Skip to main content
  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Circulation Doodle
      • Doodle Gallery
      • Circulation Cover Doodle
        • → Blip the Doodle
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
    • Subscribe to AHA Journals
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
      • Recently Published Guidelines
    • Bridging Disciplines
    • → Articles Bridging Discplines
    • Go Red for Women Issue
    • Cardiovascular Case Series
    • Circulation at ESC
    • Circulation at AHA Scientific Sessions
    • Global Impact of the 2017 ACC/AHA Hypertension Guidelines
    • Circulation at ACC 2018
    • Circulation Supplements
    • ECG Challenge
    • Hospitals of History
      • Brigham and Women's Hospital
      • Hartford Hospital
      • Hospital Santa Maria del Popolo, Naples, Italy
      • Instituto do Coração-INCOR (São Paulo, Brasil)
      • Minneapolis City Hospital
      • Parkland Hospital: Dallas, Texas
      • Pennsylvania Hospital, Philadelphia
      • Pitié-Salpêtrière Hospital
      • Royal Infirmary of Edinburgh, Scotland
      • Tufts Medical Center
      • University of Michigan
      • Uppsala University Hospital
      • Vassar Brothers Medical Center (Poughkeepsie, NY)
      • Wroclaw Medical University
      • Women's College Hospital, Toronto, Canada
      • Henry Ford Hospital, Detroit, Michigan
      • Instituto Nacional de Cardiología Ignacio Chávez – INCICh México City, México
      • Kuang-Tien General Hospital (Taichug, Taiwan)
    • On My Mind
    • Podcast Archive
    • → Subscribe to Circulation on the Run
    • →Circulation FIT Podcast 2018
    • → #FITFAVs
  • Resources
    • Instructions for Authors
      • Accepted Manuscripts
      • Revised Manuscripts
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • Circulation CME
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
  • Facebook
  • Twitter

  • My alerts
  • Sign In
  • Join

  • Advanced search

Header Publisher Menu

  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

Circulation

  • My alerts
  • Sign In
  • Join

  • Facebook
  • Twitter
  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Circulation Doodle
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
    • Subscribe to AHA Journals
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
    • Bridging Disciplines
    • → Articles Bridging Discplines
    • Go Red for Women Issue
    • Cardiovascular Case Series
    • Circulation at ESC
    • Circulation at AHA Scientific Sessions
    • Global Impact of the 2017 ACC/AHA Hypertension Guidelines
    • Circulation at ACC 2018
    • Circulation Supplements
    • ECG Challenge
    • Hospitals of History
    • On My Mind
    • Podcast Archive
    • → Subscribe to Circulation on the Run
    • →Circulation FIT Podcast 2018
    • → #FITFAVs
  • Resources
    • Instructions for Authors
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • Circulation CME
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
Correspondence

Response by Alexander et al to Letters Regarding Article, “A Shocking Development in a Young Male Athlete With Chest Pain”

Kevin M. Alexander, Mahdi R. Veillet-Chowdhury, Ciorsti J. MacIntyre, Joseph Loscalzo, Deepak L. Bhatt
Download PDF
https://doi.org/10.1161/CIRCULATIONAHA.116.023204
Circulation. 2016;134:e22-e23
Originally published July 25, 2016
Kevin M. Alexander
From the Cardiovascular Division, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mahdi R. Veillet-Chowdhury
From the Cardiovascular Division, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ciorsti J. MacIntyre
From the Cardiovascular Division, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Joseph Loscalzo
From the Cardiovascular Division, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Deepak L. Bhatt
From the Cardiovascular Division, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • eLetters

Jump to

  • Article
    • In Response:
    • Disclosures
    • Footnotes
    • References
  • Info & Metrics
  • eLetters
Loading

In Response:

We thank Dr McGorrian and colleagues for their insights on our challenging case recently presented in Circulation.1 Eosinophilic coronary periarteritis is an intriguing potential cause of our patient’s presentation. As the authors describe, the disease entity has been characterized in patients with coronary artery vasospasm and associated coronary dissection or sudden cardiac death. As in our case, some may have a preexisting history of atopy. The most distinguishing features of eosinophilic coronary periarteritis are appreciated by histology, which reveals eosinophilic infiltration isolated to the adventitia and vasa vasorum of the epicardial coronary arteries.2 Thus, this diagnosis is difficult to confirm outside of autopsy.

