Anginal Symptoms Research Articles

Trimetazidine Use in Cardiovascular Disease

Trimetazidine is an antianginal medication approved in numerous countries for use in the symptomatic treatment of stable coronary artery disease and angina pectoris. Its main mechanism of action revolves around the inhibition of β-oxidation of free fatty acids in the myocardium, in addition to its antioxidant properties and inhibition of cardiac fibrosis. Based on current evidence, trimetazidine is classified by European guidelines as a second-line antianginal agent and as an add-on for the symptomatic treatment of stable angina in patients not adequately controlled with first-line antianginal therapies such as beta-blockers. However, its role in the treatment of cardiovascular disease extends past coronary artery disease, as numerous studies have demonstrated its potential benefit in heart failure patients as well. Unfortunately, trimetazidine’s role in the treatment of heart failure is still not clearly identified, since most studies on this topic were underpowered and unable to reach a decisive conclusion regarding any potential mortality benefits in heart failure. Current European guidelines have categorized trimetazidine as a class IIb recommendation in patients with heart failure with reduced ejection fraction and angina because of its additive effects of improved left ventricular function and anginal symptom relief in patients already on beta-blockers. Additionally, trimetazidine’s use in coronary interventions (ie, percutaneous coronary intervention and coronary artery bypass grafting) showed a reduction in the frequency of anginal attacks and myocardial damage, but the studies were also underpowered and therefore unable to conclusively determine whether trimetazidine should be incorporated in guideline-directed therapy for coronary interventions.

Real-life data and the utility of echocardiography in young patients under 45 years with ischemic heart disease- a single-centered retrospective analysis

Abstract Background In the last decade there is an increased incidence of coronary artery disease occurring in young adults ≤45-year-old who were referred for selective coronary angiography (SCAG). The traditional risk factors and approach are not informative and effective enough for adequate stratification and interventional referral. Purpose This study aims to measure the predictive value of the echocardiographic data added to the conventional approach for selection of invasive diagnostic procedures (symptoms, ECG, laboratory markers- hs-troponin and lipid profile, risk factors- sex, diabetes, smoking, etc.). Reduction of the overuse of angiography in young patients without added risk for their health is a priority. Methods We did a single-centered retrospective cohort study from January 1, 2019 to June 1, 2024 of young patients under 45 years-old who underwent coronary angiography. During this 5 years period, of the 5933 SCAGs performed in our center, 225 (225/5933; 3.8%) were patients ≤45 years who presented with symptoms of angina, had elevated hs-troponin T (over 0.014 ng/ml), ischemic ECG findings or had several risk factors such as sex, diabetes, LDL> 3.0 mmol/l, smoking. Of all the young patients only 82 (82/225- 36.4%) were diagnosed with significant coronary artery disease (including unstable angina, STEMI, NSTEMI) and the data from this patient cohort was analyzed. Death, sex stratification, smoking, diabetes, number of diseased vessels were studied. The added value of echocardiographic evaluation with simple markers such as left-ventricular ejection fraction (LVEF), mitral (MR) and tricuspid regurgitation (TR) as a potential discriminator for significant CAD was evaluated. Results We identified 82 patients under age 45 with CAD diagnosed by coronary angiography. The sex stratification showed clear predominancy for male (n= 74, p=90.2%), death (n=4, p=4.9%), number of diseased vessels (one- n=28, p=34.1%; two- n=24, p=29.3%, three- n=30, p=36.6%) and the most common cardiovascular risk factors for significant CAD were dyslipidemia with LDL> 3 (n=22, p=26.8%), diabetes (all n=35, p=42.7%), smoking (n=58, p=70.7%). To better recognize the full diagnostic capability of echocardiography, we performed thorough analysis of the selected sub-population with positive echo signs represented by LVEF, MR and TR. Overall, 29.3% had reduction in EF (n=24 with EF below 49%), 92.6% had MR I stage (n=76), 7.4%- MR II stage (n=6), 95.1%- TR I stage (n=78), 4.9%- TR II stage. The sub-population of 82 young patients with CAD were divided in two groups- patients with reduced and preserved EF. Only left-ventricular EF of the investigated echo markers showed statistical significance in the single-variable analysis (r = 0.20, P < .0001) between the groups. Conclusion(s) When the predictive values of LVEF and risk factors- sex, diabetes, smoking and LDL are combined, the discrimination for the need of SCAG in young patients is more precise and clearer. Flow chart 1

Angina Severity and Symptom Improvement Are Associated With Diagnostic Acetylcholine Provocation Dose in Vasospastic Angina.

