Coronary Stenosis Research Articles

The Predictive Value of the CatLet Scoring System for Long-Term Prognosis After Percutaneous Coronary Intervention in Patients With Chronic Coronary Syndrome.

Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system is a newly developed vascular scoring for assessing the degree of coronary artery stenosis and coronary artery variability. Preliminary studies have demonstrated its superiority over the Synergy between percutaneous coronary intervention (PCI) with Taxus and Cardiac Surgery (SYNTAX) score in predicting outcome in patients with acute myocardial infarction (AMI). This study aimed to assess the predictive value of the CatLet score in long-term prognosis after PCI for chronic coronary syndrome (CCS). A total of 201 patients, who were diagnosed with chronic coronary syndrome, undergoing coronary DES implantation and calculable Catlet score at the Second Affiliated Hospital of Wannan Medical College in China were consecutively enrolled from January 2020 to June 2021. The primary endpoint was major adverse cardiac events (MACEs), defined as a composite of myocardial infarction, recurrent angina, cardiac death, heart failure and ischemia-driven revascularization, were stratified according to CatLet score tertiles: 0 ≤ CatLet_low ≤ 23(n = 66), CatLet_mid 24-43(n = 68), and CatLet_top ≥ 44(n = 67), respectively. The CatLet score predicted long-term prognosis with a median follow-up of 3.0 years. Of 201 patients analyzed, the rates of MACEs and cardiac death were 25.37% and 3.98%, respectively. The Kaplan-Meier curves for all endpoints showed increasing outcome events with the increasing tertiles of the CatLet score, with p-value < 0.05 on the trend test. For MACE and cardiac death, the area under the curve (AUC) of the CatLet score was 0.744 (95% confidence interval [CI]: 0.668-0.820) and 0.804 (95% CI: 0.672-0.936), respectively; Alone or after adjusting for risk factors, the multivariable-adjusted hazard ratio (95% CI)/unit higher score was 9.41 (3.18-27.85) for MACEs and 1.85 (1.20-2.84) for cardiac death, respectively. The CatLet score is an independent predictor of long-term clinical outcomes in patients with chronic coronary syndrome after percutaneous coronary intervention.

Relationship between Myocardial Performance Index (Tei Index) and angiographic severity of coronary artery disease in patients with Acute ST Elevation Myocardial Infarction

Background: Tei index is a Doppler derived measure of combined systolic and diastolic myocardial function and a better predictor of global LV function and outcome in patients with acute STEMI. The objective of this study was to determine the relationship between the myocardial performance index of LV (Tei index) and angiographic severity of coronary artery disease as assessed by SYNTAX score in patients with acute STEMI. Methods: This was a prospective, observational single centered study conducted from March 2022 to November 2022 at Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine. (MCVTC, IOM). 160 patients with acute STEMI were enrolled. LV Tei index was calculated with the help of 2D and Tissue Doppler imaging, and the lesion severity was categorized with the help of SYNTAX score after the patients underwent coronary angiography. Results: The mean age was 61.23±12.33 years with a male preponderance. 107 (67%) were male with male to female ratio of 2:1. Tei index was significantly higher among the hypertensive (0.74±0.17) and diabetic (0.78±0.18) patients. 64 (40%), 51(31.9%) and 45(28.1%) had Single vessel disease (SVD), Double vessel disease (DVD) and Triple vessel disease (TVD) respectively with the Mean Tei index values 0.57 ± 0.10, 0.76 ± 0.11, and 0.88±0.11 (p&lt;0.05). The Tei index increased when patients were divided into low, mid, and high SYNTAX score groups as 0.58±0.11, 0.61±0.73, 0.88±0.13 respectively, p-value &lt; 0.05). Moreover, the study showed a positive correlation between Tei index and SYNTAX score with increasing severity of coronary artery stenosis. (r=0.654, p-value&lt;0.001). Proximal LAD, LCx and RCA lesions had greater Tei index than the distal lesions. Conclusion: More proximally located LAD, LCx, RCA lesions had higher value of Tei index, as assessed with the SYNTAX score.

Effect of blood viscosity on the hemodynamic significance of coronary artery stenosis

Effect of blood viscosity on the hemodynamic significance of coronary artery stenosis

The Impact of Neutrophil-to-High-Density Lipoprotein Ratio and Serum 25-Hydroxyvitamin D on Ischemic Heart Disease.

