Clinical Presentation Of Coronary Artery Disease Research Articles

Alteration of circulating miRNAs during myocardial infarction and association with lipid levels.

Increasing mortality and morbidity of coronary artery disease (CAD) highlight the emerging need for novel noninvasive markers such as circulating microRNAs (miRNAs). To evaluate the circulating levels of miR-126-3p, miR-210-3p, let-7g-5p, and miR-326, and their associations with known contributors to CAD, in CAD subgroups. We divided the cohort into 4 groups: non-CAD controls (≤30% stenosis; n = 55), and patients with stable angina pectoris (SAP; n = 48), unstable AP (UAP; n = 46), and myocardial infarction (MI; n = 36). The circulating levels of miR-126-3p, miR-210-3p, let-7g-5p, and miR-326 were determined using TaqMan Advanced miRNA Assays in serum specimens. Circulating miR-126-3p levels were lower in the MI and UAP groups, compared with the non-CAD group, whereas miR-210-3p circulating levels were lower in the MI group than others. The levels of circulating let-7g-5p were shown to be useful for distinguishing UAP from MI, and there were substantial differences in circulating let-7g-5p levels between the UAP and MI groups. Moreover, lipid levels and ratios were lower in individuals with high circulating miR-126-3p and miR-210-3p levels. The study results suggest that circulating miR-126-3p, miR-210-3p, and let-7g-5p are differentiated between different clinical presentations of CAD and associated with lipid levels, which are important risk factors and determinants of CAD.

The effect of depressive disorder on the clinical presentation of coronary artery disease and five-year survival of patients after myocardial infarction

Aim. To assess the effect of depressive disorder (DD) on the clinical presentation of coronary artery disease (CAD) and five-year survival rate of patients with chronic CAD.Materials and methods. The study included 79 patients with functional class II–III exertional angina who experienced myocardial infarction more than 6 months before. The patients were divided into two groups: group 1 (n = 45) consisted of patients with CAD and depression and group 2 (n = 34) encompassed patients with CAD without depression. The clinical presentation of CAD was assessed by the results of filling out the angina pectoris self-control diary and exertion tests. The presence and severity of DD were determined using psychometric scales, such as Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI), and verified by the psychiatrist. Information about five-year survival was obtained via telephone interviews with the patients and their relatives.Results. Patients with CAD and DD were characterized by more frequent episodes of angina pectoris during a week (10 [8; 14] vs 6 [4; 7], p = 0.000004), an increased demand for nitroglycerin (4 [0; 10] tablets vs 0 [0; 4] tablets, p = 0.001), and lower exercise tolerance (50 [25; 75] W vs 75 [50; 75] W (p = 0.06), 350 [250; 400] meters vs 435 [350; 500] meters (p = 0.01) than CAD patients without DD. The five-year survival rate was significantly lower in group 1 than in group 2 (69 [62; 72] vs 71 [68; 72] months (p = 0.04)), 35 (77.8%) vs 32 (94.1%) patients survived. In group 1, a greater number of deaths from cardiovascular accidents (10 (22.2%) vs 2 (5.9%)) was noted (log-rank test, p = 0.03).Conclusion. In patients with CAD, associated depression results in aggravation of the clinical course of CAD and poor disease prognosis, which requires timely diagnosis and treatment of DD.

The Knowledge, Perception and Attitude of Year 1 Undergraduate Students in the Faculty of Medicine and Health Sciences (FMHS), Universiti Malaysia Sarawak (UNIMAS) on Coronary Artery Disease (CAD)

