Coronary Artery Disease Subgroup Research Articles

Adherence to guideline recommendations for antiarrhythmic drugs in atrial fibrillation

Atrial fibrillation (AF) guideline recommendations for antiarrhythmic drugs (AADs) are based on the effectiveness and safety of the AAD in patients with selected, concomitant heart disease. It is unknown to what extent these recommendations are being implemented in clinical practice. Using commercial health claims, patients with AF were identified and then categorized into mutually exclusive, guideline-established subgroups based on their most serious concurrent heart disease: heart failure, coronary artery disease (CAD), hypertension, and no heart disease. Antiarrhythmic drug use after the first AF encounter and the identified concurrent heart disease encounter was determined from prescription claims, and this was compared with guideline recommendations. From January 2006 through December 2010, a total of 331,274 patients with AF aged < 65 years were identified: 18%, heart failure; 23%, CAD; 33%, hypertension; and 25%, no heart disease. Of these, 78,877 (24%) patients filled ≥ 1 qualifying AAD prescription. The median age was 57 years (interquartile range 52-61), and 69% were male. A total of 74,191 patients had AADs after both the AF and concurrent heart disease encounters: 27% with heart failure, 25% with CAD, 21% with hypertension, and 19% with no heart disease. In the heart failure and CAD subgroups, 45% and 31% of AADs were inconsistent with first- or second-line guideline recommendations, respectively. More than one-third of the AADs used in patients with AF and CAD or heart failure did not conform to guideline recommendations. This highlights the potential need for increased clinician education and intervention to improve the safe use of AADs for AF management.

Glutathione peroxidase 1 (GPX1) single nucleotide polymorphism Pro198→Leu: Association with life span and coronary artery disease

In this study we genotyped polymorphism in GPX1 Pro198Leu (C > T) rs 1050450 in four groups: patients with coronary artery disease, long-livers - above 90 years, early died peoples (before 55 years) from cardiovascular diseases and Russian population as control group. We have found significant higher allele T frequency in men with coronary artery disease -34.84% (Chi2 = 5.228, p = 0.022; OR = 1.46) and in early died men from cardiovascular diseases--38.16% (Chi2 = 6.461, p = 0.011; OR = 1.69) compared with control men--26.8%. Moreover, significantly higher genotype TT frequency has been shown in patients with coronary artery disease and myocardial infarction before age 50--19.44% in comparison with control group--7.28% (Chi2 = 9.55, p = 0.002). The TT frequency in long-livers (4.39%) was the lowest and significantly different from coronary artery disease group--12.79% (Chi2 = 8.07, p = 0.0045) and from coronary artery disease subgroup with myocardial infarction before 50--19.44% (Chi2 = 14.49, p = 0.0001). Thus our results indicate that allele T (Leu) of GPX1 Pro198Leu (C > T) polymorphism is unfavorable for successful ageing. It predisposes to coronary heart disease, earlier myocardial infarction (before age 50) and earlier death (before age 55).

Abstract P209: Cardiovascular Medication Use Following Percutaneous Coronary Intervention: Results from the Melbourne Interventional Group Registry

Background: Aspirin, clopidogrel, angiotensin-converting-enzyme inhibitors (ACEi), angiotensin-receptor blockers (ARB), beta-blockers (BB) and statins are of proven benefit in most coronary artery disease subgroups and are guideline indicated. We aim to describe the use of these medications following PCI from 2005 to 2009. Melbourne Interventional Group (MIG) is a multi-center PCI registry in Melbourne, Australia. Methods: Patients undergoing PCI were prospectively enrolled between 1 st January 2005 and 31 st December 2009, representing 12582 PCI procedures. Follow-up at 30 days and 12 months was completed for 99.5% &amp; 91% of procedures respectively. We report the frequency of use of these medications at these time points. Results: Overall use of all 5 medications was high at both 30 days and 12 months. There was a steady increase in utilization of medication from 2005 to 2009 amongst all 5 medications, although the use of clopidogrel and BB increased the most. Utilization of all 5 medications from 30 days to 12 months was very good (see Table 1). Similar results were observed in the frequencies of total number of medications being taken, with very few patients reporting taking 0-3 medications at 30 days. At 12 months, 75.7% of patients were either taking 4 (37.6%) or 5 (38.1%) guideline-indicated medications. Table 1: Year Aspirin (%) Clopidogrel (%) BB (%) ACEi/ARB (%) Statin (%) 30 day 12 month 30 day 12 month 30 day 12 month 30 day 12 month 30 day 12 month 2005 95.6 91 89.9 57.6 65.5 59.8 75.6 74.4 91.5 91 2006 96.7 91.5 94.6 63.6 69.3 62.7 77.4 76.9 93.3 91.23 2007 97.1 92.8 96.3 64.1 73.8 68.6 79.3 78.2 94.1 92.5 2008 98.2 94.5 96.3 64.4 77.5 71.7 79.3 80.2 94.8 94 2009 98.8 95.9 96 71.1 78.9 72.7 79.1 77.2 95.7 93.9 Total 97.2 92.8 94.5 63.5 72.6 66.3 78.1 77.3 93.8 92.3 Conclusion: Overall use of these medications from 30 days through to 12 months was very good following PCI. The frequency of medication use across the years at follow-up post PCI is increasing

