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When ischaemia has more than one reason
Session:
Casos Clínicos: Cardiologia de Intervenção
Speaker:
Filipe Silva Vilela
Congress:
CPC 2024
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Filipe Silva Vilela; Carla Oliveira Ferreira; Ana Sofia Fernandes; Mónica Dias; Inês Conde; Rodrigo Silva; Fernando Mané; Rui Flores; Carlos Galvão Braga; António Gaspar
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">Angina pectoris, the most common symptom of ischaemic heart disease, affects approximately 112 million people worldwide. A significant proportion of patients undergoing coronary angiography for angina and evidence of myocardial ischaemia have no obstructive coronary arteries, a condition termed INOCA. </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">In INOCA, the mismatch between blood supply and myocardial oxygen demands </span><span style="color:black">can result from</span><span style="color:black"> coronary microvascular dysfunction and/or epicardial coronary artery spasm. Compared to asymptomatic individuals, INOCA is associated with an increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">This report presents the case of a 65-year-old man with a history of arterial hypertension, diabetes mellitus, dyslipidemia, active smoking, obesity and a ST-elevation myocardial infarction, which was treated with primary percutaneous coronary intervention. After that and despite optimal medical therapy, the patient</span><span style="color:black"> continued to experience exertional angina.</span> </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">In this context, diagnostic </span><span style="color:black">evaluations for myocardial ischaemia were initiated. He underwent a stress echocardiogram which revealed extensive ischaemia, but the invasive coronary angiography showed the </span><span style="color:black">absence of obstructive coronary arteries. </span><span style="color:black">Next, an </span><span style="color:black">invasive functional coronary angiography (FCA) was performed to assess coronary vasospasm and microvascular dysfunction. FCA revealed a decrease in </span><span style="color:black">coronary flow reserve (CFR) and an increase in the index of microcirculatory resistance (IMR), consistent with microvascular angina. Additionally, the acetylcholine test showed significant epicardial vasoconstriction with </span><span style="color:black">reproduction of the usual chest pain and </span><span style="color:black">ischemic ECG changes, conditions that define the diagnosis of vasospastic angina.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">After several months, the patient's symptoms improved with a combination of anti-ischemic drugs, lifestyle changes, and control of modifiable cardiovascular risk factor</span>s.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">These conditions are rarely correctly diagnosed;</span><span style="color:black"> therefore, </span><span style="color:black">these patients continue to experience recurrent angina with impaired quality of life, leading to repeated hospitalizations, unnecessary coronary angiography and adverse cardiovascular outcomes in the short and long term. </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">This case highlights that </span><span style="color:black">a systematic approach to diagnose and treat these patients should be implemented by clinicians and interventional cardiologists involved in their care.</span></span></span></p>
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