Cardiovascular disease(CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus,who have a risk of cardiovascular mortality two to four times that of people without diabetes.An indivi...Cardiovascular disease(CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus,who have a risk of cardiovascular mortality two to four times that of people without diabetes.An individualised approach to cardiovascular risk estimation and management is needed.Over the past decades,many risk scores have been developed to predict CVD.However,few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice.Currently,guidelines are focused on testing for CVD in symptomatic patients.Atypical symptoms or silent ischemia are more common in the diabetic population,and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy,these guidelines can be difficult to interpret.We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing.The modalities for investigation of CVD are discussed.展开更多
The spasm provocation test(SPT) is an important test in the diagnosis of vasospastic angina(VSA). In many cases, this test is performed as the gold standard test, and VSA is considered not present if the SPT is negati...The spasm provocation test(SPT) is an important test in the diagnosis of vasospastic angina(VSA). In many cases, this test is performed as the gold standard test, and VSA is considered not present if the SPT is negative. However, some patients continue to experience chest symptoms despite a negative SPT. In this study, we report four cases in which SPT was repeated to evaluate chest symptoms despite the negative results of the first SPT. Two men in their 70 s, one woman in her 60 s, and one woman in her 70 s, all with chest symptoms, underwent a second SPT at 4, 3, 2, and 3 years, respectively, after the first SPT, which was negative. Three patients had positive results in the second SPT(75%). In conclusion, even when SPT is negative, the diagnosis of VSA should be made with clinical symptoms in consideration. In some cases, a second SPT may be required to confirm the diagnosis of VSA.展开更多
BACKGROUND Although the spasm provocation test(SPT)can diagnose coronary spasms,it would be helpful if it could also predict their occurrence.AIM To investigate whether coronary spasms can be predicted using changes i...BACKGROUND Although the spasm provocation test(SPT)can diagnose coronary spasms,it would be helpful if it could also predict their occurrence.AIM To investigate whether coronary spasms can be predicted using changes in intracoronary artery pressure measured using a pressure wire during the SPT.METHODS Seventy patients underwent SPTs with pressure-wire measurement of intracoronary artery pressure.During each SPT,the pressure wire was advanced into the distal portion of the right coronary artery(RCA)and left anterior descending coronary artery,and the ratio of intracoronary pressure to aortic pressure(Pd/Pa)was monitored.Coronary spasm was defined as an arterial narrowing of>90%in response to the administration of acetylcholine(ACh),with chest symptoms and/or ischemic electrocardiographic changes.ACh was administered to the RCA at low,moderate,or high doses of 20,50,or 80μg,respectively,and to the left coronary artery(LCA)at low,moderate,or high doses of 50,100,or 200μg,respectively.Coronary arteries with coronary spasms at low doses of ACh were defined as group L,and those with coronary spasms at moderate or high doses were defined as group MH.Those who did not occur coronary spasms at any ACh dose were designated as group N.RESULTS Among the 132 coronary arteries assessed using a pressure wire,there were 49 in group N,25 in group L,and 58 in group MH.Baseline Pd/Pa was the lowest in group L(P=0.001).The decrease in the Pd/Pa between baseline to low doses of ACh was lower in group MH than in group N(P<0.001).A receiver-operating characteristics analysis showed that the cutoff baseline Pd/Pa value for predicting group L was 0.95,with a sensitivity of 0.600(15/25)and a specificity of 0.713(76/107)and that the cutoff value of Pd/Pa from baseline to low doses of ACh for predicting group MH was−0.04,with a sensitivity of 0.741(43/58)and a specificity of 0.694(34/49).CONCLUSION These findings suggest that indices of intracoronary pressure during SPT may be useful means for predicting the occurrence of coronary spasms.展开更多
Vasospastic angina(VSA)is a distinct endotype of ischemia with non-obstructive coronary arteries characterized by transient coronary artery spasm and myocardial ischemia in the absence of significant fixed stenosis.It...Vasospastic angina(VSA)is a distinct endotype of ischemia with non-obstructive coronary arteries characterized by transient coronary artery spasm and myocardial ischemia in the absence of significant fixed stenosis.It is an underdiagnosed and often challenging condition that can lead to recurrent angina,myocardial infarction,and sudden cardiac death.VSA arises from a multifactorial interplay of endothelial dysfunction,vascular smooth muscle hyperreactivity,inflammation,and autonomic dysregulation.While calcium channel blockers and nitrates remain the mainstay of therapy,there is a growing body of evidence in the use of novel and emerging treatments including Rho-kinase inhibitors,endothelin receptor antagonists,and anti-inflammatory agents for refractory cases.Diagnostic evaluation relies on clinical features and,when necessary,invasive coronary pharmacological provocation testing.This narrative review examines the current understanding of VSA,discusses current international guideline-based diagnostic and therapeutic strategies,and highlights novel and investigational approaches that may broaden the treatment armamentarium against it.展开更多
Japanese Prime Minister Sanae Takaichi's framing of a Taiwan contingency as a threat to Japan's survival is widely seen as a direct challenge to the post-World War Ⅱ settlement,contradicting Japan's longs...Japanese Prime Minister Sanae Takaichi's framing of a Taiwan contingency as a threat to Japan's survival is widely seen as a direct challenge to the post-World War Ⅱ settlement,contradicting Japan's longstanding political commitment that Taiwan is part of China.展开更多
Psoriasis and other inflammatory skin diseases remain challenging to manage,in part owing to an incomplete understanding of how stromal cells,including fibroblasts and adipocytes,shape the inflammatory milieu.In their...Psoriasis and other inflammatory skin diseases remain challenging to manage,in part owing to an incomplete understanding of how stromal cells,including fibroblasts and adipocytes,shape the inflammatory milieu.In their recent study,Xia et al.revealed an unexpected dual role for dermal adipocyte lineage cells,describing how these cells first promote and later restrain neutrophil-driven inflammation through a dynamic interplay of chemokine production and lipid-mediated resolution[1].展开更多
文摘Cardiovascular disease(CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus,who have a risk of cardiovascular mortality two to four times that of people without diabetes.An individualised approach to cardiovascular risk estimation and management is needed.Over the past decades,many risk scores have been developed to predict CVD.However,few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice.Currently,guidelines are focused on testing for CVD in symptomatic patients.Atypical symptoms or silent ischemia are more common in the diabetic population,and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy,these guidelines can be difficult to interpret.We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing.The modalities for investigation of CVD are discussed.
