Coronary Artery Narrowing Research Articles

Can Carotid Bulb Plaque Assessment Rule Out Significant Coronary Artery Disease? A Comparison of Plaque Quantification by Two- and Three-Dimensional Ultrasound

Screening tools for the detection of coronary artery disease (CAD) are of considerable interest in light of skyrocketing risk factors. Recent work suggests that carotid plaque has a relatively unexplored role in CAD risk prediction but has previously been limited by the difficulty in quantifying its irregular architecture using two-dimensional (2D) ultrasound. The aim of this study was to investigate the utility of a novel automated three-dimensional (3D) ultrasound-based carotid plaque volume quantification technique as a negative predictor of CAD. In this prospective study, 70 consecutive patients referred for coronary angiography underwent same-day 2D and 3D carotid ultrasound scans for the purpose of plaque quantification in the carotid bulbs. Two-dimensional plaque thickness was measured in its maximal value perpendicular to the vessel wall. Total 3D plaque volume was quantified using a stacked-contour method. Luminal narrowing of coronary arteries was analyzed using the established 16-segment model for coronary arteries to produce an overall angiographic score. Receiver operating characteristic curves, negative predictive value, and sensitivity of 2D and 3D plaque quantification relative to coronary angiography were determined. The novel 3D carotid ultrasound method resulted in a higher negative predictive value and sensitivity relative to 2D carotid ultrasound at their optimal thresholds as determined by Youden indices of receiver operating characteristic curves. In particular, total 3D plaque volumes less than the threshold of 0.09 mL accurately predicted the absence of significant CAD in 93.3% of patients (98.0% sensitivity), whereas maximal 2D plaque thickness less than the threshold of 1.35 mm provided significantly lower negative predictability at 75% (93.9% sensitivity). Using the determined threshold of 0.09 mL for plaque volumes, this feasibility study suggests that automated 3D ultrasound-based carotid plaque quantification may serve as an important clinical screening tool to help identify patients who are at low risk for significant CAD.

Aggressive and diffuse coronary calcification in South Asian angina patients compared to Caucasians with similar risk factors

BackgroundEthnic differences in prevalence and severity of coronary artery disease are well established and are usually attributed to risk factors variation. This study investigates the differences in coronary artery narrowing and coronary calcification between two age- and gender-matched cohorts of South Asian and Caucasian symptomatic angina patients. MethodsWe identified 101 symptomatic angina patients of South Asian origin who had undergone CT angiography and calcium scoring, and compared them with 101 age and gender matched Caucasian patients. ResultsSouth Asians had a greater mean number of arterial segments with both obstructive and non-obstructive plaque than Caucasians (p=0.006 and p=0.0003, respectively) and higher prevalence of triple-vessel disease (p=0.0004). Similarly, South Asians had a higher mean CAC score (p<0.0001) and the percentage of South Asians with CAC>0 and in all categories of CAC score 100–1000 were also higher, as was the number of arterial segments with calcified and non-calcified plaque. These results were more marked in patients aged >50 but in those ≤50, Caucasians showed a higher mean number of diseased segments (p=0.019), with non-obstructive plaque (p=0.02), possibly suggesting that Caucasians are likely to have more diffuse atherosclerosis at an earlier age. CAC prevalence and severity in this age-group were not significantly different between South Asians and Caucasians. ConclusionDespite similar conventional risk factors for CAD, symptomatic South Asians seem to have more aggressive and diffuse arterial calcification compared to Caucasians. These differences are more profound above the age of 50, suggesting potential genetic or other risk factors yet to be determined.

