Atherosclerotic Coronary Disease Research Articles

Left ventricular free wall rupture caused by myocardial ischemia without treatable atherosclerotic coronary disease: a case series

BackgroundThe clinical presentation of left ventricular free wall rupture (LVFWR) varies ranging from uneventful condition to congestive heart failure.Case summaryHere we report two cases of LVFWR with different clinical presentation and notable outcome. A 53-year-old male presenting emergently with signs of myocardial infarction received immediate coronary angiography and thoracic CT-scan showing occlusion of the first marginal coronary branch without possibility of revascularization and minimal pericardial extravasation. Under ICU surveillance, LVFWR occurred 24 h later and was treated by pericardiocentesis and ECMO support followed by immediate uncomplicated surgical repair. Postoperative therapy-refractory vasoplegia and electromechanical dissociation caused fulminant deterioration and the early death of the patient. The second case is a 76-year old male brought to the emergency room after sudden syncope, clinical sings of pericardial tamponade and suspicion of a type A acute aortic dissection. Immediate CT-angiography excluded aortic dissection and revealed massive pericardial effusion and a hypoperfused myocardial area on the territory of the first marginal branch. Immediate sternotomy under mechanical resuscitation enabled removal of the massive intrapericardial clot and revealed LVFWR. After an uncomplicated surgical repair, an uneventful postoperative course, the patient was discharged with sinus rhythm and good biventricular function. One year after the operation, he is living at home, symptom free.DiscussionWhereas the younger patient, who was clinically stable at hospital admission received delayed surgery and did not survive treatment, the older patient, clinically unstable at presentation, went into immediate surgery and had a flawless postoperative course. Thus, early surgical repair of LVFWR leads to best outcome and treating LVFWR as a high emergency regardless of the symptoms improve survival.

Characterization of myocardial injury phenotype by thermal liquid biopsy.

With the advent and implementation of high-sensitivity cardiac troponin assays, differentiation of patients with distinct types of myocardial injuries, including acute thrombotic myocardial infarction (TMI), acute non-thrombotic myocardial injury (nTMi), and chronic coronary atherosclerotic disease (cCAD), is of pressing clinical importance. Thermal liquid biopsy (TLB) emerges as a valuable diagnostic tool, relying on identifying thermally induced conformational changes of biomolecules in blood plasma. While TLB has proven useful in detecting and monitoring several cancers and autoimmune diseases, its application in cardiovascular diseases remains unexplored. In this proof-of-concept study, we sought to determine and characterize TLB profiles in patients with TMI, nTMi, and cCAD at multiple acute-phase time points (T 0 h, T 2 h, T 4 h, T 24 h, T 48 h) as well as a follow-up time point (Tfu) when the patient was in a stable state. TLB profiles were collected for 115 patients (60 with TMI, 35 with nTMi, and 20 with cCAD) who underwent coronary angiography at the event presentation and had subsequent follow-up. Medical history, physical, electrocardiographic, histological, biochemical, and angiographic data were gathered through medical records, standardized patient interviews, and core laboratory measurements. Distinctive signatures were noted in the median TLB profiles across the three patient types. TLB profiles for TMI and nTMi patients exhibited gradual changes from T0 to Tfu, with significant differences during the acute and quiescent phases. During the quiescent phase, all three patient types demonstrated similar TLB signatures. An unsupervised clustering analysis revealed a unique TLB signature for the patients with TMI. TLB metrics generated from specific features of TLB profiles were tested for differences between patient groups. The first moment temperature (TFM) metric distinguished all three groups at time of presentation (T0). In addition, 13 other TLB-derived metrics were shown to have distinct distributions between patients with TMI and those with cCAD. Our findings demonstrated the use of TLB as a sensitive and data-rich technique to be explored in cardiovascular diseases, thus providing valuable insight into acute myocardial injury events.

Cardiovascular Disease from Pathophysiology to Risk Estimation: Is Inflammation Estimated through Perivascular Attenuation on Computed Tomography the Key?

