NDLI: Microvascular Dysfunction as Opposed to Conduit Artery Disease Explains Sex-specific Chest Pain in Emergency Department Patients With Low to Moderate Cardiac Risk.

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Microvascular Dysfunction as Opposed to Conduit Artery Disease Explains Sex-specific Chest Pain in Emergency Department Patients With Low to Moderate Cardiac Risk.

Content Provider	World Health Organization (WHO)-Global Index Medicus
Author	Safdar, Basmah Ali, Asad D'Onofrio, Gail Katz, Stuart D.
Description	Author Affiliation: Safdar B ( Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut. Electronic address: basmah.safdar@yale.edu.); Ali A ( Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa.); D'Onofrio G ( Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.); Katz SD ( Department of Internal Medicine, Section of Cardiology, NYU School of Medicine, New York, New York.)
Abstract	PURPOSE: Chest pain is a common emergency department (ED) presentation that is often unexplained. Recent evidence suggests that disease of the microvessels (arterioles) as opposed to the coronary artery (conduit artery) could explain one third of these cases, particularly in women. Brachial artery reactivity (BAR) is a validated surrogate measure of coronary artery vasomotion. OBJECTIVES: The goal of this study was to compare brachial artery conduit vessel function (BAR) and microvascular function (postischemic peak reactive hyperemia [RH]) in subjects with and without chest pain and grouped according to sex. METHODS: This prospective cohort study was conducted from January through March 2010. Cases were patients admitted to an ED chest pain center with low to moderate risk of acute coronary syndrome; they were eligible for study if their creatinine level was <2.0 mg/dL and systolic blood pressure was >100 mm Hg or <180 mm Hg. Asymptomatic healthy volunteers on no medications were recruited as control subjects. BAR as a change in brachial artery diameter in response to transient forearm ischemia (endothelium-dependent vasodilation) and RH as a change in flow velocities were measured with a high-resolution ultrasound. Telephone follow-up visits were made at 1 month for recurrence of chest pain and recidivism. FINDINGS: A total of 57 patients and 21 control subjects were enrolled; there was 100% follow-up at 1 month. Most patients (86%) had at least 1 cardiac risk factor. Neither BAR nor RH varied significantly between patients and control subjects (P > 0.05). Symptomatic men had lower mean BAR than women (2.67% vs 6.22%; P < 0.01), even when normalized for shear stress (P = 0.01). Conversely, women with chest pain had lower RH compared with men (2.85 vs 4.61; P = 0.01). The sex-specific differences adjusted for age and Framingham risk scores persisted for BAR (P = 0.003) and RH (P = 0.002). Of 57 patients, 53% had recurrent pain, and 4 returned to the hospital within 1 month. IMPLICATIONS: Differences in BAR and RH in patients ruled out for myocardial infarction suggest that the pathophysiology of acute chest pain might be sex-specific. Men with chest pain exhibited lower BAR, indicating peripheral conduit artery dysfunction. Conversely, women with chest pain exhibited lower postischemic peak hyperemia, indicative of peripheral microvascular dysfunction. Sex differences in pathophysiology of chest pain and vascular dysfunction could inform development of effective therapeutics for patients with recurrent or persistent chest pain in the absence of obstructive coronary artery disease.
File Format	HTM / HTML
ISSN	01492918
Issue Number	2
Volume Number	38
e-ISSN	1879114X
Journal	Clinical Therapeutics
Language	English
Publisher	Elsevier
Publisher Date	2016-02-01
Publisher Place	United States
Access Restriction	One Nation One Subscription (ONOS)
Subject Keyword	Discipline Pharmacology Chest Pain Etiology Endothelium, Vascular Physiopathology Hyperemia Adult Blood Pressure Brachial Artery Metabolism Case-control Studies Cohort Studies Coronary Artery Disease Pathology Emergency Service, Hospital Female Humans Male Middle Aged Prospective Studies Risk Factors Vasodilation Journal Article Research Support, N.i.h., Extramural Research Support, Non-u.s. Gov't
Content Type	Text
Resource Type	Article
Subject	Pharmacology Pharmacology (medical)

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Microvascular Dysfunction as Opposed to Conduit Artery Disease Explains Sex-specific Chest Pain in Emergency Department Patients With Low to Moderate Cardiac Risk.