145 Syntax scores and real world revascularization patterns

The extent of coronary artery disease (CAD), defined by left main, single-, versus, double-, versus tripple-vessel disease (3VD), was the most influential factor associated with the choice of revascularization strategy [percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG)] in the Variation in Revascularization Practice in Ontario (VRPO) project (CCS 2010). Significant variation in revascularization strategies within CAD subgroups (i.e. multi-vessel disease) exist between centres. We hypothesized that variability in the complexity and severity of 3VD, as determined by the SYNTAX score, further contributes to the variation in revascularization pattern. The SYNTAX score-3VD angiographic sub-study of the VRPO project evaluated all 3VD coronary angiograms from the 1787 angiograms randomly selected from the 17 participating cardiac centers. Core lab assessment of the angiographic images was performed using the on-line SYNTAX score calculator. The primary objective was to demonstrate the mean and median SYNTAX scores as per the categorization of the 17 centres into PCI: CABG ratio groups (low <2, low-moderate 2-2.66, moderate-high 2.67-3.24, and high >3.24) in the VRPO study. Secondary objectives include the SYNTAX score's ability to predict the revascularization strategy within 90 days of the index angiogram and clinical outcomes (death and acute myocardial infarction, AMI) at 3 years. Syntax scores were calculated for all 203 3VD angiograms. There were no significant differences in the mean (median) SYNTAX scores across all 4 PCI: CABG ratio groups in the VRPO study [low: 26.3 (25.3), low-moderate: 25.9 (24.5), moderate-high: 25.7 (23.8), and high; 26.7 (26.0)]. However, the highest PCI:CABG group had the highest proportion of moderate and high SYNTAX scores (>22) (low: 62%, low-moderate: 57%, moderate-high: 53%, and high: 63%). Adjusted hazard ratio model demonstrates that the SYNTAX score predicts the revascularization strategy (PCI: HR 0.94, 95% CI 0.91-0.96 and CABG: 1.04, 95% CI 1.02-1.06). Furthermore, the SYNTAX score was associated with death but not AMI at 3 years (HR 1.03, 95% CI 1-1.07 and HR 1.01, 95% CI 0.96-1.06, respectively). While the SYNTAX score does predict the revascularization strategy, there are no significant differences in the mean and median SYNTAX scores between the 4 PCI:CABG ratio groups in the VRPO study. Furthermore, both high and low PCI:CABG ratio centres have the highest proportion of patients with complex anatomy. Therefore, the complexity and severity of 3VD does not seem to uniformly influence management strategies across all cardiac centres in Ontario.