Background: This study describes the complex association between the neutrophil-to-high-density lipoprotein cholesterol ratio (NHR), 25-hydroxyvitamin D (25(OH)D) levels, and cardiovascular disease (CVD), such as stable ischemic heart disease (IHD), ST elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Methods: The serum 25(OH)D concentration and NHR values were analyzed in groups of patients with chronic coronary syndrome (CCS) and acute coronary syndrome (ACS). The severity of coronary artery atherosclerosis was determined using the Coronary Artery Surgery Study (CASS) scale. Results: Significant differences in 25(OH)D and NHR concentrations were observed between CCS and (ACS)/STEMI patients (p < 0.01). Higher 25(OH)D concentrations were associated with the diagnosis of CCS, and higher NHR values with the diagnosis of ACS/STEMI. The NHR threshold for ACS was set at 0.10 (p < 0.001). Patients without significant coronary artery stenosis showed significantly higher 25(OH)D levels and lower NHR values (p < 0.01). Conclusions: The significant correlation between 25(OH)D, HDL, and the NHR suggests that vitamin D, through its influence on inflammatory processes and lipid metabolism, may play a role in the pathogenesis of chronic and acute coronary syndromes. The suggested bidirectional relationship between the NHR and 25(OH)D and the role of the NHR as a predictor of vitamin D levels require further well-designed studies.

Safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis and deferred revascularization.

This study investigated the safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their fractional flow reserve (FFR). A nationwide cohort study was conducted using the Korean National Health Insurance Service database. A total of 4657 patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR were identified from 2013 to 2020. FFR was indicated in patients with no prior evidence of myocardial ischemia and intermediate coronary artery stenosis (50%-70%) as determined by quantitative coronary angiography. Patients were classified according to whether antiplatelet therapy was initiated after the index procedure. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during a 5-year follow-up period. The primary safety outcome was any gastrointestinal bleeding. After propensity score matching, there were 1634 patients in the antiplatelet therapy group and 1634 in the nonantiplatelet therapy group. The risk of MACCE was similar between the 2 groups (24.8% vs 24.7%; adjusted HR, 0.97; 95%CI, 0.84-1.13; P = 0.745). The risk of gastrointestinal bleeding was higher in the antiplatelet therapy group than in the nonantiplatelet therapy group (2.2% vs 1.2%; aHR, 2.07; 95%CI, 1.08-4.00). These results were similar in subgroup analyses. In patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR, antiplatelet therapy may increase the risk of gastrointestinal bleeding without reducing the risk of future ischemic events.

Prognostic value of left ventricular mass measured on coronary computed tomography angiography

BackgroundLeft ventricular (LV) mass is a well-established prognostic indicator for cardiovascular risk. Measurement of LV mass on coronary computed tomography angiography (CCTA) is considered optional. We aimed to assess for associations between LV mass measured on CCTA with all-cause mortality (ACM) risk and to determine age- and sex-specific distributions. MethodsWe evaluated patients without known coronary artery disease (CAD) who underwent CCTA at a single center. We assessed age- and sex-specific distributions (10th, 25th, 50th, 75th, and 90th percentiles) of LV mass index. ACM, the primary endpoint, was recorded over a median period of 5.1 [interquartile range: 1.4–8.4] years. The association between LV mass and mortality risk was assessed using multivariable Cox models adjusted for age, sex, medical history, coronary artery calcium (CAC) score and CCTA stenosis. Results4187 patients (mean age: 61.9 ​± ​11.7, 63 ​% male) were included. Male sex, African American ethnicity, Hypertension, CAC>400, and smoking were independent predictors of increased LV mass index. During the median 5.1 years of study follow, 265 (6.3 ​%) deaths occurred. Increased LV mass index percentiles were associated with increased risk of ACM. The addition of LV mass index percentiles improved discrimination and reclassification for mortality prediction over a model with age, sex, conventional risk factors, CAC score and CCTA stenosis severity (X2 improvement: 22.68, NRI: 28 ​%, both p ​< ​0.001). ConclusionIn a large sample of patients without known CAD who underwent CCTA, increased LV mass index provided independent and incremental prognostic value for all-cause mortality. Assessment of LV mass by CCTA, considering age and gender distribution, can be utilized clinically to identify patients with high myocardial mass.