(1) Background: Systemic inflammation stands as a well-established risk factor for ischemic cardiovascular disease, as well as a contributing factor in the development of cardiac arrhythmias, notably atrial fibrillation. Furthermore, scientific studies have brought to light the pivotal role of localized vascular inflammation in the initiation, progression, and destabilization of coronary atherosclerotic disease. (2) Methods: We comprehensively review recent, yet robust, scientific evidence elucidating the use of perivascular adipose tissue attenuation measurement on computed tomography applied to key anatomical sites. Specifically, the investigation extends to the internal carotid artery, aorta, left atrium, and coronary arteries. (3) Conclusions: The examination of perivascular adipose tissue attenuation emerges as a non-invasive and indirect means of estimating localized perivascular inflammation. This measure is quantified in Hounsfield units, indicative of the inflammatory response elicited by dense adipose tissue near the vessel or the atrium. Particularly noteworthy is its potential utility in assessing inflammatory processes within the coronary arteries, evaluating coronary microvascular dysfunction, appraising conditions within the aorta and carotid arteries, and discerning inflammatory states within the atria, especially in patients with atrial fibrillation. The widespread applicability of perivascular adipose tissue attenuation measurement underscores its significance as a diagnostic tool with considerable potential for enhancing our understanding and management of cardiovascular diseases.

Can Triglycerides-HDL-C Ratio, HOMA-IR, ApoB, Non-HDL Cholesterol, and Free Cholesterol be Laboratory-Associated Flags of Female Coronary Atherosclerosis Regardless of Being Diabetic?

Aim The study aimed to evaluate biomarkers, ratios, and indexes as flags of coronary obstructions in women with established coronary atherosclerotic disease regardless of diabetes. Methods A cross-sectional study was conducted on 42 confirmed atherosclerotic coronary female patients, stratified into diabetic or not and scheduled for angioplasty or coronary graft bypass surgery. Blood samples were collected immediately before coronary intervention for laboratory determinations, such as glycemia, HbA1c, insulin, HDL-C, PON-1, free cholesterol, LDL-C, Apo A-1, Apo B, and TG. Results In diabetic patients, insulin was positively correlated with triglycerides (p < 0.0108; r = 0.2009), apo B (p < 0.0006; r = 0.3737), non-HDL cholesterol (p < 0.0084; r = 0.2156), and free cholesterol (p < 0.0084; r = 0.3251). Applying a linear regression model, insulin from diabetic patients showed an association with glycemia, triglycerides, and HOMA-IR (p < 0.001, R2 = 0.9868), but in non-diabetics, the association was only found between insulin and HOMA-IR (p = 0.002, R2 = 0.9031). On the other hand, using triglycerides as a dependent variable, its association has been found in both groups, but only with HOMA-IR (diabetics: p = 0.006, R2 = 0.2504; non-diabetics: p = 0.014, R2 = 0.4697). Also, the TG/HDL-C ratio was higher than 2.5 in 90% of diabetics and 83.33% of non-diabetic patients. Conclusion The high prevalence of females with a TG/HDL-C ratio above 2.5, the association among insulin, HOMA-IR, and TG/HDL-C, and correlations with apoB, non-HDL-C, and free cholesterol, should be evaluated as flags of female precocious coronary atherosclerosis.

Research Progress and Clinical Value of Subendocardial Viability Ratio.

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, with ischemic heart disease being a major contributor, either through coronary atherosclerotic plaque-related major vascular disease or coronary microvascular dysfunction. Obstruction of coronary blood flow impairs myocardial perfusion, which may lead to acute myocardial infarction in severe cases. The subendocardial viability ratio, also known as the Buckberg index, is a valuable tool for evaluation of myocardial perfusion because it reflects the balance between myocardial oxygen supply and oxygen demand. The subendocardial viability ratio can effectively evaluate the function of the coronary microcirculation and is associated with arterial stiffness. This ratio also has potential value in predicting adverse cardiovascular events and mortality in various populations. Moreover, the subendocardial viability ratio has demonstrated clinical significance in a range of diseases, including hypertension, aortic stenosis, peripheral arterial disease, chronic kidney disease, diabetes, and rheumatoid arthritis. This review summarizes the applications of the subendocardial viability ratio, its particular progress in the relevant research, and its clinical significance in cardiovascular diseases.

