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Coronary sinus catheter techniques for evaluation of coronary flow and myocardial metabolism have the drawback that a global sampling method is used to evaluate a regional disease (coronary artery disease). Studies on the coronary circulation are further limited by the fact that interventions acting on the coronary bed may simultaneously modify several of the principal determinants of coronary blood flow. Results are also influenced by differences among species, and whether the coronary vascular bed is normal or pathologically narrowed. Because coronary flow is intimately coupled to myocardial oxygen demand, interpretation of values as abnormal require simultaneous evaluation of some index of myocardial oxygen consumption. Under normal conditions, myocardial flow is predominantly in diastole, and is subject to compromise by factors that abbreviate diastole (e.g., tachyarrhythmias). Autoregulation maintains constant coronary blood flow over a range of perfusion pressures (60-130 mm Hg), and increased flow demands are normally met by coronary vasodilation (coronary flow reserve). In proximal coronary stenosis, this capacity for additional vasodilation may be significantly reduced, and flow to potentially ischemic beds beyond the stenosis may be maintained by collaterals. Pharmacologic coronary vasodilation in this situation can result in coronary steal. When perfusion pressure decreases below the autoregulatory range, or when coronary flow reserve is exhausted early, as in coronary stenosis, flow becomes dependent on mechanical factors including duration of diastole and the perfusion pressure. In these situations, monitoring heart rate and diastolic pressure would allow reasonable assessment of adequacy of coronary flow and myocardial perfusion.
BACKGROUND: Epicardial adipose tissue expresses adiponectin protein, and its expression is significantly lower in patients with severe coronary artery disease (CAD) than in those without CAD. Transcoronary adiponectin levels are significantly decreased in nondiabetic but not in diabetic patients with CAD. Adiponectin is also an important adipocytokine that is linked to insulin resistance and reduces coronary microvascular function. HYPOTHESIS: Adiponectin may play a significant role in the localized coronary circulation. The present study examines the local dynamics of adiponectin in the coronary circulation in nondiabetic individuals with normal coronary arteries and the relationship between adiponectin and coronary microvasculature function. METHODS: We examined 22 consecutive nondiabetic patients whose coronary arteries were angiographically normal. Plasma levels of adiponectin were measured in blood samples that were simultaneously collected from the orifice of the left coronary artery (LCA) and the great cardiac vein (GCV). To evaluate the function of the coronary microcirculation, we measured coronary flow velocity at maximal hyperemia using a Doppler wire. Coronary flow reserve (CFR) was obtained from the ratio of hyperemia to the baseline coronary flow velocity. RESULTS: Plasma adiponectin levels in the GCV (median 6.95 microg/ml) were significantly higher than those in the LCA (median 6.60 microg/ml, p < 0.0005). The difference in plasma adiponectin levels between GCV and LCA significantly correlated with CFR (R = 0.451, p < 0.05). CONCLUSIONS: Adiponectin is locally produced in the coronary circulation. This protein may participate in modulating the coronary circulation of nondiabetic patients with angiographically normal coronary arteries.
Coronary vessel stenosis increases vascular resistance and limits the dynamic range of autoregulation. In this study, the limitation imposed by stenosed vessels on oxygen delivery to the myocardium was investigated using a theoretical model. For different degrees of stenosis and for different levels of arteriovenous oxygen content difference, the model predicted the limits of the contractility range for which ventricular oxygen balance is positive. The model also predicted the existence of an optimal contractility level which minimizes the cost of arterial pressure generation and provides the largest coronary oxygen reserve. With severe stenosis, myocardial oxygen balance is extremely sensitive to changes in the level of stenosis. The range of contractility in which the coronary circulation can meet the myocardial oxygen needs is dramatically reduced by small increases in stenosis severity or small decreases in arteriovenous oxygen difference. When the optimal contractility level is maintained, the heart can tolerate these detrimental changes to a greater extent.