A relationship between CRP, adiponectin and Gensini score in the patients with coronary artery disease

We aimed to evaluate serum adiponectin and C-reactive protein (CRP) levels in the different groups of patients with angiographically defined coronary artery disease (CAD). Overall 100 patients (80 males, 20 females) with CAD (≥ 50% stenosis) and 45 controls (25 males, 20 females) with normal coronary arteries were included in this cross-sectional observational study. Gensini score was used for evaluation of the severity of coronary lesions on the angiogram. A relationship between Gensini score and serum CRP and adiponectin levels was evaluated by a logistic regression analysis. Mean age of the patients (60.5±10.2 years) was significantly higher than of the controls (55.6±10.4 years, p=0.01). While serum adiponectin levels in CAD patients (2.1±1.2 µmg/dl) were significantly lower than in the controls (3.3±1.8 µmg/dl, p=0.01); serum CRP levels of the patients (2.8±1.5 mg/dl) were significantly higher than of the controls (0.9±0.4 mg/dl). Serum adiponectin and CRP levels were not significantly different between the CAD subgroups (p>0.05). Gensini score was related with serum CRP (odds ratio: 0.98, 95% CI: 1.05-1.35, p=0.01) and adiponectin levels (odds ratio: 1.15, 95% CI: 1.10-1.25, p=0.01) by a logistic regression analysis. While serum CRP levels are increased in CAD patients comparing with the controls; serum adiponectin levels are decreased significantly. Serum CRP and adiponectin levels are related to coronary lesions severity on the angiogram.

Prognostic significance of preprocedural troponin-I in patients with non-ST elevation acute coronary syndromes undergoing percutaneous coronary intervention

Cardiac troponin elevation has been shown to be associated with adverse outcomes after percutaneous coronary intervention (PCI) for various subgroups of coronary artery disease. We sought to determine the prognostic significance of cardiac troponin I (cTnI) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with PCI. The study consisted of 760 consecutive patients undergoing PCI for NSTE-ACS. Levels of cTnI were obtained repeatedly every 6 h before PCI. Peak cTnI levels were used for analysis. Patients were followed for major adverse cardiac events (MACE) defined as death, myocardial infarction, and urgent target vessel revascularization for a mean follow-up of 2.9 years. Patients with normal cTnI levels (<or=1.0 ng/ml) were classified into subgroup 1. The remaining patients were divided based on an optimal cut-off value derived from the receiver operating characteristic analysis into subgroups 2 (1.1-20 ng/ml) and 3 (>20 ng/ml). By multivariate analyses, patients with higher peak preprocedural cTnI levels were independently associated with increased risk of 30-day mortality [adjusted odds ratio, 1.88, 95% confidence interval (CI): 1.11-3.17, P=0.019] and composite MACE [group 1 vs. group 2 (adjusted hazard ratio 2.09, 95% CI: 1.35-3.23, P<0.001), group 1 vs. group 3 (adjusted hazard ratio 3.64, 95% CI: 2.39-5.56, P<0.001)]. Preprocedural cTnI level is a strong and independent predictor of 30-day mortality and long-term MACE after PCI in the setting of NSTE-ACS.

Clinical characteristics of coronary artery disease in patients with nonalcoholic fatty liver disease

Objective To analyze the clinical characteristics of coronary artery disease (CAD) in patients with nonalcoholic fatty liver disease ( NAFLD). Methods Totally 234 subjects underwent coronary angiography, including 148 men and 86 women with complete data on metabolic syndrome ( MS) and abdominal ultrasonography; the mean age was 66. 6 years. The severity of CAD was assessed by coronary stenosis index (CSI). Metabolic syndrome was diagnosed according to the Guideline on Prevention and Treatment of Blood lipid Abnormality in Chinese Adults. Results Ultrasonography revealed that 62 patients had NAFLD (26. 5%). In patients with NAFLD, the prevalence of central obesity was higher than those without NAFLD (75. 8% vs 50. 0% , P 0.05), however the age of patients in CAD & NAFLD subgroup was significantly lower compared to CAD subgroup ( P = 0.006). According to the results of logistic regression, central obesity was the independent risk factor of NAFLD (β= 1.701, P<0.001). Logistic regression demonstrated that age was independently associated with CAD (β = 0.032, P=0.027). Further more, multiple stepwise regression analysis showed that age was the single parameter that best predicted CSI score (β= 0. 125, P = 0. 022). Conclusions It is important to screen coronary artery disease in middle aged patients with central obesity or NAFLD. Key words: Nonalcoholic fatty liver disease; Coronary artery disease; Coronary angiography

Association between angiotensin II type-1 receptor A1166C polymorphism and the presence of angiographically-defined coronary artery disease in an Iranian population