A coronary function test (CFT) isthe recommended diagnostic test to identify coronary vasomotor dysfunction as a cause of symptoms in patients with angina and nonobstructive coronary arteries (ANOCA). Acetylcholine is the commonly used pharmacological agent for spasm provocation. We aimed to investigate an association between severity of symptoms and provocative acetylcholine dose. We included ANOCA patients undergoing clinically indicated CFT from the Netherlands Registry of Invasive Coronary Vasomotor Function Testing: NL-CFT. Patients with epicardial spasm (n=251) were divided according to acetylcholine spasm triggering dose: low (2-20 mcg, EpiLOW), middle (100 mcg, EpiMIDDLE) or high (200 mcg, EpiHIGH). Patients with microvascular spasm (n=157) were analyzed irrespective of triggering dose. The patient groups were compared to each other and to a control group with negative CFT results (n=101). We assessed mean Seattle Angina Questionnaire angina frequency and summary scores at baseline and follow-up and the proportion of patients improving or deteriorating. An inverse relationship between provocation dosage and angina frequency at baseline was found in epicardial spasm: the lower the triggering dose, the more frequently patients experienced angina (EpiLOW 48±20, EpiMIDDLE 53±21, EpiHIGH 57±19, microvascular spasm61±21, controls 64±21, overall P=0.003). A trend was seen toward most patients improving in the high triggering dose group, and most patients deteriorating in the low triggering dose group. A significant dose-dependent relationship between spasm provocation and anginal complaints exists. Acetylcholine provocation dose could be incorporated as a risk stratification factor or surrogate outcome in future clinical trials. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06083155.

Accelerated Idioventricular Rhythm: Not Always a Reperfusion Arrhythmia

Accelerated idioventricular rhythm (AIVR) is a relatively slow ventricular rhythm that often occurs during the reperfusion phase of an acute myocardial infarction. It is generally considered a benign rhythm that does not require treatment. However, we present a case where AIVR was the presenting arrhythmia in a 41-year-old man with acute coronary syndrome, suggesting it might not be as benign as previously reported in the literature. The patient, who presented to our institute, underwent urgent coronary evaluation followed by revascularization, leading to the conversion of AIVR to normal sinus rhythm and improvement in anginal symptoms.

Does Rose angina in midlife women matter? Further evidence from the Royal College of General Practitioners' Oral Contraception Study.

Globally, ischaemic heart disease (IHD) is a leading cause of death among women; however, disparities remain in the diagnosis and treatment of IHD between females and males. There is limited evidence about mortality risks among women with symptoms of IHD who remain undiagnosed. We re-examined the mortality risks in midlife women who completed the Rose Angina Questionnaire, among a subset of the Royal College of General Practitioners' Oral Contraception Study cohort. 8694 women in the cohort completed the Rose Angina Questionnaire, enquiring about symptoms of exertional chest pain, likely angina, and prior myocardial infarction. The women were followed for vital status and cause of death information until 30 June 2022. The relationship between different types of Rose angina and all-cause and cause-specific mortality was examined using Kaplan-Meier survival curves, and unadjusted and adjusted Cox regression. After 27years, 3263 (37.5%) women had died. Compared with women who did not report symptoms, women with Rose angina had an increased risk of all-cause and IHD death. Women without a prior IHD diagnosis and grade II Rose angina at survey had the highest all-cause (adjusted hazard ratio [aHR] 2.14, 95% confidence interval [CI] 1.55 to 2.97) and IHD-specific (aHR 3.18, 95% CI 1.64 to 6.17) mortality risks. Women reporting Rose chest pain had a higher risk of all-cause and IHD death, even in the absence of a prior IHD history. These findings highlight the importance of identifying symptomatic women in midlife, so their IHD risk can be managed appropriately by their healthcare providers.