BACKGROUND: Platelet-derived growth factor (PDGF) is a potent mitogen for vascular smooth muscle cells and is implicated in the vascular response to injury and the pathogenesis of atherosclerosis. It is also a potent vasoconstrictor. METHODS: To examine whether acute myocardial ischemia increases the level of PDGF in the coronary circulation, we measured plasma levels of PDGF in the coronary sinus and the aortic root simultaneously in 14 patients with coronary spastic angina. These measurements were performed before and after the left coronary artery spasm induced by intracoronary injection of acetylcholine, and measurements were also taken in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid atrial pacing. Eleven patients with chest pain but normal coronary arteries and no coronary spasm served as controls. RESULTS: Plasma PDGF levels increased significantly (P < 0.01) from 274 +/- 28 pg/mL to 364 +/- 27 pg/mL only in coronary sinus after anginal attacks in the patients with coronary spastic angina. However, plasma PDGF levels in coronary sinus remained unchanged after these attacks in the patients with stable exertional angina (from 230 +/- 27 pg/ml to 247 +/- 28 pg/mL) and after intracoronary injection of acetylcholine in the control subjects. Plasma PDGF levels in aortic root remained unchanged in all three patient groups. CONCLUSIONS: PDGF is released into the coronary circulation after coronary artery spasm, and this may exacerbate coronary artery spasm.
BACKGROUND: The glycoprotein P-selectin is an adhesion molecule involved in the property change of leukocytes at the initiation of the inflammatory process. The purpose of the present study was to determine whether acute myocardial ischemia induced by coronary spasm causes an acute inflammatory response in the coronary circulation. METHODS AND RESULTS: We examined plasma soluble P-selectin levels in the coronary sinus and the aortic root simultaneously in 16 patients with coronary spastic angina before and after left coronary artery spasm induced by intracoronary injection of acetylcholine and in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid atrial pacing. Ten control patients with chest pain but normal coronary arteries and no coronary spasm also received intracoronary acetylcholine. Plasma soluble P-selectin levels were increased significantly in the coronary sinus (32.8 +/- 3.6 to 52.8 +/- 5.9 ng/mL, P < .001) and in the aortic root (34.6 +/- 3.7 to 41.9 +/- 4.4 ng/mL, P < .05) after the attacks in the coronary spastic angina group but remained unchanged in the stable exertional angina group after the attacks and in the control group after the administration of acetylcholine. Furthermore, the coronary sinus-arterial difference of soluble P-selectin increased significantly after the attacks in the coronary spastic angina group (-1.8 +/- 2.2 to 10.9 +/- 2.7 ng/mL, P < .001). CONCLUSIONS: Our data indicate that soluble P-selectin is released into the coronary circulation after coronary artery spasm. We conclude that coronary artery spasm may induce the leukocyte adhesion in the coronary circulation and may lead to myocardial damage.
Coronary shunting of 9 +/-1 micrometer and 25 +/- 5 micrometer radiolabeled microspheres was examined in anesthetized, open-chest dogs, whose left common coronary arteries were perfused at controlled pressures. Shunting was estimated from the difference in radioactivity between perfusion line and coronary sinus blood samples during selective elevations of coronary perfusion pressure (CPP), left ventricular afterload, and inspired oxygen. A linear relationship was found between coronary shunting of 9-micrometer microspheres and CPP over the range 100-200 mmHg. According to regression analysis, percent shunt flow was 4.0% at control CPP (100 mmHg) and 10.0% at CPP of 200 mmHg. No shunting of 25-micrometer microspheres occurred at any CPP. Raising afterload did not affect shunting at control CPP but attenuated the increase in shunting at elevated CPP. Changing inspired gas from room air to 100% oxygen did not influence shunting at control or elevated CPP. Raising CPP to 150 and 200 mmHg also released 2.5% and 5.9% of pretrapped 9-micrometer microspheres, respectively. This study demonstrates that vessels permitting passage of microspheres across coronary circulation are sensitive to elevated perfusion pressure.