Abstract Background: There are reported associations between a polymorphism of the angiotensin II type 1 receptor (AT1R/A1166C) gene and coronary artery disease (CAD), hypertension, and myocardial infarction in some populations. Objective: Investigate the association between A1166C polymorphism and CAD in an Iranian population. Methods: Four hundred and thirteen patients with suspected CAD were recruited. Based on coronary angiography, the patients were classified into CAD+ (n=315) and CAD- (n=98) groups defined as &gt;50% and &lt;50% stenosis of any major coronary artery, respectively. One hundred and thirty-five healthy subjects were also recruited as the control group. The AT1R polymorphism was assessed using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) based method. Results: A higher frequency of the AC and CC genotypes and lower frequency of the AA genotype was observed in both CAD+ and CAD- groups, compared with the control group (p &lt;0.05). CAD+ and CAD- groups also had a higher frequency of the C allele than controls (p &lt;0.01). There was no significant difference in genotype and allele frequencies between hypertensive and non-hypertensive patients (p &gt; 0.05). In addition, the AT1R genotype frequencies did not differ significantly among different subgroups of CAD+ patients, based on the number of affected coronary vessels (p &gt;0.05). Conclusion: The frequency AT1R/A1166C polymorphism was higher among patients with some degrees of coronary stenosis who are candidates of coronary angiography.

Datos al año de seguimiento del registro REACH en España

Atherothrombosis is one of the main causes of death worldwide. In Spain, as in other countries, this disease is a major public health problem, constituting a healthcare priority. The aim of the REduction of Atherothrombosis for Continued Health (REACH) registry is to analyze the long-term risk of atherothrombotic episodes in the at-risk population, evaluate the importance of cross risk, and define the prognostic factors of atherothrombotic episodes. More than 68,000 patients in more than 5,000 centers in 44 countries have been included in the REACH registry, of which 2,252 live in Spain. As observed internationally, in Spanish patients the complication rate at only 1-year of follow-up was high. The annual overall mortality rate in patients with established vascular disease or under primary prevention but with high atherothrombotic risk, represented by patients with risk factors only, was 3.57% and 1.98%, respectively, while that of cardiovascular mortality was 2.69% and 0.62%. In the subgroups of coronary artery disease (CAD), cerebral vascular disease (CVD) and peripheral artery disease (PAD) rates according to the affected territory were 3.47%, 2.78% and 1.46%, respectively. Involvement of more than one territory was clearly a poor prognostic factor: the annual complications rate increased according to whether 0, 1, 2, or 3 vascular beds were diseased for cardiovascular mortality (0.62%, 2.46%, 3.55% and 4.32%, respectively, p < 0.05) and for cardiovascular mortality, plus myocardial infarction, plus stroke, plus hospitalization for cardiovascular reasons these rates were 5.50%, 4.18%, 20.59% and 19.40%. Importantly, these patients have a poor prognosis even in the short-term, especially those with established vascular disease; furthermore, the greater the number of diseased vascular beds, the poorer the prognosis. This situation must therefore be improved by earlier identification of at-risk individuals and by optimizing both primary and secondary preventive measures.

Relationship between total and differential leukocyte counts and isolated coronary artery ectasia

Coronary artery ectasia (CAE) is a clinical entity characterized by localized or diffuse dilatation of more than or equal to 1.5 times that of the normal adjacent segments of vessels. Although the etiopathogenesis is not clearly understood, some studies have shown that CAE may be a form of atherosclerosis and has more potent inflammatory properties. Leukocytes have a crucial role in the development of inflammatory processes. We aimed to investigate a possible relationship between leukocytes and the coronary ectatic process without coronary artery disease (CAD) and to compare it with the inflammatory atherosclerotic process related to leukocytes. The study population consisted of 371 patients. We divided the patients into three groups: 42 patients with isolated CAE as group I, 279 patients with CAD as group II, and 50 control participants with normal coronary arteries (NCA) as group III. The counts of total leukocytes (7348+/-1898, 7569+/-1619, and 6770+/-1748 cells/mm, P=0.002), neutrophils (4260+/-2169, 4529+/-1380, and 4040+/-1649 cells/mm, P=0.037) and monocytes (630+/-216, 583+/-198, and 480+/-140 cells/mm, P<0.001) were significantly different among the CAE, CAD, and NCA groups, respectively. The CAE group also had significantly higher leukocyte and subtype counts than the nonobstructive CAD subgroup and NCA group. This study demonstrates that total and differential leukocyte counts, which play an important role in inflammation, are increased in patients with isolated CAE. In conclusion, this study's findings show that leukocytes may play an important role in the development of CAE independently of the atherosclerotic process.