Coronary Artery Disease (CAD) is a cardiovascular disease where there is plaque buildup in the wall of the coronary artery, an artery that supplies the heart. This disease is also often referred to as coronary heart disease or ischemic heart disease. Globally, CAD has been known as the most common type of heart disease and the leading cause of death. In Malaysia, CAD is also known to be the leading cause of death. Hence, this study aims to determine the knowledge, attitude, and perception of CAD among the students of the University of Malaysia, Sarawak (UNIMAS). The minimum number of Year 1 FMHS students involved in this study was calculated by using Raosoft Sample Size Calculator software. A Google online form (self- administered questionnaire) that consisted of respondent’s characteristics, perception of CAD, knowledge on risk factors and clinical presentation of CAD, and attitude towards the preventive measure of CAD was used to collect the data of the students. The data collected was analyzed by using IBM SPSS Statistics software version 27 while the frequencies, means, standard deviation, and p-value were calculated to achieve the specific objectives of this study. According to the results, out of 200 respondents, most of the respondents were female (76.5%) and participation from medical students (66.5%) is more than the nursing students (33.5%). Overall, females have a better level of knowledge on CAD compared to males. Nursing students have a better level of attitude towards the preventive measure of CAD than medical students while medical students have a higher level of knowledge on other parts of the questionnaire compared to nursing students. There is a significant correlation between the perception of CAD, its risk factors, clinical presentation, and the attitude towards the preventive measure of CAD. Knowledge of CAD clinical presentation and preventive measures has a significant correlation with the gender of the respondents. Meanwhile, the knowledge of risk factors of CAD has a significant correlation with the courses of the students. However, the perception of CAD does not have a significant correlation with both gender and the courses of the students. Furthermore, the results obtained from the study may not represent the level of knowledge regarding CAD on a large scale. Therefore, more research regarding this issue should be conducted more often as it will help to give an even better overview of the level of knowledge about CAD and its association with the attitude on CAD preventive measures among the community.

Coronary Artery Disease in Women: A Comprehensive Appraisal.

Coronary artery disease (CAD) is a significant cause of illness and death amongst women. The pathophysiology, manifestations, and outcomes of CVD and CAD differ between sexes. These sex differences remain under-recognized. The aim of this review is to highlight and raise awareness of the burden and unique aspects of CAD in women. It details the unique pathophysiology of CAD in women, cardiovascular risk factors in women (both traditional and sex-specific), the clinical presentation of CAD in women, and the range of disease in obstructive and non-obstructive CAD in women.

Characterization of cholesterol efflux capacity in diabetic and non-diabetic patients with coronary artery disease: comparison between acute coronary syndrome and stable coronary artery disease

Abstract Introduction Type 2 diabetic patients more likely exhibit a lower high-density lipoprotein (HDL) level. Given a greater glycation and oxidative stress in diabetic subjects, these atherogenic characteristics could cause dysfunctional HDL including a reduced cholesterol efflux capacity (CEC), which may account for an increased risk of diabetic macrovascular disease including acute coronary syndrome (ACS). However, it remains to be fully elucidated characteristics of HDL-mediated CEC in type 2 diabetic patients, in association with clinical presentation of coronary artery disease (CAD). Purpose To characterize CEC in CAD subjects with type 2 diabetes mellitus. Methods The current study prospectively analyzed 87 statin-naive patients with CAD. CEC was measured by using the collected apolipoprotein B-depleted serum. Liquid scintillation counting (Perkin-Elmer Analytical Sciences, MA, US) was used to quantify the efflux of radioactive cholesterol from J774 cells. Clinical characteristics and CEC were compared in diabetic and non-diabetic subjects. Results The averaged HbA1c in diabetic patients was 6.7±1.2, and 66.7% of them achieved HbA1c <7.0%. Diabetic subjects more likely exhibited a history of hypertension and dyslipidemia, and multi-vessel disease (Table). Moreover, a lower CEC level was observed in diabetic patients, accompanied by a lower HDL-C and apolipoprotein A-I levels with a higher level of triglyceride (Table). HDL-C (r=0.62, p-value<0.01) and Apolipoprotein A-I (r=0.70, p-value <0.01) were associated with CEC, whereas there was no significant difference in CEC between subjects with HbA1c <7.0% vs. ≥7.0% (0.74±0.07 vs. 0.78±0.08, p=0.22). On multivariate analysis, type 2 diabetes mellitus was an independent contributor to CEC <0.79 (median) (HR=2.75, 95% CI: 1.11–6.82, p=0.03). Interestingly in particular, CEC was substantially lower in diabetic patients with ACS compared to those with stable CAD (Figure). By contrast, clinical presentation of CAD did not affect CEC in non-diabetic subjects (Figure). Conclusions A lower CEC level was observed in subjects with type 2 diabetes mellitus. In particular, this HDL functionality was profoundly diminished in those presenting ACS. Our findings suggest functionality of HDL as a potential therapeutic target in diabetic patients experiencing ACS. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1