Right bundle branch block in suspected acute coronary syndromes: Diagnostic challenges, treatment and prognosis

BackgroundThere is still conflicting evidence regarding the prognostic implications of right bundle branch block (RBBB) in the general population but also in patients with heart diseases like acute coronary syndromes (ACS). In accordance with current guidelines, RBBB in ACS patients is considered as STEMI equivalent. However, recent studies indicate that further differentiation is necessary in this group, as we will outline below. Methods and resultsA literature search was conducted in PubMed and Google Scholar.In previous studies, RBBB in the general population were mostly considered benign changes of the electrical conduction system. However, recent studies indicate that both complete and incomplete RBBB are associated with increased cardiovascular morbidity and mortality. In addition, among unselected patients with suspected ACS presenting to the emergency department, the prevalence of RBBB was 3 % and it was associated with elevated mortality. The subsequent angiographic identification of a culprit coronary artery stenosis leading to stent implantation was similar at approximately 2 % regardless of the initial ECG presentation with narrow QRS complexes, left bundle branch block (LBBB), or RBBB.Finally, in a group of high-risk patients for ST-elevation myocardial infarction (STEMI), the prevalence of RBBB was 12 %. While RBBB was associated with poor outcome compared to non-BBB and LBBB patients, diagnostic accuracy of STEMI criteria was not affected by the presence of RBBB. However, RBBB patients without distinct STEMI signs in ECG often showed acute STEMI on angiography indicating a potential benefit from immediate transfer to the cardiac catheterization laboratory. ConclusionIn the general population, patients with RBBB and risk factors may need further evaluation. Regarding ACS patients, recent studies support current guidelines that recommend acute invasive evaluation for high-risk ACS patients with RBBB, regardless of ST-T deviations. However, in an unselected group of ACS patients, differential diagnoses should also be investigated through additional diagnostic procedures.

Perioperative Myocardial Infarction and Successful Revascularization in Patient With Primary Metasynchronic Rectal, Gastric and Bladder Cancer

The article presents a clinical case of perioperative non-ST-segment elevation myocardial infarction in a patient with primary metasynchronous cancer of the rectum, stomach and bladder, which developed during simultaneous surgical intervention in the volume of proximal gastrectomy and abdominoperineal extirpation of the rectum. Fluctuations in blood pressure and imbalance in the hemostasis system at the stages of anesthesia and surgery in a patient with severe systemic atherosclerosis caused the development of myocardial ischemia in the area of significant coronary stenosis. Emergency coronary angiography detected subtotal stenosis of the anterior descending artery; stenting of the affected area of the coronary artery was performed. Monitoring of hemodynamic parameters and changes in the hemostasis system during the optimal antianginal therapy allowed to bring the patient out of critical condition and discharge him from the hospital on the 18th day.

The Importance of Blood Inflammatory Parameters in the Assessment of Hemodynamically Significant Coronary Artery Stenosis

The Importance of Blood Inflammatory Parameters in the Assessment of Hemodynamically Significant Coronary Artery Stenosis

Research Progress on the Combination of Traditional Chinese Medicine and Western Medicine for the Treatment of Ischemic Cardiomyopathy

Ischemic cardiomyopathy (ICM) refers to contractile left ventricular dysfunction in the case of severe coronary stenosis, which is the most common cause of heart failure. In recent years, the incidence of ICM has shown a significant upward trend, and the quality of life and life safety of patients have been seriously affected. At present, the treatment of ICM mainly focuses on dilating blood vessels, diuresis, improving myocardial metabolism and enhancing myocardial function. Research shows that traditional Chinese medicine has unique advantages in improving the prognosis and quality of life of ICM patients. There are a variety of treatment methods, including decoction, injections, proprietary Chinese medicine, etc. This article summarizes the research progress of ICM's traditional Chinese medicine, western medicine and integrated traditional Chinese and western medicine, with a view to providing reference for clinical treatment.

Association of PCSK6 rs1531817(C/A) polymorphism with the prognosis and coronary stenosis in premature myocardial infarction patients: a prospective cohort study