Tissue factor pathway inhibitor (TFPI) is a physiological regulator of the extrinsic coagulation cascade. Coronary spasm can alter endothelial cell properties in the coronary artery with resultant thrombosis. To determine whether coronary spasm affects plasma TFPI level, we measured the heparin-releasable endothelial cell-associated TFPI (heparin-releasable TFPI) (ng/ml) in the coronary sinus and the aortic root before and after coronary spasm induced by an injection of acetylcholine in 18 patients with coronary spastic angina, and before and after myocardial ischemia induced by rapid atrial pacing in 18 patients with stable exertional angina, and in 17 control subjects with normal coronary arteries and no coronary spasm. Heparin-releasable TFPI level in the coronary spastic angina group significantly increased in the coronary sinus (1 22+/-46 to 147+/-63, p<0.001) after the ischemic event but not in the aortic root (113+/-44 to 121+/-58). The level in the coronary sinus and the aortic root remained unchanged after the ischemic event in the stable exertional angina group and after the injection of acetylcholine in the control group. The coronary sinus-arterial difference in the amount of the heparin-releasable TFPI significantly increased after the ischemic event only in the coronary spastic angina group (10+/-18 to 26+/-18, p<0.002). Our result suggested that heparin-releasable TFPI is increased in the coronary circulation after coronary spasm.
OBJECTIVE: To investigate changes in cytokine expression in the coronary circulation induced by percutaneous transluminal coronary angioplasty (PTCA). METHODS: The study involved 32 patients with ischaemic heart disease who underwent elective PTCA for isolated stenotic lesions of the left coronary artery. Ten patients had plain old balloon angioplasty, 10 had percutaneous transluminal rotational atherectomy, and 12 had stent implantation. Blood samples were drawn from the coronary sinus before and immediately after PTCA. Plasma concentrations of interleukin 6 (IL-6), platelet derived growth factor (PDGF), monocyte chemoattractant protein 1 (MCP-1), and macrophage coronary stimulating factor (M-CSF) were measured. The patients were scheduled for follow up angiography six months after PTCA. Late loss index was calculated using quantitative coronary angiography. RESULTS: IL-6 concentrations in coronary sinus blood increased immediately after PTCA (p < 0.001), but there was no change in PDGF, MCP-1, or M-CSF. There was a positive correlation between changes in IL-6 concentrations immediately after PTCA and late loss index six months after PTCA (r = 0.73, p < 0.001). IL-6 concentrations in coronary sinus blood were higher in patients with late restenosis than in those without restenosis (p < 0.001). CONCLUSIONS: PTCA induces IL-6 production in the coronary circulation. This may induce subsequent inflammatory responses in injured vessels and play an important role in late restenosis after PTCA.
A recently developed platelet aggregometer using a laser light scattering method is capable of monitoring the increase in size of small-sized platelet aggregates (diameter 9-25 microm), which cannot be detected with the conventional methods. Whether coronary spasm can cause platelet aggregation in the coronary circulation is unknown. We investigated platelet aggregation, especially small-sized platelet aggregates, simultaneously in the coronary sinus and the aortic root in 18 patients with coronary spastic angina before and after a left coronary artery spasm induced by intracoronary injection of acetylcholine, and in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid right atrial pacing. Platelet aggregation in 12 patients with chest pain syndrome was also examined before and after coronary spasms provoked by acetylcholine. The number of small-sized platelet aggregates increased significantly in the coronary sinus [2.0+/-0.6 x 104 to 4.1+/-1.0 x 104 (V), P<.01] and in the aortic root [1.7+/-0.6 x 104 to 3.2+/-0.6 x 104 (V), P<.05], and the coronary sinus-arterial difference in the number of small-sized platelet aggregates [2.3+/-1.9 x 103 to 1.1+/-0.4 x 104 (V), P<.01] increased significantly after attacks in the coronary spastic angina group, but remained the same in the stable exertional angina group after attacks and in the chest pain syndrome group after the administration of acetylcholine. Therefore, we can conclude that acute myocardial ischemia induced by coronary spasm causes platelet aggregation in the coronary circulation.
