Artery Disease In High-risk Patients Research Articles

B-28 | Management of Clinical Stent-In-Stent Restenosis (SISR) in High Risk Coronary Artery Disease Patients With Percutaneous Coronary Intervention (PCI) Followed by Coronary Intravascular Brachytherapy (IVBT)

In-stent-restenosis (ISR) is seen in 10% of patients with DES and is often treated with a repeat DES placement. Recurrent ISR or SISR has a high repeat failure rates, requiring target vessel revascularization (TVR). A combination of the presence of multiple layers of stents, previous restenosis, and other additional comorbidities make this patient population complex and higher risk. Angioplasty followed by IVBT is one possible treatment option in the high-risk patients. This study reviewed the efficacy and safety of PCI followed by IVBT for coronary artery disease in high-risk patients experiencing SISR. A retrospective study was performed which reviewed 78 patients treated between 2016-2021 with SISR involving a total of 91 vessels. All patients underwent PCI with balloon angioplasty followed by IVBT. These patients received localized IVBT radiation using the Novoste Beta-Cath System using a strontium-90 isotope. Radiation dose was delivered based on the vessel diameter, with vessels ≥ 3.5mm in diameter receiving 23 Gy, while vessels of <3.5mm in diameter received 18.4 Gy. Major adverse cardiac events (MACE) were defined as all-cause death, myocardial infarction (MI), and stroke. All patients in the cohort had 2 previously placed DESs in the target lesion. Of total 91 treatments, 67% and 33% treatments were delivered to the LAD or the RCA and circumflex vessel or the marginal arteries, respectively. One patient had intraprocedural cardiac arrest due to suspected intracoronary thrombosis. All patients were symptomatic pre-IVBT and 44% experienced symptomatic reduction after treatment. MACE after IVBT includes MI in 18%, stroke in 5%, and all-cause death occurred in 16% of patients at a median time of 9.3 months post treatment with median follow-up being 22.8 months. Of total, 77% retained patency of the irradiated lesion, while 23% percent experienced restenosis requiring TVR. Coronary restenosis post-deployment of multiple layers of DES remains an ongoing challenge in current times. PCI followed by balloon angioplasty with IVBT is a safe and efficacious treatment option for high-risk coronary artery disease patients with SISR, who have very few treatment options otherwise.

Presence of Calcium-Like Tissue Composition in Carotid Plaque is Indicative of Significant Coronary Artery Disease in High-Risk Patients

Grayscale pixel ranges from ultrasound images, indicating differences in atherosclerotic plaque echogenicity, have been shown to represent different tissue types. Our objective was to determine whether carotid plaque composition was correlated with severity of coronary artery disease (CAD) and risk of cardiovascular (CV) events. A focused carotid ultrasound was performed in 522 participants who had recently undergone coronary angiography. In 468 participants found to have atherosclerotic plaque in at least one carotid artery, plaque composition was assessed for tissue-like types: grayscale ranges 0-4 (blood), 8-26 (fat), 41-76 (muscle), 112-196 (fibrous), and 211-255 (calcium). Logistic regression was used to evaluate correlations with significant CAD (≥50% stenosis). Cox proportional hazards models were used to determine risk for 5-year CV outcomes. Carotid plaque percent fibrous and percent calcium increased with severity of CAD (P<.02). When adjusted for age, sex, body mass index, estimated glomerular filtration rate, and traditional cardiac risk factors, maximum plaque height and percent calcium remained independent contributors of significant CAD (P<.01). Plaque height (≥2.74mm), percent calcium (≥0.11%), and percent fat (11.6%) were associated with increased risk for CV events. Combined plaque height and percent fat gave the highest risk for events (risk ratio=2.02; CI, 1.41-2.94, P=.0002). Carotid plaque fibrous and calcium-like tissues are correlated with increased CAD. Increased percent fat or percent calcium is associated with risk for CV events; however, a combination of plaque height, percent calcium, and/or percent fat increases risk for CV events. Incorporating ultrasound carotid plaque composition into screening practice may improve patient risk stratification for heart disease.

Pattern of coronary artery disease in high-risk patients without prior myocardial infraction

Objective This study aimed to assess the causes, risk factors, outcome, and recommendation of patients with coronary artery disease without prior obstruction. Materials and methods Medline databases (PubMed, Circulation, American Society of Echocardiography, Journal of American Colleague of Cardiology, and ScienceDirect) and also materials available on the internet. The search was performed in the electronic databases from 2012 to 2017. The initial search presented 60 articles of which 23 met the inclusion criteria. The articles studied the pattern of coronary artery disease in patients with risk factors without prior obstruction. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and defined assessment measures. Comparisons were made by a structured review with the results tabulated. Findings In total, 27 potentially relevant publications were included. The studies indicate that cardiovascular risk factors have a differential effect on women, and some risk factors are more common in women than in men. Conclusion Patients with angina and nonobstructive coronary angiograms are predominantly women, and many have a prognosis that is not as benign as commonly thought. Therapy should be directed at symptom relief; aggressive anti-ischemic medication should be applied when risk factors are present or when the prognostic risk is high.