Clinical Characteristics and Outcomes of Coronary Artery Disease among South Indian Women- A Retrospective Study

Introduction: The prevalence of Coronary Artery Disease (CAD) is increasing among Indian women and is the leading cause of death. Clinical presentation of CAD in women can widely vary from atypical chest pain, silent ischemia to massive myocardial infarction and death. Women have poor prognosis than men after myocardial infarction and are less likely to undergo revascularisation compared to men. Aim: To study the risk factors, clinical characteristics, severity of CAD and to evaluate the outcomes in women undergoing coronary angiogram. Materials and Methods: This retrospective study included 912 women who had undergone coronary angiogram in our hospital from January 2018 to December 2018. The patients were divided into three groups- Group A consisted of 230 (25%) women with age <50 years. Group B consisted of 591 (65%) women with age between 50 to 69 years. Group C consisted of 91 (10%) women with age >70 years. Continuous variables were analysed by paired t-test and categorical variables were analysed by chi-square test. Results: Most women were post menopausal (73.6%). Common risk factors were diabetes mellitus (63%) hypertension (56%), and hypothyroidism (16.8%). Out of the total study population, 51% (n=466) presented with a diagnosis of chronic stable angina, 34.7% (n=317) presented with acute coronary syndrome, and 7% (n=66) had atypical chest pain. Out of 500 patients with significant CAD, requiring revascularisation only 316 (63.2%) had undergone interventions out of which 193 (61%) had undergone percutaneous coronary intervention and 123 (39%) had undergone Coronary Artery Bypass Grafting (CABG) as the modality of revascularisation. conclusion: Clinical presentation of CAD in women varies widely from atypical chest pain to acute infarction. Diabetes and hypertension are the most common risk factors for CAD in our study. Chronic stable angina was the most common spectrum of presentation. Single vessel disease is the most common finding on coronary angiogram.

Clinical Risk Factors and Angiographic Pattern of Coronary Artery Disease in Young Females

Background: Coronary artery disease (CAD) is associated with the highest mortality in women around the world. The objective of this study was to compare the clinical risk factors and angiographic pattern of coronary artery disease in young versus old age females having CAD.Material and Methods: This cross-sectional study was conducted at the Department of Cardiology, Chaudhry Pervaiz Elahi (CPE) Institute of Cardiology Multan, Pakistan from April 2018 to December 2018. All females with diagnosis of angina and consistent ischemic changes on ECG were enrolled in the study. A total of 230 females were included with 123 patients aged <45 years and 107 patients aged >45 years. Comparison of patient characteristics, clinical risk factors and angiographic pattern in young and old age females was done by using SPSS version 21 statistical software.Results: Prevalence of hypertension (P=0.001), dyslipidemia (P=0.06) and diabetes mellitus (P=0.007) was significantly higher in females of older age group (>45 years). Similarly, a larger number of older age females (32; 29.9%) presented with ST-Elevation Myocardial Infarction (STEMI) as compared to young female patients (22; 17.88%) (P=0.03). Regarding angiographic patterns of CAD, there was no difference in the prevalence of single vessel disease (SVD), double vessel disease (DVD) and triple vessel disease (TVD) between the groups. Normal angiogram was found in 13 (12.3%) old age females versus 35 (28.8%) young females, respectively (P=0.002).Conclusions: The risk factors profile and clinical presentation of CAD is different in young female patients with CAD. There is an essential need to determine the coronary atherosclerosis factors in young females and these women should be treated more aggressively to prevent adverse cardio-vascular outcomes.Key words: Angiographic Pattern, Coronary Artery Disease, Clinical Pattern, Young Females

THE DEMOGRAPHIC PROFILE, CLINICAL PRESENTATION & ANGIOGRAPHIC PREVALENCE AND PATTERN OF CORONARY ARTERY DISEASE IN WOMEN UNDERGOING CORONARY ANGIOGRAPHY.