The Complementary Roles of Radionuclide Myocardial Perfusion Imaging and Cardiac Computed Tomography

Despite recent dramatic advances in managing patients with cardiovascular disease (CVD), it still accounts for more deaths in the United States than any other medical condition. American Heart Association Statistics show that CVD accounts for 33.6% deaths, 1 every 39 seconds. 1 Costs are estimated at $286 billion, more than the cost of cancer. Given its large burden, the need for assessing CVD in an accurate, safe, and cost-effective manner is great. Noninvasive imaging has been the primary modality to effectively diagnose coronary artery disease (CAD) and, more importantly, risk stratify patients by separating low-risk patients who can be treated conservatively from those at high risk who need more aggressive management. Imaging can also be used to monitor disease progression, direct further evaluation, and guide changes in treatment. Although there is overlap, some noninvasive imaging modalities focus on cardiac physiology/function, whereas others focus on anatomy. Functional imaging consists mainly of techniques that detect physiologically significant coronary artery narrowings. Stress single-photon emission computed tomography (SPECT) radionuclide myocardial perfusion imaging (MPI) and stress echocardiography are most widely used for this purpose, although perfusion techniques with computed tomography (CT) and magnetic resonance imaging are under investigation. 2 In particular, stress MPI can accurately diagnose CAD, measure left ventricular (LV) function, risk stratify patients, and assess myocardial viability in situations of LV dysfunction. MPI, most often using singlephoton‐emitting radiotracers, is widely used and cost-effective, and its utility is supported by a large body of literature. New technology and techniques promise to overcome current limitations of MPI. In addition, CVD is more than CAD, and nuclear imaging shows promise for evaluating myocardial disease in the setting of congestive heart failure (CHF). Anatomic imaging of CAD focuses on visualization of the epicardial coronary arteries and perfused myocardium. One can quantify coronary artery calcium (CAC) reflecting disease extent, or directly visualize coronary lumens and plaque using CT angiography. Many investigators are also exploring approaches that combine functional and anatomical evaluation,eitherinsequenceorinonesetting(ie,hybridimaging), to give a more complete cardiovascular evaluation and help overcome the limitations of each modality. Hybrid imaging may be particularly useful for identifying culprit lesions, for coronary plaque imaging and in CHF. This review will examine the strengths and weaknesses of radionuclide MPI and CT imaging techniques, and explore how they provide complementary information. Throughout, one must consider that the choice of diagnostic modality should rely on not only availability and effectiveness but also each patient’s unique clinical presentation.

Coronary Artery Bypass Grafting in Patients with Intracoronary Stent Related Complications

Intracoronary stenting is an established modality of treatment to relieve narrowing of coronary arteries. Increasing use of stenting is bringing to light new complications. Here we present our experience with a newly emerging indication for surgical intervention for cardiac surgeons. This new indication is complications arising from intracoronary stents. Very little is available in the existing literature to guide the surgeon. We explain our rationale in doing things with two of our cases. DOI: http://dx.doi.org/10.3329/uhj.v7i1.10213 UHJ 2011; 7(1): 56-58

Coronary Vasospasm Induced in Transgenic Mouse With Increased Phospholipase C-δ1 Activity

We reported that phospholipase C (PLC)-δ1 activity was enhanced 3-fold in patients with coronary spastic angina. We detected variant PLC-δ1 with replacement of arginine 257 by histidine (R257H) showing increased enzymatic activity. We tested the hypothesis that increased PLC-δ1 activity causes enhanced coronary vasomotility. We generated transgenic (TG) mice with human R257H variant PLC-δ1 in vascular smooth muscle cells. PLC enzymatic activity in the coronary artery was increased by 2.57 and 1.89 times, respectively, in homozygous and heterozygous TG compared with wild-type (WT) mice. ST elevation after ergometrine occurred in 17 of 18 homozygous TG, 6 of 20 heterozygous TG, and 3 of 22 WT mice (P<0.01, homozygous TG versus WT; P<0.05, homozygous TG versus heterozygous TG; P=NS, heterozygous TG versus WT). ST elevation was associated with bradyarrhythmias in homozygous TG mice. Focal coronary artery narrowing was documented with the microvascular filling technique in 3 of 5 homozygous TG mice after ergometrine but not in any of 7 WT mice (P<0.05). In the isolated Langendorff hearts, coronary perfusion pressure was increased after ergometrine in homozygous TG mice (P<0.01) but not in heterozygous TG or WT mice. Coronary perfusion pressure increase after prostaglandin F2α was similar among homozygous TG, heterozygous TG, and WT mice. Cultured rat aortic smooth muscle cells transfected with variant PLC-δ1 showed a higher PLC activity than those with WT PLC-δ1 (P<0.05) and furthermore showed greater intracellular Ca2+ response to acetylcholine in variant than in WT PLC-δ1 (P<0.05). Increased PLC-δ1 activity enhances coronary vasomotility such as that seen in patients with coronary spastic angina.

