|Year : 2019 | Volume
| Issue : 2 | Page : 59-62
Coronary sinus filling time as a marker of microvascular dysfunction in patients with angina and normal coronaries
Farshad Shakerian, Nasrin Panahifar
Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
|Date of Submission||23-Jul-2019|
|Date of Decision||06-Aug-2019|
|Date of Acceptance||27-Aug-2019|
|Date of Web Publication||03-Oct-2019|
Dr. Nasrin Panahifar
Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Objective: Although chest pain and normal coronary arteries (known as cardiac syndrome X [CSX]) remained a prevalent clinical condition, underlying pathogenesis has not been fully explained. Microvascular dysfunction has been considered as the most likely cause of CSX. In this research, we attempted to evaluate the coronary sinus filling time (CSFT) at angiographic films, and also introducing it as a new indicator for microvascular function. Patients and Methodology: Patients with typical angina or abnormal chest pain with stress-induced ischemia in prior stress tests formed angina group and control group consisted of patients with severe mitral stenosis underwent coronary artery angiography before the balloon mitral valvuloplasty. CSFT was explained as the time necessary for the contrast with pass through myocardial capillaries and reach to the coronary sinus origin at coronary angiography. Furthermore, thrombolysis in myocardial infarction (TIMI), frame count, and myocardial blush score were evaluated for each group. At the end, we compared these parameters and reported the results. Results: The angina group consisted of 128 patients and there were 71 patients in the control group. The mean of the CSFT in angina group was 47.2 ± 9.9 (in frame count), which was greater than the mean of the control group (mean: 32.2 ± 3, P = 0.0001). Corrected TIMI frame count was 21.1 ± 3.4 in angina group and 20.1 ± 3.1 in the control group, and the differences were not statistically significant (P = 0.75). Myocardial blush score in the angina and the control group had not indicate any meaningful difference (P = 0.52). Conclusion: CSFT in contrast with TIMI frame count and myocardial blush score, was significantly prolonged in patients with angina and normal coronary arteries.
Keywords: Cardiac syndrome X, coronary sinus filling time, microvascular dysfunction, myocardial blush score, thrombolysis in myocardial infarction frame count
|How to cite this article:|
Shakerian F, Panahifar N. Coronary sinus filling time as a marker of microvascular dysfunction in patients with angina and normal coronaries. Res Cardiovasc Med 2019;8:59-62
|How to cite this URL:|
Shakerian F, Panahifar N. Coronary sinus filling time as a marker of microvascular dysfunction in patients with angina and normal coronaries. Res Cardiovasc Med [serial online] 2019 [cited 2020 Jul 9];8:59-62. Available from: http://www.rcvmonline.com/text.asp?2019/8/2/59/268475
| Introduction|| |
Women with cardiac chest pain, which indicated by myocardial ischemia signs and symptoms in the obstructive coronary artery disease (CAD) absence are often labeled as having cardiac syndrome X (CSX). Although CSX (myocardial ischemia symptoms and signs in the CAD absence) occurs in men and women with a certain predisposition, it is acknowledged as a female-predominant disorder classically, and nearly 70% of patients diagnosed as having CSX are women. The etiology of CSX appears nonhomogeneous, and despite of the considerable research effort during the past four decades, there is no generally accepted understanding about the chest pain etiopathophysiology with ischemia and nonobstructive CAD evidence. Coronary microvascular dysfunction (CMD) has been presented as an appropriate explanation for the continued symptoms and higher cardiovascular (CV) morbidity and mortality. CMD is a damaged coronary microcirculatory function. Although epicardial coronary arteries are conduit vessels, the microcirculation consists of resistance vessels, which regulate myocardial blood flow by dilation or contraction, according to cardiac demand. A resistance vessels dysfunction reduces the ability to regulate myocardial perfusion leading to a decreased blood flow, stress-induced ischemia, and altered myocardial metabolism.,, CMD assessment is very important, therefore, for CMD evaluation, invasive as well as noninvasive methods have been introduced. In this research, we have intended to measure coronary sinus filling time (CSFT) for microvascular dysfunction evaluation in patients with chest pain and normal coronary arteries.
| Patients and Methodology|| |
The angina group consisted of patients with typical angina or patients with abnormal chest pain and had stress-induced ischemia in earlier noninvasive stress tests, which had normal coronary arteries in the angiography from March 2015 to February 2017. Typical angina is explained as (1) substernal chest discomfort, (2) initiated by exertion or stress, and (3) relieved with rest or sublingual nitroglycerin. The control group was including patients with severe mitral stenosis undergoing balloon mitral valvuloplasty, who had these inclusion criteria: (1) normal left ventricular size and systolic function at echocardiography, (2) normal pulmonary artery pressure at echocardiography, (3) normal coronary arteries in the angiography, (4) sinus rhythm in the electrocardiography, and (5) no prior cardiac abnormality except mitral stenosis.
The coronary angiography was accomplished at a rate of 15 frames/s. Left coronary arteries by the injector system with 6–8 ml contrast at a rate of 2 ml/s were injected. The vascular access was either femoral or radial artery. We can describe a normal coronary artery as a smooth vessel without any stenosis, irregularity, or ecstasia. Angiographic films were studied in order to assess the thrombolysis in myocardial infarction (TIMI) frame count, myocardial blush score, and CSFT in both of the angina and control group.