ABSTRACT Objectives: The aim was to define the demographic profile, clinical presentation and angiographic prevalence and pattern of coronary artery disease (CAD) in women undergoing coronary angiography. Data Sources: Medline databases ( Pub Med , Circulation, American Heart Journal, British Medical journal and Science Direct) and also materials available in the Internet. The search was performed in the electronic databases from 2013 to 2017. Study Selection: The initial search presented 150 articles of which 25 met the inclusion criteria. The articles studied the demographic Profile, clinical Presentation of CAD in women and also studied angiographic prevalence and pattern of CAD in women. Data Extraction: If the articles did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Data Synthesis: Comparisons were made by structured review with the results tabulated. Findings: In total 25 potentially relevant publications were included. The articles discussed the characteristics and risk factors attributed to CAD in Women, and also studied angiographic prevalence and pattern of CAD in women. Conclusion: cardiovascular risk factors are highly prevalent among women and the combination of risk factors is common. Interventions to minimize CAD in our population are needed. Key words: Coronary Artery Disease, Risk Factors, Chest Pain, Coronary Angiography, Women.

CORONARY ARTERY DISEASE AND THE IMPACT OF RHEUMATOID ARTHRITIS ON THE SEVERITY, TYPE OF PRESENTATION AND PREVALENCE

Rheumatoid arthritis (RA) is associated with an increased risk coronary artery disease (CAD) compared to general population. However, the effect of RA diseases on the severity and clinical presentation of CAD has not been well elucidated. A retrospective analysis of 8,978 patients presented to a

Impact of Type II Diabetes on the Presentation of Coronary Artery Disease and Outcomes of Percutaneous Coronary Intervention in Female Patients

Abstract Background Coronary artery disease (CAD) is a well-established complication of type II diabetes mellitus affecting both men and women worldwide. A vast amount of research has shown evidence of increased risk for CAD in patients with type II diabetes compared with the general population and that this increased relative risk is more prevalent in women. The primary aim of this study is to observe the impact of type II diabetes on the severity of CAD at the time of presentation and also on the outcomes of CAD after PCI (percutaneous coronary intervention) in female patients. Methods A prospective single-center study for the period of 1 year, including 267 female CAD patients who underwent PCI was conducted. The patient population was divided into two major groups of which 171 (64%) patients had type II diabetes (group A) and 96 (36%) patients were nondiabetic (group B). The clinical presentations of CAD in type II diabetics and nondiabetics were compared in the form of chronic stable angina (CSA), acute coronary syndrome (ACS), left ventricular (LV) dysfunction, renal dysfunction, and the number of vessels involved. Primary outcomes were compared in the form of major adverse cardiovascular events (MACE), whereas secondary outcomes were compared in the form of statin-induced myopathy, also referred to as contrast-induced nephropathy (CIN). Results At presentation, 60 (35.08%) of 171 female patients with type II diabetes (group A) had CSA and 121 (70.76%) had ACS. Baseline creatinine was determined to be 1.17 ± 1.02 mg/dL amongst the participants. Moreover, 51 (29.8%) patients were observed to have LV dysfunction. The total number of lesions treated in this group was 237. Among group B, that is, 96 nondiabetic female patients, 62 (64.5%) patients had CSA, 34 (35.4%) had ACS, 39 (40.6%) had LV dysfunction, the baseline creatinine was (0.95 ± 0.39) mg/dL. The total number of lesions treated was in this group was 130.The difference in incidence of CSA, ACS, and renal dysfunction was statistically significant with p = 0.000, 0.000, and 0.016, respectively. The incidence of CSA was greater in group B, that is, nondiabetics; whereas, the incidence of ACS and renal dysfunction was found to be greater in group A, that is, type II diabetics. Moreover, the number of vascular territories involved was found to be more in patients with type II diabetes. Although, the incidence of severe LV dysfunction was greater in patients with type II diabetes, the difference was not statistically significant.When considering 1 year outcomes in female patients with type II diabetes, three cases of deaths, one case of acute stent occlusion, one subacute stent occlusion, one periprocedural myocardial infarction (MI), one CSA, one statin-induce myopathy, and one rhabdomyolysis are reported. Whereas, in nondiabetic female patients, one case of death, one CSA, one CIN, one chronic thrombus right radial artery, and one pseudoaneurysm and rupture are reported. Conclusion The results from this study suggest that in female patients with CAD, ACS presentation is more common in type II diabetes; whereas, CSA presentation is more common in nondiabetics. Moreover, multi-vessel involvement is more common in type II diabetes. Following PCI, there has been an increase in the prevalence of MACE, statin-induced myopathy and rhabdomyolysis in patients with type II diabetes. In conclusion, type II diabetes has been reported to significantly influence the severity of presentation, number of lesions involved, and complications following PCI.