Left bundle branch block, an old-new entity.

Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. LBBB may be the first manifestation of a more diffuse myocardial disease. The typical surface ECG feature of LBBB is a prolongation of QRS above 0.11 s in combination with a delay of the intrinsic deflection in leads V5 and V6 of more than 60 ms and no septal q waves in leads I, V5, and V6 due to the abnormal septal activation from right to left. LBBB may induce abnormalities in left ventricular performance due to abnormal asynchronous contraction patterns which can be compensated by biventricular pacing (resynchronization therapy). Asynchronous electrical activation of the ventricles causes regional differences in workload which may lead to asymmetric hypertrophy and left ventricular dilatation, especially due to increased wall mass in late-activated regions, which may aggravate preexisting left ventricular pumping performance or even induce it. Of special interest are patients with LBBB and normal left ventricular dimensions and normal ejection fraction at rest but who may present with an abnormal increase in pulmonary artery pressure during exercise, production of lactate during high-rate pacing, signs of ischemia on myocardial scintigrams (but no coronary artery narrowing), and abnormal ultrastructural findings on myocardial biopsy. For this entity, the term latent cardiomyopathy had been suggested previously.

Relation of Impaired Coronary Microcirculation to Increased Urine Albumin Excretion in Patients With Systemic Hypertension and No Epicardial Coronary Arterial Narrowing

Coronary flow reserve (CFR) is impaired and urinary albumin excretion is increased in patients with essential hypertension. Our aim was to investigate the associations between CFR and cardiac and renal damage in hypertensives. For this purpose we studied 37 never-treated hypertensives (57.9 years old, 16 men) without chest pain but with a positive ischemia stress test result and normal coronary arteries on coronary angiogram. CFR was calculated by a 0.014-inch Doppler guidewire (Flowire, Volcano, San Diego) in the left anterior descending artery in response to bolus intracoronary administration of adenosine (60 μg) as the ratio of hyperemic to basal average peak velocity of the distal vessel. All participants underwent complete echocardiographic study including left ventricular diastolic function evaluation by tissue Doppler imaging (peak early diastolic velocity/peak atrial systolic velocity) and determination of the albumin-to-creatinine ratio (ACR). Hypertensives with low CFR (<2.5, n = 22) compared to those with high CFR (n = 15) exhibited a larger left ventricular mass index by 10.9 g/m(2) (p = 0.045) and ACR values by 10 mg/g (p <0.001). CFR was negatively correlated with logACR (r = -0.511, p = 0.001). LogACR (beta -0.792, p <0.001), male gender (beta 0.313, p = 0.005), left ventricular mass index (beta -0.329, p = 0.007), and peak early diastolic velocity/peak atrial systolic velocity (beta 0.443, p <0.001) were the only independent predictors of CFR in linear regression analysis (adjusted R(2) = 0.672). In conclusion, never-treated asymptomatic hypertensives who exhibit impaired CFR and angiographically normal epicardial arteries are characterized by intrarenal vascular damage as reflected by increased ACR. These findings suggest a plausible role of ACR estimation in the identification of hypertensive subjects with early coronary microvascular dysfunction.

