2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary

Gulati, Martha; Levy, Phillip D.; Mukherjee, Debabrata; Amsterdam, Ezra A.; Bhatt, Deepak L.; Birtcher, Kim K.; Blankstein, Ron; Boyd, Jack; Bullock-Palmer, Renée P.; Conejo, Theresa; Diercks, Deborah B.; Gentile, Federico; Greenwood, John P; Hess, Erik P.; Hollenberg, Steven M.; Jaber, Wael A.; Jneid, Hani; Joglar, José A.; Morrow, David A.; O’Connor, Robert E.; Ross, Michael A.; Shaw, Leslee J.

doi:10.1016/j.jacc.2021.07.052

Cited by 106 publications

(30 citation statements)

References 336 publications

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“…Cardiac magnetic resonance (CMR) can be used to quantify global MP using quantitative coronary sinus flow measurements (Schwitter et al, 2000), providing both diagnostic (Shomanova et al, 2017) and prognostic value (Indorkar et al, 2018;Kato et al, 2017). The latest guidelines for evaluation and diagnosis of patients with chest pain state that quantitative perfusion assessment with CMR may be used in the evaluation of patients with suspected MVA (Gulati et al, 2021). Thus, we aimed to determine if patients with suspected MVA, defined as angina pectoris and stress-induced ST-segment changes on bicycle exercise test, with normal findings on MP single-photon emission computed tomography (MPS), have different global MP during adenosine stress compared with healthy volunteers and patients with regional stress-induced ischaemia.…”

Section: Introductionmentioning

confidence: 99%

Myocardial perfusion by CMR coronary sinus flow shows sex differences and lowered perfusion at stress in patients with suspected microvascular angina

Gyllenhammar

Carlsson

Jögi

et al. 2022

Clin Physio Funct Imaging

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Background Patients with chest pain may have normal coronary arteries and suffer from microvascular angina (MVA). The aim of this study was to determine if patients with suspected MVA have lower global myocardial perfusion (global MP) during adenosine stress compared with healthy controls and coronary artery disease (CAD) patients and to determine if there are sex differences in global MP. Methods Twenty‐three patients with suspected MVA (66 ± 11 years), 19 CAD patients (69 ± 5 years) with stress‐induced ischaemia and 24 healthy controls (61 ± 10 years) underwent cardiac magnetic resonance (CMR) including coronary sinus flow measurements and first‐pass perfusion at rest and during adenosine stress. Global MP was quantified as coronary sinus flow normalized to left ventricular mass. Results Global perfusion was lower during stress in patients with suspected MVA (2.9 ± 1.0 ml/min/g) compared with healthy volunteers (3.7 ± 1.1 ml/min/g, p = 0.018), but higher compared with CAD patients (2.0 ± 0.9 ml/min/g, p = 0.019). Female controls had higher global MP than male controls both at rest (1.0 ± 0.3 vs. 0.7 ± 0.2 ml/min/g, p = 0.003) and during stress (4.4 ± 1.0 vs. 3.1 ± 0.6 ml/min/g, p = 0.001). Furthermore, females with suspected MVA showed higher global MP than males with suspected MVA (3.3 ± 1.0 vs. 2.4 ± 0.7, p = 0.04). Conclusions Patients with suspected MVA have lower global MP at stress than healthy volunteers but higher than patients with CAD. Furthermore, there seems to be a sex difference in global MP at stress both in healthy volunteers and in patients with suspected MVA, with higher global MP in females, which implies a need for sex‐specific normal limits when assessing quantitative MP.

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Section: Introductionmentioning

confidence: 99%

Myocardial perfusion by CMR coronary sinus flow shows sex differences and lowered perfusion at stress in patients with suspected microvascular angina

Gyllenhammar

Carlsson

Jögi

et al. 2022

Clin Physio Funct Imaging

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“…The current American Heart Association/American College of Cardiology chest pain guidelines provide clinical pathways that may begin with anatomic or functional imaging, and either pathway may lead to a diagnosis of INOCA. 3 Standard stress tests have low sensitivity for detecting CMD, although the presence of ischemic electrocardiographic changes, specifically ST depression that persists for at least 1 minute into recovery, in the absence of obstructive CAD should raise suspicion for CMD. 86,87 Exercise echocardiography may be preferred in women with myocardial bridging, to assess for end-systolic to early diastolic septal wall buckling with apical sparing, a sign of dynamic focal ischemia of a compressed segment.…”