Recent studies have clarified the significance of chemokines in cardiovascular diseases, such as development of atherosclerosis, atheromatous plaque rupture and restenosis after coronary angioplasty. We investigated changes in chemokine expression in the coronary circulation induced by percutaneous transluminal coronary angioplasty (PTCA) and their clinical significance. We examined 40 patients with angina pectoris who underwent elective PTCA for isolated stenotic lesions of the left coronary artery. Eight patients received PTCA only, 14 percutaneous transluminal rotational atherectomy and 18 stent implantation. Venous blood samples were obtained from the coronary sinus before, and immediately after as well as 4 and 24 h after PTCA. Plasma levels of interleukin (IL)-8, macrophage-colony stimulating factor (M-CSF) and monocyte chemoattractant protein-1 (MCP)-1 were measured by enzyme-linked immunosorbent assay. Plasma levels of M-CSF in the coronary sinus blood showed significant increases 4 and 24 h after PTCA. On the other hand, plasma MCP-1 levels did not change significantly during a 24-h observation period after PTCA. Immunoreactive IL-8 was not detected in any patients before or after PTCA. A significant positive correlation was found between plasma M-CSF levels 24 h after PTCA and late loss index 6 months after the procedure. Plasma levels of M-CSF 24 h after PTCA were significantly higher in patients with than in those without late restenosis. PTCA induced increases in plasma levels of M-CSF in the coronary circulation. Increased M-CSF expression may be involved in neointima formation at injured vessels through activation of mononuclear phagocytes.
Effects of prostanoids on coronary circulation were studied in anesthetized open chest dogs with intact coronary arteries or in closed chest Göttingen miniature pigs with denuded vessels. In the latter model, coronary artery spasm was repeatedly provoked at the previously denuded area by histamine i.c. after pretreatment with cimetidine i.v., H2-blocker. In the canine model, prostacyclin (PGI2) dilated to a greater extent the diameter of the large epicardial coronary artery than did PGE2, and both equally reduced the total coronary resistance. Vasoconstrictive effects of carbocyclic thromboxane A2, a stable analogue of thromboxane A2 (TxA2) on the epicardial coronary artery was augmented from 1.1 +/- 0.3 to 6.5 +/- 1.3% (p less than 0.01) after pretreatment with cyclooxygenase inhibitors. In case of Göttingen miniature pigs 3 months after endothelial denudation and cholesterol freeding, neither PGI2 nor indomethacin prevented histamine-induced coronary artery spasm. Thiothromboxane A2, a stable analogue of TxA2, did not provoke coronary artery spasm in the animals. Therefore, prostanoids may not be crucial to the provocation or prevention of coronary artery spasm from which myocardial ischemia ensues.
To examine whether acute myocardial ischemia activates the coagulation system and platelet activation in the coronary circulation, we measured plasma levels of fibrinopeptide A and beta-thromboglobulin in the coronary sinus and the aortic root simultaneously in 15 patients with coronary spastic angina before and after the left coronary spasm induced by intracoronary injection of acetylcholine and in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid atrial pacing. Fifteen patients with chest pain but normal coronary arteries and no coronary spasm served as controls. The coronary sinus-arterial difference of fibrinopeptide A increased markedly (p less than 0.001) from 0.1 +/- 0.2 to 4.3 +/- 0.7 ng/ml after the anginal attacks in the coronary spastic angina group. However, fibrinopeptide A levels remained unchanged after the attacks in the stable exertional angina group and after intracoronary injection of acetylcholine in the control group. Plasma beta-thromboglobulin levels remained unchanged after the attacks in both patient groups and after acetylcholine in the control group. Our data indicate that coronary spasm induces thrombin generation and may lead to thrombus formation in the coronary artery involved, but pacing-induced ischemia does not activate the coagulation system.