Correlation of High Sensitive C-Reactive Protein with the Extent of Coronary Atherosclerotic Disease

Correlation of High Sensitive C-Reactive Protein with the Extent of Coronary Atherosclerotic Disease

Associations of the CYP7A1 Gene Polymorphisms Located in the Promoter and Enhancer Regions with the Risk of Acute Coronary Syndrome, Plasma Cholesterol, and the Incidence of Diabetes.

Cholesterol-7-alpha hydroxylase (CYP7A1) is a key enzyme in the synthesis of bile salts, and its activity can contribute to determining cholesterol levels and, consequently, the risk of developing coronary atherosclerotic disease. We evaluated whether seven (rs3808607 G/T, rs9297994 G/A, rs10504255 A/G, rs8192870 G/T, rs2081687 C/T, rs1457043 C/T, and rs10107182 C/T) polymorphisms located in the promoter and enhancer regions of the CYP7A1 gene, which have not been sufficiently explored, are candidates of risk markers of acute coronary syndrome (ACS) in the Mexican population. These polymorphisms were determined in a group of 1317 patients with ACS and 1046 control subjects. The results showed that, under different inheritance models, the alleles rs9297994 G, rs10504255 G, rs8192870 T, rs2081687 T, and rs10107182 C were significantly associated with an increased risk of ACS (pC < 0.05). In addition, the incidence of dyslipidemia among patients with ACS, notably high total cholesterol and LDL-cholesterol, and low HDL-cholesterol plasma levels, were more frequent in carriers of the same five risk alleles associated with ACS (p < 0.05). There was also an unexpected increased incidence of type 2 diabetes mellitus (T2DM) in patients with ACS who are homozygous for the rs2081687 T, rs9297944 G, rs10504255 G, and rs10107182 C alleles of the CYP7A1 gene, suggesting that such gene variants enhance the development of coronary complications in patients with diabetes (p < 0.05). In summary, our study demonstrated that five polymorphisms situated in the promoter and enhancer regions of the CYP7A1 gene are associated with the risk of ACS and higher incidences of dyslipidemia and T2DM in Mexican patients with ACS.

Abstract WP15: Early Neurological Improvement in Ischemic Stroke and Risk of Cardiac Complications

Introduction: Cardiac complications are seen in 15-20% of acute ischemic strokes (AIS). We hypothesized that early neurologic improvement (ENI) with or without revascularization would be associated with lower risk of cardiac complications after AIS. Methods: We retrospectively screened consecutive AIS patients for elevated initial cardiac troponin (cTn) and ≥1 additional cTn within 48h. Minor strokes (NIHSS≤3) or comorbidities impacting cTn were excluded from primary analysis. ENI was defined as ≥4 pt improvement in NIHSS or 24h NIHSS≤ 1. Post-stroke acute myocardial injury (PSAMI) refers to dynamic cTn pattern (rise/fall&gt;20% in serial cTn levels) in the absence of acute atherosclerotic coronary disease or cardiac death. Secondary analysis assessed full range of NIHSS at baseline and at 24h in relation to cardiac outcomes. Results: Of 2,609 patients screened, 165 (ENI=62, no-ENI=103) were included in our primary analysis. (Fig.1). In patients with ENI, a dynamic cTn pattern and PSAMI were present in 55% (n=34) and 34% (n=21) respectively, compared to 45% (n=46) and 24% (n=25) in the no-ENI group ( P =0.20 and P =0.18). Adjusted regression analysis did not show any statistical association of cardiac outcomes with ENI. Secondary analysis including NIHSS≤3, was associated with a 4-fold greater risk of PSAMI in NIHSS &gt;15 at 24h (Fig.1). Analysis of patients intervened with MT or tPA (n=77) also showed no statistical association between ENI and PSAMI (Fig 1.) Conclusion: SENI was not associated with a lower risk of cardiac complications after AIS. NIHSS at 24 hours was a strong predictor of PSAMI. Larger studies should investigate if revascularization decreases risk of PSAMI.