Ischemic heart disease with damage of the left main coronary artery

It is known and proven that the degree of damage to the left main coronary artery (LMCA), along with the indicators of the left ventricle (LV) myocardium’s contractile function, are the main factors determining the survival of patients with coronary artery disease (CAD). Therefore, the effectiveness of the chosen management strategy for such patients determines not only the quality of life, i.e relief from angina symptoms, but also long-term prognosis [1,2].

Myocardial Bridging, Unusual Cause of Myocardial Infarction; Case Report and Review of Literature.

Myocardial bridging is a common coronary anomaly. Although it is considered to be a benign condition, it can rarely be complicated by myocardial infarction. Clinicians should be suspicious of myocardial bridging as an etiology of myocardial infarction when other more common etiologies have been excluded. High resolution CT angiography is the gold standard for diagnostic evaluation, with the length and depth of the bridge, and response to conservative therapies guiding clinical decision making on surgical correction. Myocardial bridging is a congenital coronary anomaly in which the coronary arteries pass through the heart muscle rather than lying on its surface. It is typically a benign condition, and most patients are asymptomatic. However, some may experience symptoms of angina. In rare cases, patients can present with myocardial ischemia or infarction. In this report, we present the case of a 38-year-old female who presented with a 2-month history of chest pain. Further evaluation with coronary computed tomography angiography (CCTA) revealed myocardial bridging. Subsequently, she developed a myocardial infarction, a rare complication of this condition. We discuss this uncommon complication of a common anomaly.

Coronary microvascular dysfunction endotypes: IMR tips and tricks.

Coronary microvascular dysfunction (CMD) is an important clinical disease spectrum which has gained widespread attention due to chronic anginal symptoms, and worse clinical outcomes, with or without obstructive coronary artery disease (CAD). Coronary microcirculatory dysfunction is due to a wide array of mechanisms such as inflammation, platelet aggregation, vessel wall collagen deposition, imbalance of nitric oxide, free radicals, and sympathetic/parasympathetic simulation. As noted in this supplement, CMD can occur as a primary disease or co-exist with multi-array of diverse cardiac conditions such as CAD (old infarct), hypertrophic cardiomyopathy, Takotsubo cardiomyopathy, hypertension, or infiltrative diseases. CMD, which is often under diagnosed, leads to increase in medical expenses, decrease in quality of life, exacerbation of underlying conditions such as heart failure and even increased mortality. CMD presents a challenge for patients as well as physicians to manage. In this chapter, we review CMD and focus on its endotypes, techniques for microcirculatory assessment, associated tips and tricks and available treatment options.

Efficacy of Trimetazidine 80mg in Treatment of Stable Angina: A Systematic Analysis

Background: Stable angina is a prevalent form of ischemic heart disease characterized by recurrent, predictable chest pain or discomfort associated with physical or emotional stress. Trimetazidine, an anti-ischemic agent, has shown promise in alleviating angina symptoms. This systematic analysis aims to evaluate the efficacy of Trimetazidine 80mg in the treatment of stable angina. Literature research on studies published between 2015 and 2022 was performed on a computerized database through PubMed, Google Scholar, Scopus, and Web of Science. Methods: In this meta-analysis, only the randomized control trial studies published between 2015 and 2022 were selected for quantitative analysis. Four parameters, i.e., mean arterial pressure, number of stable angina attacks per week, nitrate consumption, exercise tolerance test, and Canadian Cardiovascular Society classification of stable angina, were selected for evaluation. A specific criterion was used to assess the quality of trails. The standard statistical methods, pooled odds ratio, 95% confidence interval, and pooled z and p values were applied in the analysis. Results: This systematic analysis included six randomized clinical trial studies clinically examining a total of 10238 patients of stable angina for the efficacy of Trimetazidine 80 mg single dose per day. The data was analyzed through RevMen software 5.4. The outcomes state that the lower number of per week angina attacks, nitrate consumption, and reduction in mean arterial pressure are associated with Trimetazidine 80 mg. However, Trimetazidine 80 mg improves response to exercise tolerance test and Canadian Cardiovascular Society classification. Conclusion: It is concluded through this systematic review that Trimetazidine 80 mg, a single dose per day, is more effective in improving cardiovascular health in comparison to conventional anti-angina therapies and placebo drugs. Patients with stable angina suffer from a limited number of angina attacks by using a single dose of Trimetazidine 80 mg. Therefore, Trimetazidine is the choice of drug against stable angina pectoris.