Abstract 9277: Assessment of Coronary Flow Reserve for the Prediction of Long-Term Outcome in Patients with Non-Obstructive Coronary Artery Disease; Transthoracic Doppler Echocardiographic Study

Introduction . Coronary flow reserve (CFR) is dependent on microvascular blood flow which reflects the combined effects of the epicardial coronary stenosis and microvascular dysfunction. Various coronary risk factors cause impaired CFR, even in the absence of obstructive coronary artery narrowing. However, its prognostic importance for long-term outcome has not been fully discussed. Methods . 272 patients (181 men, mean age 68 ± 12 years) with known or suspected coronary artery disease underwent transthoracic Doppler echocardiographic examination for the assessment of CFR in left anterior descending (LAD) artery. Angiolography revealed non-obstructive narrowing of LAD (&lt;70%) in these patients. The cardiovascular events included cardiac death, myocardial infarction, unstable angina pectoris, and congestive heart failure. Results . During a mean follow-up of 4.0 ± 1.9 years, cardiovascular events occurred in 32 patients, including cardiac death (n = 5), myocardial infarction (n = 6) and unstable angina (n = 9), congestive heart failure (n = 12). Multivariate analysis identified hemoglobin (p = 0.02), left ventricular mass index (p = 0.02), C-reactive protein (p = 0.01), and CFR (p &lt;0.001) as significant and independent predictors of cardiovascular events. The ROC curve provided CFR &lt;2.3 as the best cut-off value predicting late cardiovascular events (sensitivity was 0.82 and specificity was 0.69). No cardiovascular events occurred in patients with CFR ≥4.0. Conclusions. We demonstrated that the measurement of CFR provided independent prognostic information in patients without obstructive narrowing of LAD. Close follow-up and strict control of coronary risk factors may be required in patients with CFR &lt;2.3, even without obstructive narrowing of coronary arteries.

Coronary Artery Spasm After Cryo Maze III Procedure

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines.

Periodontitis is associated with angiographically verified coronary artery disease

We investigated the association of periodontitis and severity of coronary artery disease (CAD) as verified using coronary angiography. Participants were recruited among those attending coronary angiography at Helsinki University Central Hospital, Finland, in 2007 and 2008. Detailed clinical periodontal examination [number of teeth, bleeding on probing, periodontal probing depth (PPD)] and oral panoramic radiographs [alveolar bone loss (ABL), angular bone defects] were performed. Of 506 patients, 123 (24.3%) had no significant CAD, whereas 184 (36.4%) had stable CAD and 169 (33.4%) acute coronary syndrome (ACS). Both stable CAD and ACS were associated with 8-17 missing teeth with ORs 4.33 (1.61-11.7, p=0.020) and 5.24 (1.90-14.5, p=0.014), and more than seven teeth with PPD ≥6mm with ORs 2.44 (1.01-6.07, p=0.049) and 2.75 (1.16-6.53, p=0.022) respectively. Severe ABL was associated with ACS with an OR 5.39 (1.23-23.6, p=0.025). Number of stenosed arteries was linearly associated with ABL (p for trend <0.001), number of missing teeth (p<0.001), and pockets with probing depth ≥6mm (p=0.033). Compared with patients with no significant stenosis, poor periodontal health including missing teeth, periodontal inflammation, and bone loss is associated with angiographically verified coronary artery narrowing in patients with stable CAD or ACS.

Tryptase levels in coronary syndromes and in hypersensitivity episodes: A common pathway towards Kounis syndrome

Evidence exists today, that the same mediators released from imilar cells such mast cells are present in both acute coroary events and acute hypersensitivity episodes [1]. It seems ikely that a common pathway exists between the hypersensiivity coronary syndrome the so called Kounis syndrome [2] and on-hypersensitivity coronary syndromes [3]. One of these comon mediators is the mast cell derived specific neutral protease ryptase. In the very important paper, concerning 270 Chinese patients, ublished in this Journal [4] it was found that serum tryptase evels were significantly higher in patients with substantial coroary heart disease including unstable angina and acute myocardial nfarction than in patients with unsubstantial disease namely atients with less than 50% or without luminal narrowing of the ain coronary arteries. The authors of this report suggested that ryptase and the brother protease chymase are important indepenent biomarkers for atherosclerotic plaque vulnerability. Although n this cohort, patients with any kind of autoimmunity, allergic iseases, cancer, and renal failure were correctly excluded other atients with conditions known to have also elevated baseline erum tryptase levels [5] such as mastocytosis, refractory aneias, myelodysplastic syndromes, hypereosinophilic syndrome, nd patients receiving recombinant human stem cell factor should ad been excluded also. However, several other studies have also shown that elevated ryptase levels are present during acute coronary syndromes and