Development of a Novel Atherosclerotic Heart Disease Biomarker Program

Background: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of heart attack, stroke, and sudden death worldwide. Clinical risk scores help estimate the likelihood of adverse cardiac events to guide preventative strategies. Current risk scores for atherosclerotic events like heart attack and stroke use known cardiovascular risk factors including smoking, diabetes, lipid levels, and blood pressure. However, these scores underestimate risk in certain patient populations and do not predict the atherosclerotic disease in individual patients that leads to subsequent events. Our aim is to design a novel biomarker-enabled model to predict the presence and burden of coronary artery atherosclerosis in patients with diabetes, to ultimately help personalize preventive therapies that target disease burden, not just risk factors, for more effective prevention of ASCVD events.&#x0D; Methods: Patients with diabetes have been prospectively enrolled in a health plans-based screening program with co-enrollment in the Indiana Biobank, which includes coronary CT angiography, an AI-based quantitation of atherosclerosis, and biobanking of DNA, plasma, and serum. We identified candidate biomarkers based on current literature and determined which could be impactful based on cost, efficacy, and feasibility of implementation guided by interviews with potential collaborating entities.&#x0D; Results: We have identified polygenic risk scores, non-coding RNAs and candidate blood biomarkers with predictive potential for atherosclerotic heart disease. Subsequent work will entail i) direct assays of banked biospecimens for the selected minimally invasive biomarkers and ii) computational analysis to assess incremental predictive value for disease burden over clinically available risk scores.&#x0D; Conclusions and Potential Impact: We are progressing towards the development of a novel mode to predict patient-specific burden of coronary atherosclerotic disease burden in patients with diabetes. We expect that a multidimensional approach including contemporary biomarkers will improve predictive value of atherosclerotic heart disease burden, affording more tailored treatment to prevent ASCVD events.

Prognostic value of mitral annular calcification in coronary atherosclerotic disease assessed by coronary computed tomographic angiography

Abstract Background: There is a lack of evidence on the link between mitral annular calcification (MAC) and coronary atherosclerotic diseases. The present investigation was undertaken to detect the clinical and prognostic value of MAC in coronary atherosclerotic diseases in patients who underwent coronary computed tomographic (CT) angiography. Materials and Methods: Two hundred and five individuals with MAC and without it (n = 85 and 120, respectively) were included in the present cross-sectional study. Coronary artery disease-reporting and data system (CAD-RADS) at coronary CT angiography was used to define the severity of coronary atherosclerotic diseases. Patients were classified into no or non-significant CAD (CAD-RADS 0–2) and significant CAD (CAD-RADS 3–5) according to the severity of coronary atherosclerotic diseases. The association of MAC with two mentioned groups (no or non-significant CAD and significant CAD) was assessed using the Chi-squared test and logistic regression in crude and adjusted models. Results: Patients with MAC were significantly older (69.34 ± 8.20 vs. 60.64 ± 11.42, P &lt; 0.001), had lower glomerular infiltration rate (69.67 ± 20.92 vs. 78.00 ± 20.23, P = 0.005), and higher coronary artery calcification score (352.87 ± 495.85 vs. 200.55 ± 426.13, P = 0.05) in comparison to those without MAC. However, the significant difference between the two groups regarding coronary artery calcification score disappeared after adjustment for confounders (P = 0.14). In addition, a statistically significant positive link between MAC and significant CAD was observed (odds ratio [OR] [95% confidence interval (CI)]: 1.96 [1.04–3.71], P = 0.04). Nevertheless, the association became statistically insignificant after adjustment for confounders (OR [95% CI]: 1.60 [0.78–3.28], P = 0.2). Conclusion: The findings of the study revealed that MAC has no independent prognostic value in coronary atherosclerotic diseases evaluated by coronary CT angiography.

