrual irregularity and adverse events. </jats:p>
Introduction: Resistant hypertension (RHTN), a blood pressure (BP) ≥140/90 mm Hg despite ≥ 3 anti... more Introduction: Resistant hypertension (RHTN), a blood pressure (BP) ≥140/90 mm Hg despite ≥ 3 antihypertensive drugs or BP < 140/90 mm Hg using ≥ 4 drugs, is associated with increased incidence of adverse cardiovascular outcomes, especially stroke. Hypothesis and objective: We hypothesize common variants exist in the genes regulating BP response and may lead to RHTN in some patients. Methods: A discovery cohort of hypertensive participants were included as cases (as defined above) or controls (N=719; 263 whites, 322 Hispanics, and 134 African Americans) from SPS3-GENES. They were genotyped on the Illumina Omni 5 Exome chip. Multiple logistic regression analysis was conducted separately in each race using an additive genetic model, adjusting for predictors for RHTN, principle components for ancestry and BP target treatment arms. Results from the 3 racial groups were combined using meta-analysis with inverse-variance weighting, with the hypothesis that functional variants are consis...
There has been increasing interest in open artery syndrome, also known as ischemia with non-obstr... more There has been increasing interest in open artery syndrome, also known as ischemia with non-obstructive coronary arteries (INOCA). INOCA has been increasingly recognized as a heterogeneous clinical entity. Diagnostic evaluation of this heterogeneous entity, including invasive assessment, remains key to diagnose this clinical condition and provide the appropriate treatment. Importantly, medical stratification based on the type of INOCA has shown benefit in improving the symptoms in these patients, as illustrated in the CorMicA trial. The Women’s IschemiA Trial to Reduce Events in Non-ObstRuctIve CORonary Artery Disease (WARRIOR) is another promising landmark trial that is currently enrolling patients and will address some of the unanswered questions for management of women with INOCA. In this review, we discuss the pathophysiology, management options, knowledge gaps, and future directions while highlighting the rationale and design of the ongoing WARRIOR trial.
Elevated nighttime blood pressure (BP) and heart rate (HR), increased BP and HR variabili-ty, and... more Elevated nighttime blood pressure (BP) and heart rate (HR), increased BP and HR variabili-ty, and altered diurnal variations of BP and HR (nighttime dipping and morning surge) in pa-tients with systemic hypertension are each associated with increased adverse cardiovascular events. However, there are no reports on the effect of hypertension treat-ment on these important hemodynamic parameters in the growing population of hyperten-sive patients with atherosclerotic coronary artery disease (CAD). This was a pre-specified subgroup analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable patients aged50 years with hypertension and CAD ran-domized to either verapamil SR- or atenolol-based hypertension treatment strategies. The subgroup consisted of 117 patients undergoing 24-hour ambulatory monitoring at baseline
Impact of resting heart rate on outcomes in hypertensive patients with coronary artery disease: f... more Impact of resting heart rate on outcomes in hypertensive patients with coronary artery disease: findings from the INternational
Hypertension is associated with gut bacterial dysbiosis and gut pathology in animal models and pe... more Hypertension is associated with gut bacterial dysbiosis and gut pathology in animal models and people. Butyrate-producing gut bacteria are decreased in hypertension. RNA-seq analysis of gut colonic organoids prepared from spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto (WKY) rats was used to test the hypothesis that impaired interactions between the gut microbiome and gut epithelium are involved and that these would be remediated with butyrate supplementation. Gene expressions in immune responses including antigen presentation and antiviral pathways were decreased in the gut epithelium of the SHR in organoids and confirmed in vivo; these deficits were corrected by butyrate supplementation. Deficits in gene expression driving epithelial proliferation and differentiation were also observed in SHR. These findings highlight the importance of aligned interactions of the gut microbiome and gut immune responses to blood pressure homeostasis.
A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found ... more A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.
OBJECTIVES To assess the prognostic value of a left ventricular energy-model in women with suspec... more OBJECTIVES To assess the prognostic value of a left ventricular energy-model in women with suspected myocardial ischemia. BACKGROUND The prognostic value of internal energy utilization (IEU) of the left ventricle in women with suspected myocardial ischemia is unknown. METHODS Women (n=227, mean age 59±12 years, range 31-86), with symptoms of myocardial ischemia, underwent myocardial perfusion imaging (MPI) assessment for regional perfusion defects along with measurement of ventricular volumes separately by gated Single Photon Emission Computed Tomography (SPECT) (n= 207) and magnetic resonance imaging (MRI) (n=203). During follow-up (40±17 months), time to first major adverse cardiovascular event (MACE, death, myocardial infarction or hospitalization for congestive heart failure) was analyzed using MRI and gated SPECT variables. RESULTS Adverse events occurred in 31 (14%). Multivariable Cox models were formed for each modality: IEU and wall thickness by MRI (Chi-squared 34, p<0.0...
Cardiovascular disease (CVD) prevalence remains elevated globally. We have previously shown that ... more Cardiovascular disease (CVD) prevalence remains elevated globally. We have previously shown that a one-week lifestyle “immersion program” leads to clinical improvements and sustained improvements in quality of life in moderate to high atherosclerotic CVD (ASCVD) risk individuals. In a subsequent year of this similarly modeled immersion program, we again collected markers of cardiovascular health and, additionally, evaluated intestinal microbiome composition. ASCVD risk volunteers (n = 73) completed the one-week “immersion program” involving nutrition (100% plant-based foods), stress management education, and exercise. Anthropometric measurements and CVD risk factors were compared at baseline and post intervention. A subgroup (n = 22) provided stool, which we analyzed with 16S rRNA sequencing. We assessed abundance changes within-person, correlated the abundance shifts with clinical changes, and inferred functional pathways using PICRUSt. Reductions in blood pressure, total cholester...
Aims To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis o... more Aims To provide multi-national, multi-ethnic data on the clinical characteristics and prognosis of patients with microvascular angina (MVA). Methods and results The Coronary Vasomotor Disorders International Study Group proposed the diagnostic criteria for MVA. We prospectively evaluated the clinical characteristics of patients according to these criteria and their prognosis. The primary endpoint was the composite of major cardiovascular events (MACE), verified by institutional investigators, which included cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina. During the period from 1 July 2015 to 31 December 2018, 686 patients with MVA were registered from 14 institutes in 7 countries from 4 continents. Among them, 64% were female and the main ethnic groups were Caucasians (61%) and Asians (29%). During follow-up of a median of 398 days (IQR 365–744), 78 MACE occurred (6.4% in men vs. 8.6% in women, P =...
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