Some features of our case make eosinophilic coronary periarteritis less likely to be the main contributor to his presentation. On coronary angiography, there was no evidence of aneurysmal changes, which have been described for other cases of coronary periarteritis.3 Similarly, his serum C-reactive protein level, a marker of inflammation, albeit nonspecific, was normal. His case was striking for the large burden of premature coronary artery disease and potential genetic predisposition for aggressive atherosclerosis, as suggested by markedly elevated lipoprotein (a) levels in the patient and multiple first-degree relatives. Nevertheless, a recent report describes a patient with concomitant coronary artery disease and eosinophilic coronary periarteritis.4 Therefore, it is possible that our patient could also have had underlying periarteritis that acted synergistically to cause endothelial dysfunction and subsequent coronary vasospasm.

Increasing awareness of eosinophilic coronary periarteritis as a potential cause of coronary vasospasm is warranted, as these patients may benefit from adding immunosuppressive therapy to a standard antivasospasm regimen. Pursing further diagnostic tests in coronary vasospasm patients, such as computed tomography coronary angiography with positron emission tomography or intravascular ultrasound, may prove useful for identifying individuals with underlying periarteritis.3

We also thank Dr Bairey Merz and colleagues for their interest and thoughtful comments on our case. We agree that coronary artery vasospasm represents a wide spectrum of disease, requiring precise definitions and prognostic tools to devise optimal treatment strategies. Potentially, sex, race/ethnicity, genetic factors, and the specific cause of coronary spasm all affect prognosis and, in part, explain the variability in prognosis described in the literature. The standardized diagnostic criteria proposed by COVADIS (Coronary Vasomotor Disorders International Study Group) and recently developed clinical risk score are important initial steps.5,6 An essential goal for future prospective studies using these tools is the ability to identify patients, like ours, who have a high risk of cardiovascular complications despite optimal medical management. Moreover, delineating indications for advanced interventions (eg, implantable cardioverter defibrillator implantation) will be imperative. We look forward to seeing future data from this study group.

Kevin M. Alexander, MD
Mahdi R. Veillet-Chowdhury, MD
Ciorsti J. MacIntyre, MD
Joseph Loscalzo, MD, PhD
Deepak L. Bhatt, MD, MPH

Disclosures

Dr Bhatt discloses the following relationships: Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Vice-Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical; Trustee: American College of Cardiology; Unfunded Research: FlowCo, PLx Pharma, Takeda. The other authors report no conflicts.

Footnotes

  • Circulation is available at http://circ.ahajournals.org.

  • © 2016 American Heart Association, Inc.

References

  1. 1.↵
    1. Alexander KM,
    2. Veillet-Chowdhury MR,
    3. MacIntyre CJ,
    4. Loscalzo J,
    5. Bhatt DL
    . A shocking development in a young male athlete with chest pain. Circulation. 2016;133:756–763. doi: 10.1161/CIRCULATIONAHA.115.019127.
    OpenUrlFREE Full Text
  2. 2.↵
    1. Kajihara H,
    2. Tachiyama Y,
    3. Hirose T,
    4. Takada A,
    5. Takata A,
    6. Saito K,
    7. Murai T,
    8. Yasui W
    . Eosinophilic coronary periarteritis (vasospastic angina and sudden death), a new type of coronary arteritis: report of seven autopsy cases and a review of the literature. Virchows Arch. 2013;462:239–248. doi: 10.1007/s00428-012-1351-7.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Urabe Y,
    2. Fujii T,
    3. Kurushima S,
    4. Tsujiyama S,
    5. Kihara Y
    . Pigs-in-a-blanket coronary arteries: a case of immunoglobulin G4-related coronary periarteritis assessed by computed tomography coronary angiography, intravascular ultrasound, and positron emission tomography. Circ Cardiovasc Imaging. 2012;5:685–687. doi: 10.1161/CIRCIMAGING.112.975946.
    OpenUrlFREE Full Text
  4. 4.↵
    1. Kobayashi M,
    2. Cohle SD
    . A case of sudden cardiac death due to eosinophilic coronary periarteritis: possible significance of coexisting atherosclerosis and eosinophilic inflammation of the esophagus. Cardiovasc Pathol. 2016;25:67–71. doi: 10.1016/j.carpath.2015.08.010.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Beltrame JF,
    2. Crea F,
    3. Kaski JC,
    4. Ogawa H,
    5. Ong P,
    6. Sechtem U,
    7. Shimokawa H,
    8. Bairey Merz CN
    ; Coronary Vasomotion Disorders International Study Group (COVADIS). International standardization of diagnostic criteria for vasospastic angina (published online ahead of print August 4, 2015). Eur Heart J. doi: 10.1093/eurheartj/ehv351. http://eurheartj.oxfordjournals.org/content/early/2015/08/04/eurheartj.ehv351.long
  6. 6.↵
    1. Takagi Y,
    2. Takahashi J,
    3. Yasuda S,
    4. Miyata S,
    5. Tsunoda R,
    6. Ogata Y,
    7. Seki A,
    8. Sumiyoshi T,
    9. Matsui M,
    10. Goto T,
    11. Tanabe Y,
    12. Sueda S,
    13. Sato T,
    14. Ogawa S,
    15. Kubo N,
    16. Momomura S,
    17. Ogawa H,
    18. Shimokawa H
    ; Japanese Coronary Spasm Association. Prognostic stratification of patients with vasospastic angina: a comprehensive clinical risk score developed by the Japanese Coronary Spasm Association. J Am Coll Cardiol. 2013;62:1144–1153. doi: 10.1016/j.jacc.2013.07.018.
    OpenUrlFREE Full Text
View Abstract
Back to top
Previous ArticleNext Article