Human ApoC3 overexpression aggravates hyperlipidemia but mitigates diet-induced coronary atherosclerotic disease in SR-BI and LDL receptor double knockout mice

Human ApoC3 overexpression aggravates hyperlipidemia but mitigates diet-induced coronary atherosclerotic disease in SR-BI and LDL receptor double knockout mice

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

MODIFIABLE RISK FACTORS AND CORONARY ARTERY DISEASE SEVERITY: INSIGHTS FROM A CASE-CONTROL ANALYSIS

Atherosclerotic coronary disease stands as a leading cause of both mortality and morbidity globally. The well-documented risk factors for coronary artery disease (CAD) include abnormal lipid levels, obesity, smoking, high blood pressure, and diabetes. The established association between these cardiovascular risk factors and ischemic heart disease is widely recognized. However, the correlation between risk factors for ischemic heart disease and the severity of CAD on coronary angiography remains less explored, with varying findings across studies. Our research involved a total of 200 patients aged 30 to 70 years, comprising 100 cases diagnosed with severe CAD and 100 controls with insignificant CAD. Factors contributing to CAD, such as smoking, high sugar levels, high blood pressure, lipid profiles, family history of CAD, and obesity, were assessed in all patients. Statistical analysis, employing the chi-square test, was conducted, and a significant association was considered when the odds ratio value exceeded 1. The mean age in our study population was 51.01 ± 7.76 years, with 159 (79.50%) being male. Among the patients, 99 (49.50%) were obese, 90 (45.0%) were diabetic, 94 (47.0%) were hypertensive, 77 (38.5%) were smokers, 53 (26.5%) had a positive family history, and 17 (8.5%) were dyslipidemic. In evaluating the association of cardiovascular risk factors with CAD severity, smoking (odds ratio 1.73, p-value 0.04), hypertension (odds ratio 1.6, p-value 0.05), diabetes (odds ratio 1.6, p-value 0.05), and obesity (odds ratio 1.98, p-value 0.016) emerged as independent factors significantly linked to the severity of CAD. Our findings underscore the independent roles of smoking, hypertension, diabetes, and obesity as risk factors contributing to the severity of ischemic heart disease.

Isolated coronary artery ectasia presenting as inferior-posterior STEMI—a case-based state-of-the-art review of the current literature

Abstract Background This review is based on the case of a 71-year-old female patient, with cardiovascular risk factors, who was referred for emergency cardiological evaluation after experiencing severe anterior chest pain that had lasted for more than 5 hours at the time of admission. A diagnosis of inferior-posterior ST-segment elevation myocardial infarction was established, and emergency coronary angiography was performed. It revealed severe, diffuse dilation of the entire arterial coronary tree with slow flow and the presence of a large quantity of thrombotic material in the right coronary artery. Thromboaspiration was deemed unfit since the operator believed that there was a high risk of distal embolization with subsequent no-reflow, when passing with the catheter. As such, the patient started receiving anticoagulant therapy, and after one month she was scheduled for a control angiogram. The follow-up coronary angiography identified complete dissolution of the thrombus from the right coronary artery and a moderate stenosis in the distal segment, so no stent implantation was required. Rationale for review After performing a complete and comprehensive differential diagnosis, presence of isolated coronary artery ectasia was established. Coronary artery ectasia is a rare disease, usually found incidentally during coronary angiograms performed for other indications (chronic and acute coronary syndromes) with a vast etiology and complex pathophysiology. Because there are common morphopathologic pathways between coronary artery ectasia and atherosclerotic coronary artery disease, the clinical presentation of the former might have similar characteristics with the latter, but the management and prognosis of these patients is much less studied compared to the patients suffering from different phenotypes of coronary atherosclerosis. This review aims to summarize the etiopathogenesis, clinical presentation, diagnostic modalities, and different management pathways of coronary artery ectasia.

Modifiable risk factors and inflammatory burden stratified by the presence and extent of atherosclerotic cardiovascular disease: insights from a population based cohort study