Diverse morphologic manifestations of cardiac allograft vasculopathy: A pathologic study of 64 allograft hearts

Cardiac allograft vasculopathy (CAV) is a major limitation to the long-term success of cardiac transplantation. Although there are published descriptions of the lesions, there have been no studies delineating the pathology of CAV in a large series of patients who underwent retransplantation for CAV. We reviewed archival records and microscopic sections of surgically explanted hearts from 64 patients who underwent cardiac retransplantation: 54 adults (18 to 70 years old) and 10 children (3 to 15 years old). Vascular lesions were categorized as showing intimal fibromuscular hyperplasia, atherosclerosis and/or inflammation. The degree of luminal narrowing was estimated from gross descriptions and microscopic sections. In total, 75% of hearts had evidence of acute cellular rejection, mostly mild. Intramyocardial arteries showed primarily intimal fibromuscular hyperplasia and inflammation with no atheromas present. Large and branch epicardial coronary arteries were narrowed in at least one artery of all hearts. Lesions in the epicardial coronary arteries were composed of intimal fibromuscular hyperplasia, atherosclerosis and/or inflammation affecting one or more vascular layers (intima, media and adventitia). Severe CAV with >75% luminal narrowing was seen in the LAD in 17% of hearts, the LCx in 17% and the RCA in 22% of hearts. Two hearts had severe narrowing of the left main coronary artery. Nineteen arteries had luminal thrombi. All hearts had narrowing of smaller epicardial branch coronary arteries that was often severe. Atheromas were present in arteries of adults and children; thus, not all atheromas could be considered pre-existing prior to transplantation. Both arteries and veins showed intimal hyperplasia and inflammation. CAV is a pathologically multifaceted disorder that affects large and small epicardial coronary arteries of adults and children, with different types of lesions: intimal fibromuscular hyperplasia; atherosclerosis; and/or inflammation (vasculitis). Therapies to address this disease must take into account the protean nature of the vascular lesions.

Fatal Coronary Artery Disease in an Infant With Severe Mucopolysaccharidosis Type I

A previously healthy 10-month-old boy was referred to our hospital because of coarse facial features that were suggestive of lysosomal storage disease. Apart from noisy respiration, there was no medical history. Elevated levels of urinary glycosaminoglycans and complete deficiency of leukocyte α-l-iduronidase indicated severe mucopolysaccharidosis type I. A chest radiograph revealed a markedly enlarged heart, and echocardiography revealed hypertrophic cardiomyopathy. While hematopoietic stem cell transplantation was being planned, progressive cardiac failure developed with a striking hypokinesia of the left-ventricle free wall. In combination with ischemic changes on the electrocardiogram, this was suggestive of coronary artery disease. Results of coronary echo Doppler interrogation were inconclusive, and intravascular ultrasound in this little infant was not feasible. Despite the patient's small size, a successful selective coronary angiography was performed and revealed diffuse narrowing of the left coronary artery with collateral flow from the right coronary artery. Enzyme-replacement therapy was started immediately in an attempt to improve myocardial performance. Evaluation after 3 months, however, revealed complete obliteration of the left coronary main stem with diffuse hypokinesia/akinesia of the left ventricle. At the age of 13 months the boy died of terminal cardiac failure. This case report illustrates the importance of considering early development of coronary artery disease in children with severe mucopolysaccharidosis type I and cardiomyopathy.