Improving Cardiovascular Risk Prediction of Sri Lankans using Artificial Intelligence

There are no CV risk prediction models derived from Sri Lankan cohorts. Therefore, the World Health Organization(WHO) risk charts developed for the Southeast Asia Region are being used to risk stratify Sri Lankans. However, Sri Lankans are quite different to some Southeast Asian countries and may not agree with Sri Lankans. Therefore, we aimed to develop a CV risk prediction model specific to a cohort of Sri Lankans. Using supervised machine learning of 10-year follow-up data of a randomly selected, population-based cohort of Sri Lankans, we developed a model to predict the 10-year risk of developing a cardiovascular event. We compared predictions of the new model at baseline in 2007 with the observed events in 2017 following a 10-year follow-up using receiver operating characteristic curves(ROC) to find the predictive performance. We compared the predictions of the new model and the currently used WHO risk charts. We selected 2596 Sri Lankans between 40 and 65 years old with no history of previous CV diseases (CVD) at recruitment and who had completed 10-year follow-ups. There were 179 hard CVDs recorded over the ten years. CVD included all cardiovascular deaths confirmed or presumed cases as mentioned in death certificates, non-fatal strokes, and physician-diagnosed non-fatal acute coronary syndromes, including elective percutaneous coronary interventions and coronary artery bypass grafts done on patients with symptomatic unstable angina. Any cardiac presentation except those mentioned here was excluded. Of 179 events, the ML-based model predicted 124; only 33 were predicted by the new model, while only 33 were predicted by 2019 WHO risk charts. The new ML-based model had 0.93 accuracy with an AUC-ROC of 0.74 ± 0.06. Machine learning of individual data of a Sri Lankan cohort improved CV risk prediction of Sri Lankans than using risk charts developed for an epidemiological region using a modelling approach.

A Comprehensive Approach to the Treatment of Ischemic Heart Disease in Patients with Cardiorenal Metabolic Syndrome

Ischemic heart disease (IHD) remains the leading cause of mortality and disability due to cardiovascular diseases. IHD often manifests itself as stenosing atherosclerosis of the coronary arteries, which can be treated surgically or interventionally. However, chronic coronary syndromes with intact coronary vessels are a serious problem for modern medicine. Coronary microvascular dysfunction is accompanied by impaired coronary blood flow reserve, which leads to myocardial ischemia and angina pectoris, despite the absence of significant coronary artery stenosis. The objective: to study the mechanisms of myocardial ischemia in patients with coronary artery disease and cardiorenal metabolic (CRM) syndrome and to analyze the effectiveness of different treatment approaches depending on the identified mechanisms. Materials and methods. The study included 104 patients with CRM syndrome who underwent examination at the State Institution “The Scientific and Practical Medical Center of Pediatric Cardiology and Cardiac Surgery of the Ministry of Health of Ukraine” during 2023. Various forms of CHD were detected in the patients. Exercise stress tests were used to diagnose myocardial ischemia. Patients with confirmed stenosing atherosclerosis by percutaneous coronary angiography received appropriate interventional treatment. Microvascular angina was suspected in 21 patients without significant coronary artery lesions. The coronary blood flow reserve index was determined by echocardiography with intravenous administration of dipyridamole. Results. It was determined that of 21 patients with microvascular angina who received a comprehensive treatment including nicorandil, 20 (95.2%) persons were free of ischemic symptoms after 4 weeks. One patient had a decrease in complaints, but discomfort during exercise continued, which was successfully corrected after increasing the dose of nicorandil. Of 83 participants with CRM syndrome, CHD, and stenosing atherosclerosis who underwent coronary angiography, 74 (89.1%) patients had no ischemic symptoms and negative exercise test results after 28 days. In 9 cases ischemia persisted and a positive/doubtful exercise stress test was found. These patients were additionally prescribed nicorandil at a dose of 10 mg 2 times a day, which led to the disappearance of symptoms of angina pectoris and negative results of the exercise test at an additional re-examination after 7 days. Conclusions. In patients with CRM syndrome, the causes of ischemic heart disease were stenosing atherosclerosis (71.2%), microvascular angina (20.2%) and their combination (8.6%). Interventional treatment and nicorandil are effective in the treatment of coronary artery disease with different mechanisms, especially in cases of their combination.