Abstract Background/Introduction Inflammation is recognized as a residual risk factor and mediator in patients with Atherosclerotic Cardiovascular Disease (ASCVD). High-sensitivity C-Reactive Protein (hsCRP), a marker of systemic inflammation, can be affected by modifiable risk factors (modRF). On the other hand, ASCVD and its extent might modify hsCRP levels. Data regarding the relationship between hsCRP, modRF and the extent of ASCVD remain scarce. Purpose We aimed to analyse the inflammatory burden in relation to the number of vascular beds affected by atherosclerosis and modRF in a contemporary large-scale population cohort. Methods After exclusion of individuals with inflammatory disorders, cancer, hsCRP concentrations &amp;gt;10 mg/L, missing hsCRP values and/or missing covariates 3,348 cases were left for analysis. Vascular beds affected were defined as coronary, peripheral and cerebrovascular atherosclerotic disease. ModRF were classified as follows: Lack of physical activity (PA) as &amp;lt;1.5 hours/week of exercise, a BMI ≥25 kg/m2 was considered as overweight, active smoking was defined as either current or quitted smoking within the last 6 months, and lastly poor adherence to a Mediterranean diet as a simple Mediterranean diet score (sMDS) of ≤2 points. Multivariable analyses were computed with hsCRP as dependent variable and modRF as covariates according to the number of vascular beds affected adjusting for age, sex, diabetes and intake of cholesterol-lowering drugs. Results Of the 3,348 participants at baseline 1,622 (48.1%) were female and mean age was 62 (1st, 3rd quartile: 54, 69) years. Concerning modRF 1,199 (39.5%) individuals showed low levels of PA, 1,877 (58.7%) were defined as overweight, poor adherence to MDS was determined in 1,421 (51.9%) participants and 694 (20.8%) were active smokers. Whilst no ASCVD was present in 1,612 (48.1%) participants, 1,134 (33.9%) and 602 (18.0%) individuals displayed atherosclerosis in 1 or ≥2 vascular beds, respectively. We found a stepwise increase of hsCRP levels with each incremental increase of modRF (median hsCRP for 0–4 modRF: 0.7, 0.9, 1.2, 1.5, 2.5 mg/L, respectively; p &amp;lt;0.05) and according to the number of vascular beds (median hsCRP for 0-≥2 vascular beds affected: 1.0, 1.1, 1.3 mg/L, respectively; p &amp;lt;0.05). The highest hsCRP concentration was found in individuals with atherosclerosis ≥2 beds and 4 modRF (Figure 1). In multivariable regression analyses, an independent association for increasing numbers of modRF with hsCRP levels across the extent of ASCVD was demonstrated (Table 1). Conclusion We demonstrate an increasing inflammatory burden according to the number of modRF and also with the presence and extent of ASCVD in a contemporary population-based cohort. These findings emphasize the important role of subclinical inflammation in the pathogenesis of ASCVD, and might be helpful for the definition of target populations for anti-inflammatory compounds across the extent of atherosclerotic disease.Figure 1Table 1

A Backing-Layer-Shared Miniature Dual-Frequency Ultrasound Probe for Intravascular Ultrasound Imaging: In Vitro and Ex Vivo Validations.

Intravascular ultrasound (IVUS) imaging has been extensively utilized to visualize atherosclerotic coronary artery diseases and to guide coronary interventions. To receive ultrasound signals within the vessel wall safely and effectively, miniaturized ultrasound transducers that meet the strict size constraints and have a simple manufacturing procedure are highly demanded. In this work, the first known IVUS probe that employs a backing-layer-shared dual-frequency structure and a single coaxial cable is introduced, featuring a small thickness and easy interconnection procedure. The dual-frequency transducer is designed to have center frequencies of 30 MHz and 80 MHz, and both have an aperture size of 0.5 mm × 0.5 mm. The total thickness of the dual-frequency transducer is less than 700 µm. In vitro phantom imaging and ex vivo porcine coronary artery imaging experiments are conducted. The low-frequency transducer achieves spatial resolutions of 40 µm axially and 321 µm laterally, while the high-frequency transducer exhibits axial and lateral resolutions of 17 µm and 247 µm, respectively. A bandpass filter is utilized to separate the ultrasound images. Combining in vitro phantom imaging analysis with ex vivo imaging validation, a comprehensive demonstration of the promising application of the proposed miniature ultrasound probe is established.

Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease

ObjectiveTo directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD. MethodsFrom 2017–2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke). ResultsOf 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively. ConclusionsPatients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.

Invasive imaging modalities in a spontaneous coronary artery dissection: when "believing is seeing".