The TIMI frame count was explained as the frame numbers, which are required for the contrast with pass through the coronary artery and also reach to the distal landmark. The standardized distal landmark in left coronary system arteries is the last bifurcation. TIMI frame count for left anterior descending artery (LAD) is revised and also corrected by dividing it to 1.7.
CSFT (in frame count) started from the frame, in which LAD has completely opacified, and ended when the contrast reached to the coronary sinus origin. In fact, CSFT is a time mandatory for the contrast in order to transfer throughout myocardial capillaries and reach to the coronary sinus starting site. By dividing the CSFT in frame count into 15, second CSFT can be counted.
Myocardial blush score is a myocardial perfusion semiquantitative measurement, grading from 0 (no myocardial blush) to 3 (normal myocardial blush), according to the myocardial opacification degree. TIMI frame count, CSFT, and myocardial blush score in both groups, and also demographic data just in angina group attained and analyzed with IBM SPSS Statistic (DP Iran Co, Tehran, Iran). For means comparing, the two-tailed t-test was used.
| Results|| |
The angina group included 128 patients (83 females and 45 males) with the mean age of 53 ± 9.7 years. Furthermore, there were 71 patients in the control group. Angina group demographic data are shown in [Table 1]. The patients CSFT in angina group (mean: 47.2 ± 9.9 frame count) was evidently longer than that of the control group (mean: 32.2 ± 3 frame count), and the difference was statistically significant (P = 0.0001).
Corrected TIMI frame count was as 21.1 in the angina group and 20.1 in the control group without any statistical significant difference (P = 0.75). Two mentioned groups were also compared with regard to myocardial blush score (2.95 ± 0.21 in the angina group, and 2.97 ± 0.16 in the control group), and the difference have not any statistical importance (P = 0.52) [Table 2].
|Table 2: CS filling time, thrombolysis in myocardial infarction frame count, and myocardial blush score in angina and control groups|
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| Discussion|| |
A normal coronary angiogram eliminates obstructive epicardial CAD, as the patient's chest pain cause; however, there are a variety of noncardiac and cardiac causes that may be are responsible and warrant for this consideration. The potential cardiac causes for the chest pain are including: both noncoronary and coronary conditions. The noncoronary causes are typically recognizable readily, because of their associated structural valvular or myocardial pathology. Recognizing coronary dysfunction as a reason for the chest pain is more obscure. Provocation test with vasodilator agents has been considered as the major technique for microvascular function evaluation in most of the earlier surveys.
In 1972, Tambe et al. described coronary slow flow pattern (CSFP) as the slow passage of contrast throughout the normal epicardial coronary arteries. Features are similar to CSFP, which may exist in small myocardial arteries. In this research, we attempted to reveal that maybe spontaneous prolonged blood flow transition time, within the myocardial capillaries is responsible for the chest pain in CSX.
Although CSX occurs in men and women with a certain predisposition, it is acknowledged as a female-predominant disorder classically, and nearly 70% of patients diagnosed as having CSX are women. Our study indicated that the female predominance is 64% in angina group.
TIMI frame count and myocardial blush grade (MBG) methods are new angiographic techniques in order to evaluate epicardial coronary blood flow, and myocardial perfusion, respectively., Atmaca et al. have stated that the amount of MBG in patients with syndrome X was decreased significantly, and Mahfouz et al. declared increased TIMI frame count among the patients with CSX; however, other researchers reported no remarkable difference in MBG and TIMI frame count between the patients with syndrome X and the control group., In this study, there were no significant differences in TIMI frame count and myocardial blush score between the two groups.
Sangareddi and Alagesan  have defined the CSFT as a time taken for the contrast with the traverse the coronary microvasculature, and coronary sinus, and also, CSFT was a useful parameter in differentiating patients with CSX from the control group. Haridasan et al. introduced CSFT as a novel method for evaluating microvasculur function, and also defined CSFT as the time necessary for the contrast from LAD fully opacification to reach to CS ostium. This research had the same method and findings. We described the CSFT as the time between the LAD maximum opacification frames to the frame in which CS origin was seen. This research established that CSFT in normal coronaries population was prolonged significantly in comparison with the control group, which was similar to earlier researches., Also in this study, the number of cases in the angina and control groups was significantly larger in comparison with the former researches.
CSX prognosis is determined by its components, including chest pain, endothelial dysfunction described as reduced coronary blood flow to acetylcholine, and myocardial ischemia. In a large cohort of women with chest pain and no obstructive CAD by angiography, persistent chest pain happened for the 45% of patients, and was associated with considerably more than twice of the CV events, including MIs, strokes, congestive heart failure, and CV death, compared to those in women without persistent chest pain. This study did not include CSX prognosis.
There were some limitations for this retrospective research. The angiographic films were too short, and it did not show the CS origin; consequently, these cases were excluded. Majority of patients in the angina group were designated by relying just on the background of typical angina (70.3%), and remained cases had positive stress tests. Coronary sinus pressure has important effect on microcirculation time and is correlated with the right atrium pressure. It was not possible for us to have access to the right atrium or pulmonary capillary wedge pressure, and systemic pulmonary artery pressure was considered as the normal CS pressure indicator. Our superiority in this study was large number of cases in both angina and control groups in comparison with the cases of Haridasan et al. research.
| Conclusion|| |
CSFT was significantly prolonged in patients with angina and normal coronary arteries. TIMI frame count and myocardial blush score did not show meaningful difference between the angina and control groups in contrast with the CSFT. CSFT may be considered as a useful method for evaluating the microvascular dysfunction.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]