文摘The spasm provocation test(SPT) is an important test in the diagnosis of vasospastic angina(VSA). In many cases, this test is performed as the gold standard test, and VSA is considered not present if the SPT is negative. However, some patients continue to experience chest symptoms despite a negative SPT. In this study, we report four cases in which SPT was repeated to evaluate chest symptoms despite the negative results of the first SPT. Two men in their 70 s, one woman in her 60 s, and one woman in her 70 s, all with chest symptoms, underwent a second SPT at 4, 3, 2, and 3 years, respectively, after the first SPT, which was negative. Three patients had positive results in the second SPT(75%). In conclusion, even when SPT is negative, the diagnosis of VSA should be made with clinical symptoms in consideration. In some cases, a second SPT may be required to confirm the diagnosis of VSA.
文摘BACKGROUND Although the spasm provocation test(SPT)can diagnose coronary spasms,it would be helpful if it could also predict their occurrence.AIM To investigate whether coronary spasms can be predicted using changes in intracoronary artery pressure measured using a pressure wire during the SPT.METHODS Seventy patients underwent SPTs with pressure-wire measurement of intracoronary artery pressure.During each SPT,the pressure wire was advanced into the distal portion of the right coronary artery(RCA)and left anterior descending coronary artery,and the ratio of intracoronary pressure to aortic pressure(Pd/Pa)was monitored.Coronary spasm was defined as an arterial narrowing of>90%in response to the administration of acetylcholine(ACh),with chest symptoms and/or ischemic electrocardiographic changes.ACh was administered to the RCA at low,moderate,or high doses of 20,50,or 80μg,respectively,and to the left coronary artery(LCA)at low,moderate,or high doses of 50,100,or 200μg,respectively.Coronary arteries with coronary spasms at low doses of ACh were defined as group L,and those with coronary spasms at moderate or high doses were defined as group MH.Those who did not occur coronary spasms at any ACh dose were designated as group N.RESULTS Among the 132 coronary arteries assessed using a pressure wire,there were 49 in group N,25 in group L,and 58 in group MH.Baseline Pd/Pa was the lowest in group L(P=0.001).The decrease in the Pd/Pa between baseline to low doses of ACh was lower in group MH than in group N(P<0.001).A receiver-operating characteristics analysis showed that the cutoff baseline Pd/Pa value for predicting group L was 0.95,with a sensitivity of 0.600(15/25)and a specificity of 0.713(76/107)and that the cutoff value of Pd/Pa from baseline to low doses of ACh for predicting group MH was−0.04,with a sensitivity of 0.741(43/58)and a specificity of 0.694(34/49).CONCLUSION These findings suggest that indices of intracoronary pressure during SPT may be useful means for predicting the occurrence of coronary spasms.
文摘Vasospastic angina(VSA)is a distinct endotype of ischemia with non-obstructive coronary arteries characterized by transient coronary artery spasm and myocardial ischemia in the absence of significant fixed stenosis.It is an underdiagnosed and often challenging condition that can lead to recurrent angina,myocardial infarction,and sudden cardiac death.VSA arises from a multifactorial interplay of endothelial dysfunction,vascular smooth muscle hyperreactivity,inflammation,and autonomic dysregulation.While calcium channel blockers and nitrates remain the mainstay of therapy,there is a growing body of evidence in the use of novel and emerging treatments including Rho-kinase inhibitors,endothelin receptor antagonists,and anti-inflammatory agents for refractory cases.Diagnostic evaluation relies on clinical features and,when necessary,invasive coronary pharmacological provocation testing.This narrative review examines the current understanding of VSA,discusses current international guideline-based diagnostic and therapeutic strategies,and highlights novel and investigational approaches that may broaden the treatment armamentarium against it.
文摘Japanese Prime Minister Sanae Takaichi's framing of a Taiwan contingency as a threat to Japan's survival is widely seen as a direct challenge to the post-World War Ⅱ settlement,contradicting Japan's longstanding political commitment that Taiwan is part of China.
文摘Psoriasis and other inflammatory skin diseases remain challenging to manage,in part owing to an incomplete understanding of how stromal cells,including fibroblasts and adipocytes,shape the inflammatory milieu.In their recent study,Xia et al.revealed an unexpected dual role for dermal adipocyte lineage cells,describing how these cells first promote and later restrain neutrophil-driven inflammation through a dynamic interplay of chemokine production and lipid-mediated resolution[1].