Recent Advances in Treatment of Coronary Artery Disease: Role of Science and Technology.

Coronary artery disease (CAD) is one of the most common causes of death worldwide. In the last decade, significant advancements in CAD treatment have been made. The existing treatment is medical, surgical or a combination of both depending on the extent, severity and clinical presentation of CAD. The collaboration between different science disciplines such as biotechnology and tissue engineering has led to the development of novel therapeutic strategies such as stem cells, nanotechnology, robotic surgery and other advancements (3-D printing and drugs). These treatment modalities show promising effects in managing CAD and associated conditions. Research on stem cells focuses on studying the potential for cardiac regeneration, while nanotechnology research investigates nano-drug delivery and percutaneous coronary interventions including stent modifications and coatings. This article aims to provide an update on the literature (in vitro, translational, animal and clinical) related to these novel strategies and to elucidate the rationale behind their potential treatment of CAD. Through the extensive and continued efforts of researchers and clinicians worldwide, these novel strategies hold the promise to be effective alternatives to existing treatment modalities.

Risk factor profile of coronary artery disease in black South Africans

Objectives: The aim of this study was to investigate the risk factor profile of coronary artery disease (CAD) in black South Africans. The study was motivated by the increased prevalence of CAD in South Africa, probably as a result of urbanisation. Despite this increase, however, very little is known regarding the cause, risk factor profile and clinical presentations of CAD in the black South African population. Design: A case control study was performed investigating 40 (33 men, 7 women) angiographically defined CAD patients and 20 (13 men and 7 women) age and body composition matched controls. Results: There was no difference in physical activity, sociodemographic factors or dietary intakes between the CAD and control group, except for the CAD patients consuming less vit C (40.9 vs 61.3 mg). The CAD group had significantly higher LDL-C, fasting glucose and CRP. There was also a significantly higher prevalence of smokers (35 vs 10%), hypertension (95 vs 75%) small dense LDL (73 vs 15%) and insulin resistance (M-value of 4.15 vs 12.5 mg/kg/min) in the CAD compared to the control group. In a logistic regression model, small dense LDL and insulin resistance were the main predictors of CAD. Conclusions: Black South African CAD patients had increased levels of the same risk factors that are typically seen in Caucasians with insulin resistance and small dense LDL being particularly significant in their contribution.

Abstract 12201: High-Density Lipoprotein Cholesterol Levels and Cardiovascular Outcomes in Japanese Patients After Percutaneous Coronary Intervention: A Report From the CREDO-Kyoto Registry Cohort-2