Abstract Background An increasing proportion of younger patients are currently hospitalized for acute myocardial infarction. Exploring the factors affecting coronary artery lesions and prognosis in patients with premature myocardial infarction (PMI) from a genetic perspective is of great significance to clinical management. Proprotein convertase subtilisins/kexins 6(PCSK6), a member of the PCSK family, functions in protein hydrolytic cleavage. It has been shown that PCSK6 polymorphisms are associated with carotid atherosclerosis. Purpose This research intended to evaluate the relationship between the PCSK6 rs1531817 polymorphism and the prognosis of PMI patients and their coronary stenosis. Methods This study was a prospective cohort study, which consecutively included 605 patients with PMI who underwent emergency PCI from January 2017 to August 2022 at X Hospital. Using the Massarray technique, the single nucleotide polymorphisms(SNPs) of PCSK6 rs1531817 were identified, and the patients underwent follow-up for 12 to 72 months, with major adverse cardiovascular events (MACEs) as the outcome. Analyze the relationship between patients' SNPs, Gensini score(GS), Triple vessel diseases(TVD), and MACEs. Results In PMI patients with PCSK6 rs1531817 CA+AA genotypes, ApoA1/ApoB levels were higher than in patients with CC genotype, and TC/HDL levels were lower (p &amp;lt; 0.05). Logistic regression analysis showed that the PCSK6 rs1531817 polymorphism (Dominant model: CA+AA vs.CC) was significantly correlated with the GS (high vs. low GS, adjOR=0.297, 95%CI:0.139-0.632, p=0.002; high vs. medium GS, adjOR=0.449, 95%CI:0.211-0.956, p=0.038), and it was correlated with the number of coronary artery lesions (TVD vs. SVD, adjOR=0.420, 95%CI:0.226-0.782, p=0.006; TVD vs. DVD, adjOR=0.406, 95%CI:0.214-0.773, p=0.006). According to multivariate Cox regression analysis, the PCSK6 rs1531817 dominant model was associated with the MACEs in PMI patients (adjHR=0.454, 95%CI:0.269-0.766, p=0.003). The mediation effect results showed that ApoA1/ApoB played a partially mediating role in the association between PCSK6 rs1531817 polymorphism and the severity of coronary stenosis (the effect leading to high GS and TVD accounted for 14.6% and 8.3% respectively), TC/HDL and TVD partially parallel mediated the association between PCSK6 rs1531817 polymorphism and MACEs (effect proportions were 8.1% and 17.1%, respectively). Conclusion Carrying the PCSK6 rs1531817 mutant A allele is an independent protective predictor of severe coronary stenosis and long-term prognosis in patients with PMI. Patients with the PCSK6 CA+AA genotypes have milder coronary stenosis partially because they have higher levels of ApoA1/ApoB; in addition, these patients have a better long-term prognosis partially because they have lower TC/HDL levels and fewer TVD patients.Figure 1.ApoA1/ApoB and TC/HDL were compareFigure 2.Correlation of PCSK6 rs1531817 pol

Prognostic implications of microvascular resistance reserve in symptomatic patients with intermediate coronary stenosis

Abstract Background Microvascular resistance reserve (MRR) is a novel index reflecting coronary microcirculatory function, irrespective of epicardial coronary artery stenosis. There is limited evidence regarding whether MRR can be an independent prognostic tool in patients with stable ischemic heart disease (IHD). Objective To evaluate clinical outcomes according to MRR in patients with stable IHD accompanied with or without significant epicardial coronary artery stenosis. Methods The current study included 547 consecutive patients undergoing systematic echocardiographic and invasive physiologic assessment for suspected stable IHD. Significant epicardial coronary artery stenosis was defined as fractional flow reserve (FFR)≤0.80. Coronary microvascular dysfunction (CMD) was defined as MRR≤3.0. Primary outcome was major adverse cardiovascular event (MACE), a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure. Results Among the total patients, 172 patients (31.4%) had FFR≤0.80 and 200 patients (36.6%) had CMD defined by MRR≤3.0. MRR showed no significant correlation with FFR (R=-0.031, P=0.469), however, it was significantly correlated with index of microcirculatory resistance (R=-0.353, P&amp;lt;0.001), NT-proBNP (R=-0.296, P&amp;lt;0.001), left ventricular filling pressure (E/e’) (R=-0.224, P&amp;lt;0.001), and diastolic dysfunction grade (P&amp;lt;0.001). During median follow-up of 3.3 years (interquartile range from 2.0 to 4.5 years), MRR was significantly associated with MACE risk (HR 1.23 per-1 decrease, 95% CI 1.12-1.36, P&amp;lt;0.001). CMD defined by MRR≤3.0 was associated with an increased MACE risk in both FFR&amp;gt;0.80 (41.0% vs. 26.0%; HRadj 1.59, 95% CI 1.07-2.35, P=0.021) and FFR≤0.80 (34.7% vs. 14.8%; HRadj 2.32, 95% CI 1.12-4.82, P=0.024) groups. Conclusion Decreased MRR was associated with the presence of cardiac diastolic dysfunction as well as with increased left ventricular filling pressure. The presence of CMD defined by MRR was independently associated with the risk of a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure in patients with stable IHD, irrespective of significant epicardial coronary artery stenosis.