Evidence of the Advantages of Preoperative Intra-aortic Balloon Pump in Surgical Revascularization of Acute Myocardial Infarction

Background: Early coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) is associated with considerable risk. The optimal timing of surgery and the preoperative use of an intra-aortic balloon pump (IABP) in these patients remain unclear. Methods: To asses the effect of preoperative IABP on troponin levels, surgical timing, and postoperative outcomes, 230 AMI patients scheduled for CABG were divided into two groups: Group A received support with IABP, whereas Group B served as the control group without IABP. The analysis evaluated the preoperative reduction in high-sensitivity cardiac troponin I (hsCTI) levels, timing of surgery, durations of intensive care unit (ICU) and hospital stays (HS), and mortality rates. Results: After propensity score matching, Group A comprised 64 patients with a mean age of 63.1 ± 8.9 years, and Group B comprised 92 patients with a mean age of 65.2 ± 8.1 years. In the IABP group, participants exhibited relief from angina symptoms, faster reduction in hsCTI levels, improved transit-time flow measurement (TTFM) of grafts, and shorter ICU and HS durations. The overall mortality rate was 7.1%. However, preoperative IABP support reduced the mortality rate by a factor of 0.6 compared to intraoperative IABP (β = –0.86; Z = –2.41; OR = 0.42, 95% CI: 0.2–0.85; p = 0.016). Conclusions: The IABP provides myocardial preconditioning in patients with AMI, thus preparing the myocardium for CABG. Its use should be considered, particularly for high-risk patients. This study has obtained a clinical registration number (NCT number: NCT06468982).

Heart–brain microvascular MRI study: protocol for a multicentre, observational, cohort study in the UK assessing associations between small vessel disease of the heart and brain

IntroductionIschaemic heart disease (IHD) and cerebrovascular disease are leading causes of morbidity and mortality worldwide. Cerebral small vessel disease (CSVD) is a leading cause of dementia and stroke. While coronary...