Background: Low levels of HDL-C is associated with increased coronary risks in patients without known coronary artery disease (CAD) and high risks of cardiovascular events in patients with stable CAD. But it is still controversial whether low HDL-C influences cardiovascular outcomes, especially in patients with known CAD receiving current optimized treatments. Objective: We determined whether low HDL-C is a risk factor for adverse cardiovascular events in patients with known CAD who underwent percutaneous coronary intervention (PCI). Methods: We evaluated 10,391 patients who underwent PCI from January 2005 to December 2007. In total, 3,838 (36.9%) patients had low HDL-C (HDL-C <40 mg/dL in males and <50 mg/dL in females) and 6,553 (63.1%) patients had normal HDL-C based on measurements on admission. Results: The unadjusted 5-year incidence of major adverse cardiac events (MACE: composite of cardiovascular death, myocardial infarction or stroke) was significantly higher in the low HDL-C group than in the normal HDL-C group (17.6% vs. 14.0%, P<0.0001). However, after adjusting for confounders, low HDL-C was not associated with a higher risk of MACE (adjusted hazard ratio [HR] 1.07, 95% confidence interval (CI) 0.97-1.19; P=0.19). There was no significant interaction between the effect of low HDL-C on MACE and several subgroup factors including age, sex, clinical presentation of CAD, statins use, serum low-density lipoprotein cholesterol level, and serum triglycerides level. Conclusions: Low HDL-C, as compared with normal HDL-C, was not associated with higher 5-year risk of MACE in patients who underwent PCI.

Difference of ruptured plaque morphology between asymptomatic coronary artery disease and non-ST elevation acute coronary syndrome patients: An optical coherence tomography study

BackgroundAutopsy studies have reported that rupture of a thin-cap fibroatheroma and subsequent thrombus formation is the major mechanism leading to acute coronary syndrome (ACS). However, it is not clear why only some plaque ruptures lead to ACS. Optical coherence tomography (OCT) is a high-resolution imaging modality which is capable of investigating detailed coronary plaque morphology in vivo. The objective of this study was to determine whether ruptured plaque morphology assessed by OCT differs between asymptomatic coronary artery disease (CAD) and non-ST elevation acute coronary syndrome (NSTEACS). MethodsWe examined ruptured plaque morphology using OCT in 80 patients, 33 with asymptomatic CAD and 47 with NSTEACS. ResultsThe frequency of lipid-rich plaque and intracoronary thrombus was significantly lower in asymptomatic CAD than in NSTEACS (61% vs. 85%, p = 0.013 and 9% vs. 83%, p < 0.001, respectively). Although maximal ruptured cavity cross-sectional area (CSA) was similar in both groups, lumen area at the rupture site and minimal lumen area were significantly larger in asymptomatic CAD than in NSTEACS (3.78 ± 1.50 mm2 vs. 2.70 ± 1.55 mm2, p = 0.003 and 2.75 ± 0.99 mm2 vs. 1.72 ± 0.90 mm2, p < 0.001, respectively). ConclusionsOCT revealed that the morphology of ruptured plaques differs between asymptomatic CAD and NSTEACS in terms of lumen area and the frequency of lipid-rich plaques and thrombi. These morphological features may be associated with the clinical presentation of CAD.

Hypoxia-inducible factor-1α polymorphisms link to coronary artery collateral development and clinical presentation of coronary artery disease

This study aimed to investigate the association of Hypoxia-inducible factor-1α (HIF-1α) C1772T and G1790A single nucleotide polymorphisms (SNPs) with: incidence, clinical type, severity of coronary atherosclerosis and coronary collaterals of coronary artery disease (CAD). The clinical data and genomic DNA were gathered in 958 subjects, including 560 controls and 398 patients with CAD. CAD was confirmed with coronary angiography (CAG). The genotypes for two SNPs were determined by high resolution melting after PCR amplification. Neither the HIF-1α C1772T nor the G1790A genotype was significantly associated with CAD and, no gene-gene or gene-environmental interactions were identified. However, both HIF-1α C1772T and G1790A (P<0.05) alleles were associated with clinical type and formation of coronary collaterals (P<0.05). Patients carrying genotype CT (P=0.019, OR=4.905,91, 95% CI: 1.355-17.761) and GA (P=0.026, OR=3.052, 95% CI: 1.180-7.892) had significantly higher stable angina pectoris (SAP) than unstable angina pectoris (UAP) and acute myocardial infarction (AMI). The presence of HIF-1 genotype CT (P=0.016, OR=13.373, 95% CI: 15.468-32.709) and GA (P=0.001, OR=19.741, 95% CI: 8.125-47.966) predicted lower collateral formation and severity of CAD secondary to the absence of collaterals (r=0.242, P<0.001). We conclude that functional polymorphisms in the HIF-1α gene do not modify CAD risk but they are associated with the formation of coronary collaterals and clinical presentation of CAD.