Relation of Albuminuria to Angiographically Determined Coronary Arterial Narrowing in Patients With and Without Type 2 Diabetes Mellitus and Stable or Suspected Coronary Artery Disease

Albuminuria is associated with atherothrombotic events and all-cause mortality in patients with and without diabetes. However, it is not known whether albuminuria is associated with atherosclerosis per se in the same manner. The present study included 914 consecutive white patients who had been referred for coronary angiography for the evaluation of established or suspected stable coronary artery disease (CAD). Albuminuria was defined as a urinary albumin/creatinine ratio ≥ 30 μg/mg. Microalbuminuria was defined as 30 to 300 μg albumin/mg creatinine, and macroalbuminuria as a urinary albumin/creatinine ratio of ≥ 300 μg/mg. The prevalence of stenoses of ≥ 50% was significantly greater in patients with albuminuria than in those with normoalbuminuria (66% vs 51%; p <0.001). Logistic regression analysis, adjusted for age, gender, diabetes, smoking, hypertension, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, C-reactive protein, body mass index, estimated glomerular filtration rate, and the use of angiotensin-converting enzyme inhibitors/angiotensin II antagonists, aspirin, and statins, confirmed that albuminuria was significantly associated with stenoses ≥ 50% (standardized adjusted odds ratio [OR] 1.68, 95% confidence interval [CI] 1.15 to 2.44; p = 0.007). The adjusted OR was 1.54 (95% CI 1.03 to 2.30; p = 0.034) for microalbuminuria and 2.55 (95% CI 1.14 to 5.72; p = 0.023) for macroalbuminuria. This association was significant in the subgroup of patients with type 2 diabetes (OR 1.66, 95% CI 1.01 to 2.74; p = 0.045) and in those without diabetes (OR 1.42, 95% CI 1.05 to 1.92; p = 0.023). An interaction term urinary albumin/creatinine ratio*diabetes was not significant (p = 0.579). In conclusion, micro- and macroalbuminuria were strongly associated with angiographically determined coronary atherosclerosis in both patients with and those without type 2 diabetes mellitus, independent of conventional cardiovascular risk factors and the estimated glomerular filtration rate.

The favourable effect of Helicobacter pylori eradication therapy in patients with recurrent angina-like chest pain and non-responsive to proton pump inhibitors – a preliminary study

IntroductionThe outcome of Helicobacter pylori (Hp) eradication therapy from the aspect of prevention of chest pain recurrence is still uncertain. The aim of this study was to assess the influence of Hp eradication therapy on the risk of hospitalization due to acute coronary syndrome.Material and methodsThe analysis was carried out in 63 consecutive patients with recurrent retrosternal symptoms: 28 (44%) with significant coronary artery narrowing in coronarography not qualified for revascularization by an invasive cardiologist, and 35 (56%) with no obstructive coronary artery lesions. In 33 (52%) of the patients, Hp infection was found and standard eradication therapy with omeprazole (2 × 20 mg), amoxicillin (2 × 1 g) and metronidazole (2 × 500 mg) was recommended. The mean follow-up period was 977 ±249 days.ResultsChest pain requiring hospitalization because of unstable angina within the follow-up period was observed in 9 (27%) of the Hp-infected individuals and in 15 (50%) subjects in whom a urease test and histology did not confirm this infection (p = 0.055). The recommendation of Hp-eradication treatment was a significant factor prolonging the hospitalization-free period, both in the two Kaplan-Meier curve analyses (Cox’s F test = 1.96; p = 0.049) and the Cox proportional hazard model (beta = –1.18; p = 0.045), but was weaker than the effect of the non-obstructive coronary angiogram (beta = –1.45; p = 0.03).ConclusionsThe recommendation of Hp-eradication therapy may prolong the hospitalization-free period for patients with recurrent chest pain.

Relation of Albuminuria to Angiographically Determined Coronary Arterial Narrowing in Patients With and Without Type 2 Diabetes Mellitus and Stable or Suspected Coronary Artery Disease

Relation of Albuminuria to Angiographically Determined Coronary Arterial Narrowing in Patients With and Without Type 2 Diabetes Mellitus and Stable or Suspected Coronary Artery Disease

Relation of Albuminuria to Angiographically Determined Coronary Arterial Narrowing in Patients With and Without Type 2 Diabetes Mellitus and Stable or Suspected Coronary Artery Disease

Relation of Albuminuria to Angiographically Determined Coronary Arterial Narrowing in Patients With and Without Type 2 Diabetes Mellitus and Stable or Suspected Coronary Artery Disease

Does esophageal dysfunction affect the course of treadmill stress test in patients with recurrent angina-like chest pain?