Section: Noninvasive Risk Stratification and Diagnosismentioning

confidence: 99%

“…3,89 For symptomatic patients with nonobstructive CAD, intensification of preventive therapies is recommended. 3 Statins and ACE inhibitor/ ARB (angiotensin receptor blocker) therapy is suggested to improve microvascular function. Lifestyle counseling, including stress management, should be also supported as outlined in the stable IHD guidelines.…”

Section: Evidence From Cormicamentioning

confidence: 99%

“…6 Determination of atypical angina may thus contribute to misdiagnosis and delayed recognition and treatment of ischemia in women. 3,6 In recognition of this, the recently published chest pain guidelines recommend the term atypical should be avoided. 3 Additional challenges to the diagnosis and prognosis of IHD based on symptom presentation include poor correlation of angina with evidence of myocardial ischemia in women and men.…”

Section: Risk Perception and Stratificationmentioning

confidence: 99%

“…Recently, a clinical practice guideline for the evaluation and diagnosis of chest pain underscored the uniqueness of chest pain in women. 3 Emerging data from the past 2 decades have significantly improved the understanding of IHD in women, including mechanisms of ischemia with no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA). This review highlights the contemporary understanding of coronary arterial function and disease in women with no obstructive coronary arteries, including risk perception and stratification, coronary anatomy and physiology, mechanisms of INOCA and MINOCA, noninvasive and invasive diagnostic strategies, and management of IHD.…”

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confidence: 99%

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Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries

Reynolds

Merz

Berry

et al. 2022

Circulation Research

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Ischemic heart disease (IHD) is the leading cause of mortality in women. While traditional cardiovascular risk factors play an important role in the development of IHD in women, women may experience sex-specific IHD risk factors and pathophysiology, and thus female-specific risk stratification is needed for IHD prevention, diagnosis, and treatment. Emerging data from the past 2 decades have significantly improved the understanding of IHD in women, including mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries. Despite this progress, sex differences in IHD outcomes persist, particularly in young women. This review highlights the contemporary understanding of coronary arterial function and disease in women with no obstructive coronary arteries, including coronary anatomy and physiology, mechanisms of ischemia with no obstructive coronary arteries and myocardial infarction with no obstructive coronary arteries, noninvasive and invasive diagnostic strategies, and management of IHD.

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Influence of intensive lipid‐lowering on CT derived fractional flow reserve in patients with stable chest pain: Rationale and design of the FLOWPROMOTE study

Mortensen

Sand²,

Busk

et al. 2022

Clinical Cardiology

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Introduction Coronary CT angiography (CTA) derived fractional flow reserve (FFR CT ) shows high diagnostic performance when compared to invasively measured FFR. Presence and extent of low attenuation plaque density have been shown to be associated with abnormal physiology by measured FFR. Moreover, it is well established that statin therapy reduces the rate of plaque progression and results in morphology alterations underlying atherosclerosis. However, the interplay between lipid lowering treatment, plaque regression, and the coronary physiology has not previously been investigated. Aim To test whether lipid lowering therapy is associated with significant improvement in FFR CT , and whether there is a dose–response relationship between lipid lowering intensity, plaque regression, and coronary flow recovery. Methods Investigator driven, prospective, multicenter, randomized study of patients with stable angina, coronary stenosis ≥50% determined by clinically indicated first‐line CTA, and FFR CT ≤ 0.80 in whom coronary revascularization was deferred. Patients are randomized to standard (atorvastatin 40 mg daily) or intensive (rosuvastatin 40 mg + ezetimibe 10 mg daily) lipid lowering therapy for 18 months. Coronary CTA scans with blinded coronary plaque and FFR CT analyses will be repeated after 9 and 18 months. The primary endpoint is the 18‐month difference in FFR CT using (1) the FFR CT value 2 cm distal to stenosis and (2) the lowest distal value in the vessel of interest. A total of 104 patients will be included in the study. Conclusion The results of this study will provide novel insights into the interplay between lipid lowering, and the pathophysiology in coronary artery disease.

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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary

Cited by 106 publications

References 336 publications

Myocardial perfusion by CMR coronary sinus flow shows sex differences and lowered perfusion at stress in patients with suspected microvascular angina

Myocardial perfusion by CMR coronary sinus flow shows sex differences and lowered perfusion at stress in patients with suspected microvascular angina

Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries

Influence of intensive lipid‐lowering on CT derived fractional flow reserve in patients with stable chest pain: Rationale and design of the FLOWPROMOTE study

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