Parâmetros ecocardiográficos de deposição de gordura epicárdica e sua relação com doença arterial coronariana

Epicardial fat has been associated to the presence of significant coronary artery disease (CAD). However, the association of lipomatous infiltration of the atrial septum and fat infiltration of the right ventricle remains uncertain. None of these parameters has been thoroughly studied in Hispanic patients.To determine the association between epicardial fat, lipomatous infiltration of the atrial septum and fat infiltration of the right ventricle with the presence of CAD.Two hundred and fifty Hispanic patients (86 women and 164 men, mean age 61.5 ± 8 vs 62 ± 10 respectively), undergoing their first invasive coronary angiography (ICA) were studied. The day after the ICA, parameters of cardiac fat deposition were evaluated using 2D-echocardiography. Clinical (age, sex, personal antecedents of smoking habit, hypertension and diabetes mellitus, as well as clinical presentation of CAD) and anthropometric (waist circumference and body mass index [BMI]) variables were also collected.Epicardial fat (OR 1.27 p = 0.009), as well as fat infiltration of the right ventricle (OR 2.94 p = 0.027), had a significant and independent association with the presence, but not the extent (p = 0.516) and clinical presentation (p = 0.153) of CAD. The extent of epicardial fat deposition showed a proportional and significant association (p = 0.001) with the presence of CAD.Epicardial fat and fat infiltration of the right ventricle were both significant and independent factors associated to the presence of CAD, which was proportionally increased according to the extent of cardiac fat deposition.

Role of the CD14 C(−260)T promoter polymorphism in determining the first clinical manifestation of coronary artery disease

Acute coronary syndromes (ACS) and chronic stable angina represent extremes of the clinical spectrum of coronary artery disease (CAD). It is unknown whether genetic determinants affect the first clinical manifestation of CAD. We evaluated the role of the C(-260)T polymorphism in the promoter of the CD14-receptor gene, an important mediator of the inflammatory response to lipopolysaccharide. CD14 C(-260)T polymorphism was assessed in 100 patients with an acute presentation of CAD (group 1), 66 patients with stable presentation (group 2) and 88 healthy people (group 3); all patients were whites. In addition, baseline sCD14 plasma levels, and interleukin-6 production by circulating monocytes after in-vitro stimulation with lipopolysaccharide (1 ng/ml) were assessed. T/T homozygosis was more frequent in group 1 (36%, P < 0.001 versus others). Interleukin-6 production was higher in T/T homozygotes (median 4092.4; range 387-10 582 pg/ml) than in C/T heterozygotes (median 2442, range 40.5-9625 pg/ml, P < 0.001) and C/C homozygotes (median 3277.5; range 374.4-6250 pg/ml, P < 0.001). At multivariate analysis, T/T homozygosis and interleukin-6 production were independent predictors of acute presentation of CAD. The present study shows that genetic factors that influence the reactivity of inflammatory cells may play a role in determining the first clinical presentation of CAD.

Impact of coronary artery remodeling on clinical presentation of coronary artery disease: an intravascular ultrasound study