Coronary autoregulation appears to be closely coupled to myocardial oxidative metabolism. Recent data suggest that coronary autoregulation depends on the prevailing balance between myocardial oxygen supply and demand. It seems likely that pO2 within a critical range may be the initial metabolic stimulus for coronary autoregulation. Whether adjustments in vascular resistance result from changes in myocardial pO2 directly or indirectly through changes in vasoactive metabolites remains unclear. The observation that intracoronary infusion of adenosine deaminase in concentrations sufficient to attenuate myocardial reactive hyperemia has no effect on coronary autoregulation strongly suggests that adenosine is not essential for autoregulation in the blood-perfused dog heart. This is supported by the recent finding that the interstitial concentration of adenosine (estimated from epicardial exudate) remained unchanged during autoregulation. Prostaglandins may play a role in autoregulation in buffer-perfused rabbit hearts but do not appear to be involved in blood-perfused dog hearts. Potassium is probably not involved in autoregulation. It is also unlikely that changes in tissue pressure can account for coronary autoregulation. The role of adenine nucleotides, hydrogen ion, carbon dioxide, and intermediate metabolites of the citric acid cycle, in coronary autoregulation has not been examined. The possibility that a myogenic mechanism contributes to coronary autoregulation has not been directly tested. Finally, it is entirely possible that coronary autoregulation may result from the concerted interaction of several different mediators or mechanisms. In this regard, it should be emphasized that blocking or destroying one mediator could elicit a compensatory increase in the contribution of another.
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Coronary artery disease is the most important cause of morbidity and mortality in Western countries. Its pathogenesis is unknown but involves an enhanced vasoconstriction and increased interaction of platelets and monocytes with the vessel wall, as well as proliferation, migration, and extracellular matrix formation of vascular smooth-muscle cells. The endothelium lies in a strategic anatomical position between the circulating blood and vascular smooth-muscle cells. This supports the concept that dysfunction of these cells plays a crucial role in the pathogenesis of coronary artery disease. Endothelial cells are a source of vasodilators such as nitric oxide, prostacyclin, and hyperpolarizing factor. In addition, the cells produce heparin-like substances as well as other molecules with antiproliferative properties. These effects of endothelial cells may explain why platelets and monocytes usually do not adhere at the blood vessel wall and why vascular smooth-muscle cells remain in a vasodilated state and neither migrate nor proliferate. However, under pathological conditions, in particular in the presence of cardiovascular risk factors, endothelial dysfunction occurs and significantly contributes to the increase of platelet-vessel wall interaction, vasoconstriction, and proliferation in the coronary system. Under these conditions, endothelium-dependent vasodilation is reduced and endothelium-dependent constrictor responses are augmented. Furthermore, endothelial cells are also able to produce growth promoters. Hence, endothelial cells are important targets and mediators of coronary artery disease. Therapeutic strategies aimed at improving or preserving endothelial function therefore may be promising in the prevention and treatment of coronary artery disease.
Coronary resistance can be modified by perivascular, endothelial and humoral vasoactive substances. A network of perivascular nerve fibres is present in the adventitia and at the adventitial-medial border of human coronary arteries and veins, and immunocytochemical studies have provided evidence that several neuropeptides are localized in subpopulations of afferent and efferent nerve fibres supplying the human coronary vasculature. Neuropeptide Y seems to be co-localized with noradrenaline in adrenergic perivascular nerve fibres and vasoactive intestinal peptide co-localized with acetylcholine in parasympathetic nerves, whereas sensory perivascular nerves contain immunoreactivity to substance P and calcitonin gene-related peptide. On the other hand, nitric oxide and endothelin are synthesized in coronary endothelial cells. Humoral substances like gonadal hormones are also likely candidates in the regulation of coronary resistance. The presence of different vasoactive substances in the coronary vasculature and the potential of these substances to affect coronary vessel tone, suggest that they have an important role in the regulation of coronary blood flow.