cardioesophageal reflex may increase severity of chest pain and signs of myocardial ischemia on electrocardiogram (ECG), both in patients with and without significant coronary artery stenosis. the aim of the study was to evaluate the relationships between esophageal pH and pressure and clinical and electrocardiographic signs of myocardial ischemia. in 129 consecutive patients with recurrent chest pain, 77 without significant coronary artery lesions in coronary angiography and 52 with myocardial ischemia, panendoscopy, pH-metry, manometry, and treadmill stress test were performed. The prevalence of esophageal disorders was similar in patients with and without significant coronary artery narrowing. Subjects with significant ST interval depression in the stress test had a higher rate of simultaneous esophageal contractions. There were no differences in the results of the treadmill test between patients with and without esophageal disorders. Forty percent of patients with significant coronary artery lesions, who had to stop the test because of chest pain, did not present significant ST interval depression on ECG; however, such depression was observed in 60% of patients with normal coronary angiography. Patients with exercise-provoked chest pain had more pronounced abnormalities in esophageal pH, together with the amplitude and coordination of esophageal contractions. Demographic and clinical factors associated with chest pain and changes in exercise ECG were not evaluated. esophageal disorders are an important cause of chest pain, potentially affecting the results of the treadmill stress test. However, further research is needed to determine the predictors of the cardioesophageal loop activity.

Treatment effects of renin-angiotensin system inhibitor and calcium channel blocker in patients with coronary artery narrowing (from the Japanese Coronary Artery Disease Study)

Low-dose antihypertensive drugs in combination are prescribed frequently in clinical practice. Combination treatment is superior to monotherapy with higher doses of each drug in terms of blood pressure reduction and side effects. However, it is unclear whether combination treatment provides additional prognostic benefit beyond the blood pressure lowering effects. We assessed the usefulness of the combined treatment of a renin-angiotensin system inhibitor (RASI) and a calcium channel blocker (CCB) for all cardiovascular events in the Japanese Coronary Artery Disease (JCAD) Study population. In the JCAD Study, which is an observational and non-randomized trial, 13,812 patients with angiographically shown narrowing >50% in ≥1 of 3 major coronary arteries were followed up for a mean of 2.7years. The primary endpoint of the study was all cardiovascular events. In the present study, baseline covariates possibly influencing the event rate were adjusted between the different treatment groups. There was no statistically significant difference in the event rate between the RASI monotherapy and combined treatment groups, although Kaplan-Meier analysis showed a 23% (p=0.0003) relative risk reduction with an RASI monotherapy compared with the control group. In conclusion, there may be no additional benefit beyond blood pressure lowering effects in the combination of an RASI and a CCB in patients with angiographically documented CAD.

Efficacy of Fractional Flow Reserve Measurements at Side Branch Vessels Treated With the Crush Stenting Technique in True Coronary Bifurcation Lesions

Measurement of fractional flow reserve (FFR) has been frequently used to optimize the results of coronary stenting in patients with significant narrowing of coronary arteries. There has been a consensus that an FFR value > 0.90 after stenting is a useful surrogate for favorable long-term clinical outcome. We evaluated the efficacy of FFR measurement at side branch vessels of true coronary bifurcation lesions that were treated with the crush stenting technique. This study included 12 patients with significant narrowing in both a main coronary vessel and side branch vessel who underwent the crush stenting procedure. After crush stenting, FFR measurement was performed at the side branch vessel prior to and after kissing balloon angioplasty (KBA). FFR values increased significantly, from 0.94 +/- 0.04 pre-KBA to 0.97 +/- 0.03 post-KBA (P = 0.011). FFR values after crush stenting but prior to KBA already measured > 0.90 in 9 of the 12 patients (75%). FFR values for the remaining 3 patients were 0.88, 0.88, and 0.90, respectively. FFR measurement at side branch vessels of coronary bifurcation lesions treated with crush stenting may not contribute to adequate decision-making for improvement of long-term clinical outcomes. KBA should be strongly considered for patients with bifurcation lesions treated with crush stenting.