OBJECTIVESWe examined the association between the features of the culprit lesion in coronary artery disease (CAD) and clinical presentation as shown by intravascular ultrasound (IVUS).BACKGROUNDThe association between coronary remodeling pattern and clinical presentation of CAD is unclear.METHODSWe analyzed 125 selected patients who underwent preintervention IVUS. Acute myocardial infarction (AMI) and unstable angina pectoris (UAP) were categorized as an acute coronary syndrome (ACS), and stable angina pectoris (SAP) and old myocardial infarction (OMI) as stable CAD. Coronary remodeling patterns and plaque morphology of the culprit lesion obtained by IVUS were analyzed in terms of their association with clinical presentation or angiographic morphology.RESULTSAngiographically complex lesions were associated with ACS and OMI. In patients with a complex lesion, positive remodeling was observed more frequently than in those with a simple lesion. In AMI and UAP, positive remodeling was observed more frequently than in SAP and OMI (82% vs. 78% vs. 33% vs. 40%, respectively, p < 0.0001). The remodeling ratio was greater in AMI and UAP than in SAP and OMI (1.26 ± 0.15 vs. 1.11 ± 0.10 vs. 0.94 ± 0.11 vs. 0.96 ± 0.13, respectively, p < 0.0001). Furthermore, within ACS, the remodeling ratio was greater in AMI than in UAP (1.26 ± 0.15 vs. 1.11 ± 0.10, respectively, p < 0.05), whereas the frequency of positive remodeling was not different.CONCLUSIONSPositive remodeling was more frequently observed in ACS than in stable CAD. Moreover, the degree of positive remodeling was greater in AMI than in UAP. These results may reflect the impact of remodeling types and its degree in the culprit lesion of CAD on clinical presentation.

Noncardiac causes of angina-like chest pain

S INCE 1910, WHEN OSLER described a young man with a history of angina pectoris who was found not to have coronary artery disease (CAD) at autopsy, it has been recognized that angina1 chest pain may occur in the absence of significant atherosclerotic CAD.’ Angiographic studies have confirmed that the probability of CAD is higher in patients with chest pain typical of angina pectoris than in patients with less typical pain patterns.’ However, the prevalence of CAD among patients with atypical angina has varied considerably among different studies, and physicians demonstrate considerable variation in their classification of individual patients as having either typical or atypical patterns of angina-like pain.’ One reason for variations in the clinical presentation of CAD might be that common physiologic factors variably influence the development of angina in individual patients. These influential factors need to be appreciated lest a patient’s history of chest pain be inappropriately viewed as being inconsistent with myocardial ischemia. To be considered are the adequacy of warm-up,“ the relationship of physical activities to eating or exposure to cold,S-‘o smoking,“-‘6 variable thresholds to exertional angina,“-19 and the frequency of myocardial ischemic events that cannot be accounted for by increases in myocardial oxygen demand.20~2’ Nevertheless, CAD can be reliably excluded in most patients with chest pain, and therefore, clinicians must systematically consider noncardiac conditions when evaluating patients with chest pain in whom CAD has been excluded. There have been many recent published series of patients diagnosed as having angina pectoris but having minimally or nonobstructed coronary arteries by coronary arteriography (Table 1).2245 Typically, these reports have included minimal discussion of the means by which other noncardisc disorders capable of producing angina1 chest pain were excluded. It is apparent from these studies, however, that the exclusion of CAD in patients with angina1 pain is associated with a low risk of subsequent myocardial infarction or sudden death when compared with similar patients with CAD.23~25*28*3033”3934’45 Nevertheless, defining the absence of CAD without identification and appropriate treatment of the specific condition causing the chest pain does not adequately address a patient’s needs. Such patients often continue to have chest pain and repeatedly seek medical attention for it, resulting in recurrent outpatient visits and subsequent hospitalizations. They often continue to live in fear, believing that they have CAD despite negative diagnostic tests.34 Finally, physicians often treat these patients indefinitely with antianginal drugs despite telling them that they do not have CAD. 23V28734*35*36,4’,43 Although some of these individuals may have a myocardial ischemic disorder which, as yet, remains to be clearly defined, 26327*2973’~40*4648 others have noncardiac disorders capable of producing chest pain mimicking that caused by myocardial ischemia. Because recurrent angina1 pain can be caused by many different disorders, with prognoses ranging from benign to severe, it is essential that both cardiologists and primary care physicians have a strategy for further evaluation and management of patients in whom significant CAD and other causes of myocardial ischemia have been excluded. It is the purpose of this paper to review those disorders that might cause recurrent angina-like chest pain and substantial disabilities relating to employment and everyday living.