COMPARISON OF EFFICACY AND SAFETY OF RANOLAZINE AND IVABRADINE IN CHRONIC ISCHEMIC HEART DISEASE PATIENTS

Background: Ischemic heart disease (IHD) frequently produces persistent angina that may significantly impair quality of life despite standard treatment. There is need for effective adjunctive therapies to manage refractory angina. Ranolazine and Ivabradine are two potential options that have shown efficacy in alleviating angina symptoms and improving quality of life in IHD patients. Methods: Ethical clearance was obtained from hospital ethical committee before initiation of study. Those patients fulfilling study inclusion criteria were enrolled. Written informed consent was obtained from all the patients. This randomized clinical trial enrolled patients from the Department of Cardiology, PIMS Hospital, Islamabad. The information regarding demographic and baseline patient characteristics were recorded. Patients were randomly assigned into two groups by lottery method. Treatment group (group A) was Ranolazine 500 mg tablets twice daily for 8 weeks plus standard treatment while the Placebo group (group B) was Ivabradine 5 mg tablets twice daily for 8 weeks plus standard treatment. The primary outcome of study was improvement in angina as assessed by SAQ. Other outcomes like hemodynamic stability (heart rate and Blood pressure) and associated side effects were also recorded at 2, 4, 6, and 8 weeks after the start of treatment in both the study groups. The collected data was analyzed by using SPSS 23 version. Results: The mean age of patients in Group A was 64.59±5.47 years and in Group B were 65.41±5.95 years. In Group A 36(78.3%) patients were male and 10(21.7%) patients were female and in Group B 38(82.6%) patients were male and 8(17.4%) patients were female. The baseline score of SAQ in Group A and Group B was as (41.93±4.23 vs 43.24±4.44) and at 8 week as (90.98±3.12 vs 81.48±2.52). Ranolazine had better clinical outcome than Ivabradine for the treatment of persistent angina in patients with chronic stable ischemic heart disease in terms of SAQ score, systolic & diastolic blood pressure and safety profile. Conclusion: This study concluded that Ranolazine in comparison to Ivabradine has better clinical outcomes in terms of efficacy & safety in patients with chronic IHD who had persistent symptoms.

Application of optical coherence tomography angiography to study retinal and choroidal vascular changes in patients with first-time coronary artery stenosis

ObjectiveTo study the changes in retinal and choroidal vessels in patients with coronary artery stenosis via optical coherence tomography angiography (OCTA). MethodsA total of 100 subjects were enrolled in this study and divided into two groups:the observation group consisted of 50 patients with angina who were first diagnosed with coronary artery stenosis, and the control group consisted of 50 healthy adults without angina symptoms. All of the subjects underwent OCTA to investigate changes in retinochoroidal vessel density in patients with a first diagnosis of coronary artery stenosis. The parameters included superficial capillary plexus density (SCD), deep capillary plexus density (DCD), retinal peripapillary capillary plexus density(RPD), the choroidal vascular index (CVI), and the macular foveal avascular zone(FAZ area, perimeter, acircularity index, FD-300 vessel density). ResultsSCD and DCD in the coronary artery stenosis group were lower than those in the control group (P=0.045 and P=0.034, respectively), the CVI was lower than that in the control group (P=0.029), the FAZ perimeter and acircularity index were greater than those in the control group (P=0.003,P=0.024). Logistic regression and ROC curve analysis revealed that FAZ perimeter was the most significant risk factor for predicting coronary artery stenosis (P=0.005, AUC=0.664), and the cut-off value for FAZ perimeter was 2.065 mm. ConclusionsIn patients with a first diagnosis of coronary artery stenosis, both retinal and choroidal blood flow are reduced. FAZ perimeter is a risk factor for predicting the occurrence of coronary artery stenosis.

Comparison of Body Quality Composition, Including Phase Angle, in PostMyocardial Infarction Patients Qualified for Rehabilitation under the MC-AMI Program and Patients with Angina Pectoris

Background: In some diseases, such as heart failure, there is talk of an obesity paradox, as lower mortality is observed in patients with higher BMI. Both obesity and frailty syndrome are risk factors for adverse prognosis and treatment, including high mortality. Body composition analysis with electrical bioimpedance (BIA) appears to be a good method for assessing changes in patients after various cardiovascular incidents, as well as for primary prevention of cardiovascular disease. Aim of the study: The aim of this study is to evaluate the qualitative composition of the body (including but not limited to phase angle (PhA), visceral fat, and lean body mass) using BIA in post-MI patients qualified for rehabilitation under the Managed Care after Acute Myocardial Infarction (MC-AMI) program. The control group consisted of patients with suspected ischemic heart disease with symptoms of angina but without myocardial infarction. Methods: The project was conducted as a retrospective analysis of prospectively collected data from 148 patients. The final study included 94 patients after revascularization for myocardial infarction and 54 patients with stable angina admitted electively to the Cardiology Department for coronary angiography. Results: The group of patients after myocardial infarction had statistically significantly higher values of total cholesterol, LDL, and triglycerides. The group of women after myocardial infarction had lower values for fat-free tissue mass and muscle mass in the trunk and limbs. No significant differences in PhA values were observed between the two groups. Conclusions: Learning more about the role of electrical bioimpedance brings much hope as a non-invasive method that can be used as a predictive marker of health change in cardiology.