RAS gene polymorphisms, classical risk factors and the advent of coronary artery disease in the Portuguese population

BackgroundSeveral polymorphisms within the renin-angiotensin system cluster of genes have been associated with the advent of coronary artery disease (CAD) or related pathologies. We investigated the distribution of 5 of these polymorphisms in order to find any association with CAD development and distinguish if any of the biochemical and behavioural factors interact with genetic polymorphisms in the advent of the disease.MethodsACE I/D (rs4340), ACE A11860G (rs4343), AT1R A1166C (rs5186), AGT T174M (rs4762) and AGT M235T (rs699) gene polymorphisms were PCR-RFLP analysed in 298 CAD patients and 510 controls from Portugal. Several biochemical and behavioural markers were obtained.ResultsACE I/D DD and ACE11860 GG genotypes are risk factors for CAD in this population. The simultaneous presence of ACE I/D I and ACE11860 A alleles corresponds to a significant trend towards a decrease in CAD incidence. We found several synergistic effects between the studied polymorphisms and classical risk factors such as hypertension, obesity, diabetes and dyslipidaemia: the presence of the DD genotype of ACE I/D (and also ACE11860 GG) increases the odds of developing CAD when associated to each one of these classical risk factors, particularly when considering the male and early onset CAD subgroup analysis; AGT235 TT also increases the CAD risk in the presence of hypertension and dyslipidaemia, and AT1R1166 interacts positively with hypertension, smoking and obesity.ConclusionACE polymorphisms were shown to play a major role in individual susceptibility to develop CAD. There is also a clear interaction between RAS predisposing genes and some biochemical/environmental risk factors in CAD onset, demonstrating a significant enhancement of classical markers particularly by ACE I/D and ACE11860.

RELATIONSHIP BETWEEN TOTAL AND DIFFERENTIAL LEUKOCYTE COUNTS AND ISOLATED CORONARY ARTERY ECTASIA

BACKGROUND: Coronary artery ectasia (CAE) is a clinical entity characterized by localized or diffuse dilatation of more than or equal to 1.5 times that of the normal adjacent segments of vessels. Although the etiopathogenesis is not clearly understood, some studies have shown that CAE may be a form of atherosclerosis and has more potent inflammatory properties. Leukocytes have a crucial role in the development of inflammatory processes. We aimed to investigate a possible relationship between leukocytes and the coronary ectatic process without coronary artery disease (CAD) and to compare it with the inflammatory atherosclerotic process related to leukocytes. METHODS AND RESULTS: The study population consisted of 371 patients. We divided the patients into three groups: 42 patients with isolated CAE as group I, 279 patients with CAD as group II, and 50 control participants with normal coronary arteries (NCA) as group III. The counts of total leukocytes (7348+/-1898, 7569+/-1619, and 6770+/-1748 cells/mm, P=0.002), neutrophils (4260+/-2169, 4529+/-1380, and 4040+/-1649 cells/mm, P=0.037) and monocytes (630+/-216, 583+/-198, and 480+/-140 cells/mm, P<0.001) were significantly different among the CAE, CAD, and NCA groups, respectively. The CAE group also had significantly higher leukocyte and subtype counts than the nonobstructive CAD subgroup and NCA group. CONCLUSION: This study demonstrates that total and differential leukocyte counts, which play an important role in inflammation, are increased in patients with isolated CAE. In conclusion, this study's findings show that leukocytes may play an important role in the development of CAE independently of the atherosclerotic process.