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute coronary syndrome (ACS) with recent advancements in cardiac imaging facilitating its identification. However, SCAD is still often misdiagnosed due to the absence of angiographic hallmarks in a significant number of cases, highlighting the importance of meticulous interpretation of angiographic findings and, when necessary, additional usage of intravascular imaging to verify changes in arterial wall integrity and identify specific pathoanatomical features associated with SCAD. Accurate diagnosis of SCAD is crucial, as the optimal management strategies for patients with SCAD differ from those with atherosclerotic coronary disease. Current treatment strategies favor a conservative approach, wherein intervention is reserved for cases with persistent ischemia, patients with high-risk coronary anatomy, or patients with hemodynamic instability. In this paper, we provide a preview of invasive imaging modalities and classical angiographic and intravascular imaging hallmarks that may facilitate proper SCAD diagnosis.

Stroke-Heart Syndrome: Does Sex Matter?

Background Cardiovascular complications after acute ischemic stroke (AIS) can be related to chronic/comorbid cardiac conditions or acute disruption of the brain-heart autonomic axis (stroke-heart syndrome). Women are known to be more vulnerable to certain stress-induced cardiac complications, such as Takotsubo cardiomyopathy. We investigated sex differences in cardiac troponin (cTn) elevation, cardiac events, and outcomes after AIS. Methods and Results We retrospectively analyzed consecutive patients with AIS from 5 stroke centers. Patients with AIS with elevated baseline cTn and at least 2 cTn measurements were included, while patients with acute comorbid conditions that could impact cTn levels were excluded. Poststroke acute myocardial injury was defined as the presence of a dynamic cTn pattern (rise/fall >20% in serial measurements) in the absence of acute atherosclerotic coronary disease (type 1 myocardial infarction) or cardiac death (type 3 myocardial infarction). From a total cohort of 3789 patients with AIS, 300 patients were included in the study: 160 were women (53%). Women were older, had a lower burden of cardiovascular risk factors, and more frequently had cardioembolic stroke and right insula involvement (P values all <0.05). In multivariate analysis, women were more likely to have a dynamic cTn pattern (adjusted odds ratio, 2.1 [95% CI, 1.2-3.6]) and develop poststroke acute myocardial injury (adjusted odds ratio, 2.1 [95% CI, 1.1-3.8]). Patients with poststroke acute myocardial injury had higher 7-day mortality (adjusted odds ratio, 5.5 [95% CI, 1.2-24.4]). Conclusions In patients with AIS with elevated cTn at baseline, women are twice as likely to develop poststroke acute myocardial injury, and this is associated with higher risk of short-term mortality. Translational studies are needed to clarify mechanisms underlying sex differences in cardiac events and mortality in AIS.

Treatment effect of canagliflozin for patients on therapy for heart failure: Pooled analysis of the CANVAS program and CREDENCE trial

BackgroundCanagliflozin is a sodium–glucose cotransporter 2 inhibitor that has been shown to reduce cardiovascular events in diabetic patients with and without heart failure (HF). Whether the clinical benefits and safety profile of canagliflozin are different in those on a beta blocker and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (BB + RAASi) is unknown. MethodsWe pooled participants with HF at baseline from the CANVAS Program and CREDENCE trial and assessed major adverse cardiovascular events and its components; hospitalization for heart failure (HHF); HHF or CV death; all-cause mortality; a renal composite; and a combined renal and CV composite. ResultsOf 14,543 participants, 2113 had HF at baseline, and 1280 were on BB + RAASi. In those with a history of HF, participants on BB + RAASi therapy were more likely to have coronary atherosclerotic disease (82 vs 72%, p < 0.001), history of myocardial infarction (42 vs 29%, p < 0.001), higher mean body mass index (34 vs 32 kg/m2, p < 0.001), and lower mean estimated glomerular filtration rate (67 vs 70 mL/min/1.73 m2, p < 0.01). They were also more likely to be on insulin, a statin, antithrombotic agent, and a diuretic (all p < 0.001). In unadjusted analysis and when adjusted for selected baseline factors, there was no heterogeneity in canagliflozin treatment effect except for HHF/CV death in those on baseline BB + RAASi vs. those not on baseline BB + RAASi (Pheterogeneity = 0.02). ConclusionCanagliflozin mostly improved CV and kidney outcomes in participants with a history of HF irrespective of use of BB + RAASi at baseline, with possible greater benefit on HHF/CV death in participants on BB + RAASi.