Non-invasive detection of coronary artery disease in high-risk patients based on the stenosis prediction of separate coronary arteries

Background and objectiveCardiovascular diseases are an extremely widespread sickness and account for 17 million deaths in the world per annum. Coronary artery disease (CAD) is one of such diseases with an annual mortality rate of about 7 million. Thus, early diagnosis of CAD is of vital importance. Angiography is currently the modality of choice for the detection of CAD. However, its complications and costs have prompted researchers to seek alternative methods via machine learning algorithms. MethodsThe present study proposes a novel machine learning algorithm. The proposed algorithm uses three classifiers for detection of the stenosis of three coronary arteries, i.e., left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) to get higher accuracy for CAD diagnosis. ResultsThis method was applied on the extension of Z-Alizadeh Sani dataset which contains demographic, examination, ECG, and laboratory and echo data of 500 patients. This method achieves an accuracy, sensitivity and specificity rates of 96.40%, 100% and 88.1%, respectively for the detection of CAD. To our knowledge, such high rates of accuracy and sensitivity have not been attained elsewhere before. ConclusionThis new algorithm reliably distinguishes those with normal coronary arteries from those with CAD which may obviate the need for angiography in the normal group.

Clinical Implications of Glucose Variability: Chronic Complications of Diabetes.

Glucose variability has been identified as a potential risk factor for diabetic complications; oxidative stress is widely regarded as the mechanism by which glycemic variability induces diabetic complications. However, there remains no generally accepted gold standard for assessing glucose variability. Representative indices for measuring intraday variability include calculation of the standard deviation along with the mean amplitude of glycemic excursions (MAGE). MAGE is used to measure major intraday excursions and is easily measured using continuous glucose monitoring systems. Despite a lack of randomized controlled trials, recent clinical data suggest that long-term glycemic variability, as determined by variability in hemoglobin A1c, may contribute to the development of microvascular complications. Intraday glycemic variability is also suggested to accelerate coronary artery disease in high-risk patients.

Radial artery pulse wave analysis for non-invasive assessment of coronary artery disease

BackgroundAngiographically-normal coronary arteries are reported in 10–20% of patients undergoing diagnostic coronary angiography despite screening with risk factors and functional tests. We sought to validate and determine the clinical value of radial artery pulse wave analysis (PWA), a simple, quick and non-invasive marker of central artery stiffness and define its ability to predict coronary artery disease in high-risk patients. Materials and methods531 consecutive patients referred for elective coronary angiography, irrespective of previous co-morbidity, were assessed in a prospective, multicenter observational study [the Alternative Risk Markers in Coronary Artery Disease (ARM-CAD) study]. ResultsMean age was 65±11years, 33% were women, 18% had impaired left-ventricular function and 22% a prior myocardial infarction. Angiography demonstrated normal coronary arteries in 20% of participants. The only independent associations with this outcome were younger age, female gender, absence of diabetes and PWA-derived central augmentation pressure <24mm Hg. The odds ratio for the latter after adjustment for medications and baseline risk factors (including blood pressure, high-sensitivity C-reactive protein and B-type natriuretic peptide) was 3.4 (95% CI 1.2 to 9.5; p=0.021). The specificity for the multivariate model that included PWA was 95.7% with a receiver operator curve area of 0.876. Validation studies suggested that systolic variables from PWA were robust regardless of waveform quality and similar to measured aortic pressures (mean difference 2.7mm Hg). ConclusionsAssessment of radial artery waveforms is a useful non-invasive clinical test that can stratify the likelihood of coronary disease and assist in identifying patients who require diagnostic angiography.

Hybrid Coronary Revascularization for the Treatment of Left Main Coronary Artery Disease in High-Risk Patients

Hybrid coronary revascularization is an alternative for treatment for high-risk patients with coronary artery disease. We evaluated the efficacy of staged hybrid coronary revascularization for the treatment of unprotected left main coronary artery disease in high-risk patients. Patients with left main or proximal left anterior descending coronary artery stenosis who are not good candidates for percutaneous coronary intervention and who had suitable lesions in the right coronary and circumflex arteries were considered for staged hybrid therapy if they had poor left ventricular functions (ejection fraction <0.40) and comorbid illnesses. From January 2008 through December 2010, 11 patients (8 men, 3 women; mean age: 66.1 ± 9.1 years) were treated with off-pump coronary artery bypass grafting combined with staged percutaneous coronary intervention. Nine patients had left main coronary artery stenosis together with circumflex or right coronary artery stenosis, and 2 patients had proximal left anterior descending artery stenosis and right coronary artery stenosis. After off-pump coronary artery bypass grafting, procedure-related complications did not occur, and there was no in-hospital death. Coronary re-angiography after a median of 16 days revealed patent and functioning left internal mammarian artery grafts in all patients. Applying subsequent percutaneous transluminal coronary angioplasty and occasional stenting (n = 14), a total of 14 lesions were treated successfully. Procedure related complications did not occur. All patients remained angina-free, and no stress electrocardiographic changes were recorded. Our preliminary results indicate that a "staged hybrid" approach to the treatment of left main coronary artery disease in high-risk patients is safe and effective. Hybrid coronary revascularization enables complete revascularization and may be an alternative method of treating left main coronary artery disease in selected high-risk patients.