High triglyceride level is associated with severe coronary artery disease in hypertensive subjects

Background. The contribution of triglycerides (TG) to the extent of coronary artery disease (CAD) in hypertensive patients remained unclear. Methods. Consecutive 821 (aged 64.5±11.5 years, 482 males) hypertensive patients undergoing coronary angiography were included. The relationship of TG levels (<150 vs. ≥150 mg/dl) to the extent of CAD in all patients was examined by multiple logistic regression, adjusting for other CAD risk factors. In the lipid group, low levels of HDL were also adjusted. Results. Higher levels of TG were found in subjects with severe CAD compared to those with no or minimal CAD. The adjusted odds ratios for high levels of TG in the severe CAD subgroup versus the no or minimal CAD subgroup were 5.20 (95% CI, 3.13 to 8.63) in all patients and 7.51 (95% CI, 3.19 to 17.65) in the lipid group. Conclusions. High levels of TG are strong clinical markers of greater extent of CAD in hypertensive subjects undergoing coronary angiography. The results may have clinical relevance for physicians in therapeutic decision making.

Do allelic variants of the connexin37 1019 gene polymorphism differentially predict for coronary artery disease and myocardial infarction?

A C1019T polymorphism in the human connexin37 (hCx37) gene has been associated with cardiovascular risk, but it remains debatable whether the 1019C or the 1019T allele carries this risk. Here, we investigated whether these allelic variants are differentially predictive of increased risk for coronary artery disease (CAD) and myocardial infarction (MI). A total of 781 Swiss participants, including 597 patients diagnosed with CAD, 50% who reported previous MI, and 184 control subjects were genotyped. Patients in the +CAD group had a higher frequency of the Cx37-1019C allele (70.3% versus 65.0%, p = 0.004). Multivariate analysis showed that the hCx37-C1019T polymorphism is an independent predictor of CAD (odds ratio = 2.13, confidence interval = 1.31–3.46 and p < 0.01). Moreover, this polymorphism is not associated with any of the other characteristics examined, including gender, age, body-mass-index, diabetes, total/HDL/LDL-cholesterol, triglycerides, apoA-I, apoB, hypertension and cigarette smoking. In comparison with the −CAD group, we observed an increase of the Cx37-1019C allele in the +MI +CAD subgroup (71.2% versus 65.0%, p = 0.002) but not in the −MI +CAD subgroup. Allelic frequency comparisons of these three subgroups predicted that this polymorphism is also an independent risk factor for MI. In conclusion, our results reveal the importance of screening the Cx37-1019C allele for both CAD and MI risk assessments.

A Single Chinese Center Investigation of Renal Artery Stenosis in 141 Consecutive Cases with Coronary Angiography

Background: There is an increasing prevalence of ischemic nephropathy in the aging population of the world. However, the exact incidence of ischemic nephropathy in the Chinese population is still uncertain. The present study investigated the incidence of renal artery stenosis (RAS) in patients with suspected coronary artery disease (CAD) using renal angiography. Methods: Renal angiography was performed immediately after coronary artery angiography in 141 patients with suspected CAD, including 59 males and 82 females whose mean ages were 59 ± 10 years. Comorbidities included hypertension (n = 69), diabetes mellitus (n = 21), hyperlipidemia (n = 19), hypokalemia (n = 7) and preoperative renal insufficiency (Cr >132 µmol/l; n = 14). The patients were divided into CAD (luminal narrowing of ≧50%) and non-CAD (luminal narrowing of <50%) subgroups, and RAS (luminal narrowing of ≧50%) and non-RAS subgroups. In the RAS group, there were 11 patients (5 males, 6 females) in whom percutaneous transluminal renal angioplasty was performed in conjunction with stent implantation due to refractory hypertension. Results: The incidence of RAS was 18.4% (26/141) in all cases and 30.8% (16/52) in patients with CAD identified by coronary artery angiography. Ten cases with RAS were found among the 89 cases with normal coronary arteries (11.2%). The incidence of RAS in patients with CAD was higher than that in patients without CAD (30.8 vs. 11.2%, p< 0.05). In 52 cases with CAD, the incidence of RAS with three vessel lesions was significantly higher than that with one or two vessel lesions. Hypertension, CAD, renal insufficiency, hyperlipidemia and hypokalemia were associated with a higher risk of RAS. Conclusions: This study suggests that RAS is very common in the elderly Chinese population, specifically for those with three vessel lesions in CAD. For early detection of potential ischemic nephropathy, renal angiography is necessary in patients who receive coronary artery angiography.