Prognostic significance of stress dynamic myocardial CT perfusion: comparison with CT-FFR and CT angiography stenosis-the multicenter VALIDITY trial.

This study aimed to investigate the prognostic significance of stress dynamic myocardial CT perfusion imaging (CTP) and determine whether it has incremental advantages over coronary computed tomography angiography (CTA)-derived parameters. This prospective multicenter study included patients with suspected coronary artery disease who had undergone coronary CTA and CTP and were followed for 6 years. The endpoint was time-to-first major adverse cardiovascular event (MACE). MACEs included all-cause mortality, cardiac death, nonfatal myocardial infarction, unstable angina, late revascularization, and heart failure or aggravated angina symptoms requiring hospitalization. The CTP-derived absolute myocardial blood flow (MBF), relative MBF ratio (r-MBF), and the CTA-derived fractional flow reserve (CT-FFR) and stenosis were analyzed. The independent predictors, time-to-event distributions and the incremental prognostic value of CTP over CTA-derived parameters were assessed. A total of 226 patients (66.7 ± 11.3 years, 37.6% women) were enrolled with a median follow-up time of 1233 days. Twenty-one patients (9.29%) experienced MACEs and ten patients (4.4%) experienced hard MACEs. The r-MBF was the only independent predictor for MACEs in both all patients (hazard ratio [HR]: 0.82 (0.69-0.97), p = 0.01) and patients available for CTA stenosis (%) and CT-FFR calculation (HR: 0.72 (0.57-0.91), p = 0.006). The incremental prognostic significance of r-MBF over CT-FFR was confirmed after combining with CTA-derived parameters (concordance index: 0.919 vs. 0.811; p < 0.01). Patients with r-MBF < 0.77 were more likely to experience MACEs and have a lower average survival time (1565 vs. 1790 days; p < 0.01) after stent implantation. CTP-assessed r-MBF was independently correlated with MACEs and provided incremental prognostic significance. Question The prognostic significance of CT perfusion (CTP) lacks sufficient support from clinical research. Findings In this Chinese population, CTP has the strongest prognostic significance, over CT-Fractional Flow Reserve (FFR) and CTA stenosis in predicting major adverse cardiovascular events (MACEs). Clinical relevance Relative myocardial blood flow ratio had the strongest prognostic value and incremental advantages in predicting MACEs beyond CT-FFR and coronary CTA stenosis quantification, as well as advantages in patients with stents, aiding in personalized diagnosis and treatment plans.

The Hypothesis of Trace Elements Involvement in the Coronary Arteries Atherosclerotic Plaques' Location.