The Value of Brachial-Ankle Pulse Wave Velocity as a Predictor of Coronary Artery Disease in High-Risk Patients

Background and ObjectivesArterial stiffness has been known as an independent contributory factor for coronary artery disease (CAD). Brachial-ankle pulse wave velocity (baPWV) is widely used as a simple noninvasive measure of arterial stiffness. The aim of our study was to test whether baPWV had predictive value for CAD in the subset of patients with high pretest probability.Subjects and MethodsWe enrolled 174 consecutive patients who were referred for evaluation of suspected CAD, and who underwent both baPWV measurement and computed tomography (CT) for coronary artery calcium scoring (CACS) as part of a diagnostic work-up. Subsequently, 160 of those patients underwent invasive coronary angiography. The CAD indices consisted of 1) CACS, 2) modified Gensini scoring system, and 3) presence of obstructive CAD and 4) multi-vessel obstructive CAD.ResultsbaPWV correlated with CACS (r=0.25, p=0.001), but not with modified Gensini scoring (r=0.10, p=0.19). However, after adjustment for factors influencing PWV, baPWV no longer correlated with CACS (r=0.14, p=0.14). By receiver operating characteristic (ROC) curve analysis, baPWV was neither a sensitive nor specific index for predicting the presence of obstructive CAD or multi-vessel obstructive CAD (sensitivity: 53% and 59%; specificity: 50% and 55%, respectively).ConclusionOur findings demonstrated that baPWV is associated with CACS, however, this may be primarily attributed to common risk factors, such as age. Furthermore, baPWV may be of limited value in identifying patients at risk for CAD.

Are stents the best treatment for extracranial carotid artery disease in high-risk patients?

Are stents the best treatment for extracranial carotid artery disease in high-risk patients?

Clinical Predictors of Left Main Coronary Artery Disease in High-Risk Patients With a First Episode of Non-ST-Segment Elevation Acute Coronary Syndrome

Risk stratification in non-ST-elevation acute coronary syndrome makes use of clinical variables that can identify patients at an increased risk of complications. Our objective was to identify clinical variables that predict significant stenosis (i.e., >50%) of the left main coronary artery in high-risk patients who have had a first episode of non-ST-elevation acute coronary syndrome but who do not have a history of coronary artery disease. The study included 102 high-risk patients with no history of coronary artery disease who were admitted because of non-ST-elevation acute coronary syndrome. All underwent coronary angiography. Patients were divided into two groups: those with significant left main coronary artery stenosis (n=14) and those without (n=88). Univariate analysis showed that the variables significantly associated with left main coronary artery stenosis were age >65 years (57.1% vs 15.9%, P=.002), diabetes mellitus (71.4% vs 33.0%, P=.006), chronic renal failure (28.6% vs 5.7%, P=.019), left heart failure (71.4% vs 6.8%, P< .0001), cardiogenic shock (21.4% vs 1.1%, P=.008), and a low left ventricular ejection fraction at admission (49.9% [14.7%] vs 58.8% [9.9%], P=.044). In the multivariate analysis, the only significant independent predictor of left main coronary artery disease was left heart failure. The presence of left heart failure at initial assessment of high-risk patients with non-ST-elevation acute coronary syndrome but without a history of coronary artery disease could be a useful predictor of significant left main coronary artery disease.

Usefulness of tachycardic-stress perfusion imaging to predict coronary artery disease in high-risk patients with chronic renal failure

Uncertainty remains as to the most appropriate preoperative screening investigation to evaluate patient cardiac risk in prospective renal transplant recipients. We prospectively compared tachycardic-stress (exercise/pacing) scintigraphy with coronary angiography for the detection of significant coronary artery disease in this group. With a negative predictive value of 92%, tachycardic-stress scintigraphy may reduce the need for unnecessary coronary angiography in these patients.

Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high-risk patients (Indo-Mediterranean diet heart study): a randomized single-blind trial

Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high-risk patients (Indo-Mediterranean diet heart study): a randomized single-blind trial

Correlation of Lp(a) phenotypes and Lp(a) levels with premature coronary artery disease in high-risk patients

Correlation of Lp(a) phenotypes and Lp(a) levels with premature coronary artery disease in high-risk patients