Comparative Assessment of the Diagnostic Value of Neopterin and Acute Phase Proteins in Angiographically Assessed Stahle Coronary Artery Disease

Abstract Assessment of markers of systemic inflammation, such as acute-phase reactants C-reactive protein (CRP), fibrinogen and ceruloplasmin, sialic acid, a major component of these proteins and neopterin, a specific marker of cellular immune activation, in clinically stable coronary artery disease, may contribute to Staging and risk stratification. These markers were measured in 225 consecutive stable coronary artery disease patients before undergoing coronary angiography. According to their angiographic scores 32 patients were designated as having minor, 34 moderate and 96 severe coronary artery disease. 63 patients with negative angiograms were taken as the angiographic controls. High sensitive-CRP (hs-CRP) and fibrinogen were found to be higher in patients with angiographically established coronary artery disease, than in angiographic controls (p&lt;0.05) and correlated with the severity and extent of disease. Ceruloplasmin and sialic acid concentrations did not differ between patients with and without angiographically cstablished coronary artery disease. Serum neopterin levels were sigificantly higher in patients undergoing coronary angiography than in healthy controls. Neopterin levels were similar between the different subgroups of coronary artery disease, suggesting that neopterin determinations do not contribute to the assessment of the presence and severity of disease in clinically stable patients. In stable angina, serum hs-CRP and plasma fibrinogen levels proved to be more effective than ceruloplasmin, sialic acid and neopterin in discriminating between patients with positive and negative angiograms and various degrees of coronary artery disease, thus in pointing out to increased risk. Our results, do not support the inclusion of neopterin in risk assessment of stable coronary artery disease.

Prevalence and predictors of renal artery stenosis in patients undergoing cardiac catheterization.

Renal artery stenosis (RAS) is recognized as a major co-morbid condition for patients with cardiovascular disease. Although the prevalence of RAS in Western countries has been reported as 13.5-18% in patients with suspected coronary artery disease (CAD) undergoing coronary angiography, there is little information available about the prevalence of RAS in Asian populations, which are less susceptible to atherosclerosis. To evaluate the prevalence of RAS in Japanese patients suspected of cardiovascular disease and the relationships among RAS and vascular risk factors, especially hypertension, renal artery angiography was performed in a total of 289 consecutive patients receiving diagnostic cardiac catheterization. RAS with a stenosis diameter greater than 50% was considered significant. The prevalence of RAS was 21/289 (7%) including 18 (6%) cases of unilateral stenosis and 3 (1%) of bilateral stenosis. RAS accompanied 14/220 (6%) cases of CAD, 4/34 (12%) cases of valvular heart disease and 1/14 (7%) cases of cardiomyopathy. In the subgroups of CAD, the prevalence of RAS was 5%, 10%, 9%, and 19% in cases of 0, 1, 2 and 3-vessel disease, respectively. Hypertension was more frequent among patients with than among those without RAS (86% vs. 45%, p=0.0003). The prevalence of RAS was 13% in hypertensives and 2% in normotensives (p = 0.004). Thus RAS was frequent in patients with established CAD, and particularly in those with 3-vessel disease. Together, the results showed that hypertension was closely associated with RAS, appearing as both a risk factor and a possible clinical manifestation of the disease. We conclude that more attention should be paid to RAS in Japanese patients with hypertension and cardiovascular disease.

Risk of developing an acute myocardial infarction or sudden coronary death in patients with exercise-induced silent myocardial ischemia. A report from the coronary artery surgery study (CASS) registry

To evaluate whether patients with silent myocardial ischemia during exercise testing are at increased risk for developing a subsequent acute myocardial infarction or sudden death, the data on 424 such patients with proven coronary artery disease (CAD) from the Coronary Artery Surgery Study (CASS) registry were analyzed. These patients (group 1) were compared with 456 other patients with CAD (group 2) who had both ischemic ST depression and angina pectoris during exercise testing and with 1,019 control patients without CAD. The probability of remaining free of a subsequent acute myocardial infarction or sudden death at 7 years was 80 and 91%, respectively, for group 1, 82 and 93%, respectively, for group 2 (difference not significant, compared with group 1), and 98 and 99%, respectively, for the control patients (p < 0.001, compared with group 1 or 2). Among patients in group 1, the probability of remaining free of myocardial infarction and sudden death at 7 years was related to the severity of CAD and presence of left ventricular (LV) dysfunction, and ranged from 90% for patients with 1-vessel CAD and preserved LV function to 38% for patients with 3-vessel CAD and abnormal LV function (p < 0.001). Thus, patients with either silent or symptomatic ischemia during exercise testing have a similar risk of developing an acute myocardial infarction or sudden death—except in the 3-vessel CAD subgroup, where the risk is greater in silent ischemia. The risk of patients with silent myocardial ischemia is based primarily on angiographic variables.