Background: Coronary artery disease (CAD) is a chronic inflammatory disease with multiple well-known risk factors. Although epidemiological studies report improvements in classical CAD risk-factor control, except for diabetes and obesity, cardiovascular diseases remain the leading causes of morbidity and mortality in the current population. The question regarding the atherosclerotic plaque location in particular arteries remains unanswered. Research on novel possible aspects that could help to properly understand atherosclerosis pathophysiology is essential. This study was based on a body trace-elements analysis, measured in scalp hair samples, as possible co-factors of various enzymes that may be crucial for CAD development. Methods: A total of 133 consecutive male patients with a median age of 71 (65-75) years, who presented with anginal symptoms of CCS class 2.0 (0.3) without previous heart-related interventions, were included in the analysis. The results of the cine-angiography were compared with the demographical, clinical, and laboratory results, followed by scalp-hair trace analysis. The possible predictors for coronary disease locations in the left descending artery (LAD), the circumflex artery (Cx), and the right coronary artery (RCA) were the subjects of this study. Results: Statistically significant differences in the scalp-hair trace elements concentration between the CAD and normal angiogram groups were noticed for magnesium (p = 0.003), calcium (p < 0.001), chromium (p = 0.011), and copper (p = 0.043). The multivariable analysis for epicardial atherosclerotic disease revealed the co-existence of diabetes mellitus (OR: 2.94, 95% CI: 1.27-6.79, p = 0.012) as a possible causative factor for the LAD location. The multivariable analysis for the atherosclerosis location in the Cx artery presented scalp-hair magnesium as a possible predictive factor (OR: 0.98, 95% CI: 0.96-1.00, p = 0.024). The multivariable model for the RCA location of atherosclerotic plaque indicated scalp-hair Zn concentration (0.99, 95% CI: 0.98-1.00, p = 0.002) and serum HDL (OR: 0.61, 95% CI: 0.04-0.09, p = 0.016). Conclusions: Possible hypothetical distinctive pathomechanisms, in particular, coronary artery involvement, in atherosclerosis processes are presented in the male group. Diabetes mellitus was found to be the primary factor for left descending artery disease. The low scalp-hair magnesium concentration was found to be a possible risk factor involved in the circumflex artery atherosclerotic plaque location. The inverse relation between serum high-density lipoprotein, the scalp hair zinc concentration, and right coronary disease was noticed.

Abstract 4126987: A Case of Recurrent Neurocardiogenic Syncope in a COVID-19 Patient

Background: COVID-19 infection has been associated with a broad range of clinical manifestations. There are very few reported cases of COVID-19 patients presenting with syncope as an initial symptom. We present an extraordinary case of recurrent neurocardiogenic syncope in a COVID-19 patient. Case: A 66-year-old male presented after experiencing two episodes of syncope. He denied any prodromal or anginal symptoms. His medications included propranolol 10 mg twice daily for essential tremors. He had no family history of unexplained syncope or sudden cardiac death. He was hemodynamically stable and had one episode of fever at 102°F. Telemetry recording showed vagal-mediated sinus arrest and pauses without escape. Blood work showed normal cell counts, electrolytes, thyroid-stimulating hormone, and erythrocyte sedimentation rate, with a slightly elevated C-reactive protein of 22.2 mg/L. He tested positive for COVID-19 and had negative Lyme and Ehrlichia serologies. Decision Making: Due to symptomatic long sinus pauses, propranolol was discontinued, and he received a temporary pacemaker set at 50 beats per minute (bpm). He had another syncopal episode while being paced at 50 bpm, suggesting a neurocardiogenic mechanism, so the pacing rate was increased to 70 bpm. An echocardiogram showed a normal ejection fraction without any significant valvular disease. The syncope was determined to be vasovagal due to autonomic dysfunction in the setting of COVID-19. After 72 hours without further syncope, the temporary pacemaker was removed, and he was discharged home with an implantable loop recorder (ILR). A one-month follow-up showed no syncope, and ILR interrogation showed no bradycardia or pauses. Conclusion: Neurocardiogenic syncope with prolonged asystole and sinus pauses is an uncommon presentation of COVID-19 infection. The clinical course of autonomic dysfunction following COVID-19 is not very clear, and monitoring with an ILR is reasonable before considering permanent pacemaker implantation.

Controversias en la revascularización y el estudio de viabilidad miocárdica en el síndrome coronario crónico

The broad spectrum of patients with chronic coronary syndrome and the controversies in diagnosis and treatment pose a major challenge in clinical decision making. Concerning the diagnosis, the utility of myocardial viability study has been questioned by recent clinical trials. Regarding the therapeutic approach, in patients with simple coronary disease, percutaneous revascularization has proved its utility in anginal symptoms relieve, but the evidence regarding a prognostic benefit is contradictory. In complex coronary disease, coronary artery bypass grafting surgery has reported better results than percutaneous intervention. Besides, surgical revascularization has demonstrated a reduction in cardiovascular events over medical treatment in patients with ischemic left ventricular dysfunction. In this review we critically analyse the current evidence on viability study and myocardial revascularization in patients with chronic coronary syndrome.