This Issue

Circulation
July 26, 2016, Volume 134, Issue 4
  • Table of Contents
Previous ArticleNext Article

Jump to

  • Article
    • In Response:
    • Disclosures
    • Footnotes
    • References
  • Info & Metrics
  • eLetters

Article Tools

  • Print
  • Citation Tools
    Response by Alexander et al to Letters Regarding Article, “A Shocking Development in a Young Male Athlete With Chest Pain”
    Kevin M. Alexander, Mahdi R. Veillet-Chowdhury, Ciorsti J. MacIntyre, Joseph Loscalzo and Deepak L. Bhatt
    Circulation. 2016;134:e22-e23, originally published July 25, 2016
    https://doi.org/10.1161/CIRCULATIONAHA.116.023204

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
  • Article Alerts
    Log in to Email Alerts with your email address.
  • Save to my folders

Share this Article

  • Email

    Thank you for your interest in spreading the word on Circulation.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Response by Alexander et al to Letters Regarding Article, “A Shocking Development in a Young Male Athlete With Chest Pain”
    (Your Name) has sent you a message from Circulation
    (Your Name) thought you would like to see the Circulation web site.
  • Share on Social Media
    Response by Alexander et al to Letters Regarding Article, “A Shocking Development in a Young Male Athlete With Chest Pain”
    Kevin M. Alexander, Mahdi R. Veillet-Chowdhury, Ciorsti J. MacIntyre, Joseph Loscalzo and Deepak L. Bhatt
    Circulation. 2016;134:e22-e23, originally published July 25, 2016
    https://doi.org/10.1161/CIRCULATIONAHA.116.023204
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo

Related Articles

Cited By...

Circulation

  • About Circulation
  • Instructions for Authors
  • Circulation CME
  • Statements and Guidelines
  • Meeting Abstracts
  • Permissions
  • Journal Policies
  • Email Alerts
  • Open Access Information
  • AHA Journals RSS
  • AHA Newsroom

Editorial Office Address:
200 Fifth Avenue, Suite 1020
Waltham, MA 02451
email: circ@circulationjournal.org
 

Information for:
  • Advertisers
  • Subscribers
  • Subscriber Help
  • Institutions / Librarians
  • Institutional Subscriptions FAQ
  • International Users
American Heart Association Learn and Live
National Center
7272 Greenville Ave.
Dallas, TX 75231

Customer Service

  • 1-800-AHA-USA-1
  • 1-800-242-8721
  • Local Info
  • Contact Us

About Us

Our mission is to build healthier lives, free of cardiovascular diseases and stroke. That single purpose drives all we do. The need for our work is beyond question. Find Out More about the American Heart Association

  • Careers
  • SHOP
  • Latest Heart and Stroke News
  • AHA/ASA Media Newsroom

Our Sites

  • American Heart Association
  • American Stroke Association
  • For Professionals
  • More Sites

Take Action

  • Advocate
  • Donate
  • Planned Giving
  • Volunteer

Online Communities

  • AFib Support
  • Garden Community
  • Patient Support Network
  • Professional Online Network

Follow Us:

  • Follow Circulation on Twitter
  • Visit Circulation on Facebook
  • Follow Circulation on Google Plus
  • Follow Circulation on Instagram
  • Follow Circulation on Pinterest
  • Follow Circulation on YouTube
  • Rss Feeds
  • Privacy Policy
  • Copyright
  • Ethics Policy
  • Conflict of Interest Policy
  • Linking Policy
  • Diversity
  • Careers

©2018 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. The American Heart Association is a qualified 501(c)(3) tax-exempt organization.
*Red Dress™ DHHS, Go Red™ AHA; National Wear Red Day ® is a registered trademark.

  • PUTTING PATIENTS FIRST National Health Council Standards of Excellence Certification Program
  • BBB Accredited Charity
  • Comodo Secured