Asynchronous segmental early relaxation of the left ventricle.

AbstractAsynchronous left ventricular segmental early relaxation (SER) is an angiographic finding with unclear pathophysiological mechanism. We analyzed 158 consecutive, technically adequate left ventricular cineangiograms of patients undergoing diagnostic cardiac catheterization. Patients with valvular disease, cardiomyopathy, or borderline coronary artery disease (50‐74% lumen diameter reduction) were excluded. The patients were divided according to the presence or absence of coronary artery disease, segmental early relaxation, and left ventricular asynergy. Significant coronary artery disease was detected in 127 patients (80%), segmental early relaxation in 63 (40%), and asynergy in 85 (54%).Forty‐five percent of patients with unobstructed arteries and 38% with significant coronary artery disease exhibited segmental early relaxation. Twenty‐nine percent of patients with coronary artery disease and no asynergy, had segmental early relaxation, while this phenomenon was present in patients with coronary artery disease and asynergy.Since coronary artery disease subgroups are difficult to compare in terms of left ventricular mechanics, two groups of normal patients, 15 with and 14 without segmental early relaxation, were further evaluated: Left ventricular pressure, heart rate, dPdT, left ventricular diastolic volume and wall thickness were not significantly different. Left ventricular end‐systolic volume index was 30.3 ± 4.6 ml/m2 in patients with segmental early relaxation and 22.5 ± 5.1 ml/m2 in those without segmental early relaxation (p &lt; 0.01), while peak wall stress was 332.4 ± 66.6 dynes/cm2 × 103 and 272.2 ± 47.1 dynes/cm2 × 103, respectively (p &lt; 0.02). A third group of patients with segmental early relaxation and coronary artery disease had a repeat left ventricular angiogram after nitroglycerin: Segmental early relaxation disappeared in 12 (group A) and persisted in 4 (group B). After nitroglycerin, end‐systolic volume index decreased by 22% ± 8% in group A and by 1% ± 8% in group B (p &lt; 0.005), while wall stress decreased by 24% ± 12% in group A and did not change in group B (p &lt; 0.01). We conclude that segmental early relaxation, is (1) a very common finding (40% of the entire group); (2) frequent among normals (48%); (3) not a reliable predictor of coronary artery disease; (4) appears to be directly related to end‐systolic volume index and wall stress; (5) disappears following nitroglycerin when this drug decreases end‐systolic volume index and wall stress.

Effect of sublingual nitroglycerin on regional flow in patients with and without coronary disease.

We evaluated the effects of sublingual nitroglycerin on indices of regional coronary flow and coronary resistance (CR) in 12 selected patients with coronary artery disease (CAD) and eight with normal coronary arteries (NCA), using continuous thermodilution. Resting total left ventricular flow, reflected by coronary sinus flow (CSF), and anterior regional flow, reflected by great cardiac vein flow (GCVF), in NCA and CAD patient groups, were similar. However, in a subgroup of six patients, with CAD limited to the anterior descending artery, GCVF was lower and anterior regional CR (CRANT) higher than the NCA subjects. Nitroglycerin reduced the systolic pressure-heart rate product similarly in both patient groups. CSF and GCVF in NCA subjects declined 15% and 17%, respectively, as total CR (CRT) and CRANT increased. In the CAD subgroup, consisting of patients with CAD limited to the anterior descending, GCVF increased 48% as CRANT declined 50%, and CSF was unchanged. In the other CAD subgroup of patients with CAD in the right and/or circumflex arteries, GCVF declined 32% and CRANT increased 46% as CSF was minimally increased. These data imply that sublingual nitroglycerin reduces both CSF and GCVF in NCA patients as oxygen demands decrease. In certain CAD patients, however, nitroglycerin alters regional coronary venous blood flow, suggesting a redistribution of flow from normally perfused to hypoperfused regions.