Coronary CT angiography using photon counting CT for the detection of coronary artery stenoses and coronary atherosclerotic plaque: comparison of reconstructions with 0.2 mm and 0.4 mm slice thickness

Abstract Photon Counting CT allows the acquisition of high-resolution data sets with 0.2 mm reconstructed slice thickness. It is unknown whether the detection of coronary artery stenoses, of coronary plaque or of vulnerable plaque characteristics is improved in data sets that employ maximum resolution. We therefore compared the identification of above characteristics in data sets reconstructed with 0.2 mm and 0.4 mm slice thickness In 30 patients with suspected coronary artery disease, sinus rhythm, a heart rate ≤65 beats/min, and body weight ≤ 100 kg, high-resolution data sets were acquired by photon counting CT (60 ml contrast i.v. at 6 ml/s) after s.c. application of nitrates in inspiratory breathhold. Data were reconstructed with 0.2 mm slice thickness at 0.1 mm increment and 0.4 mm slice thickness at 0.2 mm increment. Next to quantitative analysis of image quality parameters, all data sets were evaluated by two independent expert reviewers concerning subjective image quality as well as the ability to determine the presence of coronary artery stenoses, calcified and non- calcified plaque, as well as parameters of plaque vulnerability (positive remodeling, necrotic core, density &amp;lt; 30 HU and napkin-ring sign) using a 5-point Likert scale (-2 to +2) and a dedicated 11-segment coronary model. Of the 30 patients, 47% were male (mean age 58±12 years, mean heart rate 53±6 bpm, mean body weight 80±15 kg). The median dose length product was 508 mGy*cm. Mean image noise was 42±7 HU vs. 34±7 HU for 0.2 mm vs. 0.4 mm reconstructions (p &amp;lt; 0.001). The median image quality score was significantly higher for 0.2 mm reconstructions (3.8±0.8 vs 3.6±0.7). Of 335 coronary segments, none were classified as "unevaluable" while 87% vs. 76% were classified as "perfect" in 0.2 mm vs. 0.4 mm reconstructions (p &amp;lt; 0.001). Full confidence to rule-in or rule out significant coronary stenoses was achieved in 93% of segments in both reconstructions. The number of non-calcified plaques identified in 0.2 mm reconstructions was numerically higher than in 0.4 mm reconstructions (77 vs. 71, p = n.s.). On the Likert scale, the confidence to identify parameters of plaque vulnerability was significantly higher for 0.2 mm reconstructions (1.93 vs. 1.85, p &amp;lt; 0.001). In a selected patient group, photon counting CT coronary angiography demonstrated excellent image quality and an extremely low rate of unevaluable coronary segments. High-resolution reconstructions improve subjective image quality as was as the assessment of vulnerable plaque characteristics.

Diastolic hyperemia-free ratio for the assessment of intermediate coronary artery stenosis in patients with hemodialysis

Abstract Background Diastolic hyperemia-free Ratio (DFR) is new resting index and uses a pragmatic definition by including areas below the average aortic pressure with negative slope. Hemodialysis (HD) exhibits left ventricular hypertrophy and impaired microcirculation. The relationship between DFR and fractional flow reserve (FFR) in the patients with HD has not been yet investigated. Purpose We aimed to compare the rate of physiological discordance between HD patients and non-HD patients, and to elucidate the best DFR cut-off value predicting less than 0.80 of FFR in HD patients. Methods We enrolled 761 consecutive patients (1033 vessels) who underwent both DFR and FFR in the intermediate coronary artery stenosis between July 2020 and December 2023 in our hospital. The cutoff values of DFR 0.89 or less and FFR 0.80 or less were used for the study. We compared the DFR values with FFR values between HD group and Non-HD group. Results HD group consisted of 110 patients and Non-HD group consisted of 651 patients. A good correlation between DFR and FFR was observed in HD group (R=0.780 ; p &amp;lt; 0.0001) and Non-HD group (R=0.770 ; p &amp;lt; 0.0001). The rate of physiological discordance between HD group and non-HD group was each 31.3% and 20.5% (p &amp;lt; 0.01). Receiver operating characteristic curve showed that a suitable cut off value of DFR for equivalent FFR value of 0.80 was 0.84 in HD group and 0.89 in Non-HD group, respectively (Figure). Conclusion In the patients with HD, DFR may overestimate intermediate coronary artery stenosis and the suitable cut off value was 0.84.2024 ESC HD DFR Figure

Antiplatelet agents in patients with intermediate coronary artery stenosis and deferred revascularization

Abstract Background There is no specific recommendation regarding optimal antiplatelet therapy after deferral of revascularization in patients with established coronary artery disease. Objectives The current study investigated safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis in whom revascularization was deferred based on fractional flow reserve (FFR). Methods In the Korean National Health Insurance Service database 2013-2020, we identified 4,657 patients who had intermediate coronary artery disease on angiography for which revascularization was deferred based on FFR. During this period, reimbursement criteria of FFR were patients with no previous evidence of myocardial ischemia and intermediate coronary artery stenosis (50-70%) by quantitative coronary angiography. Patients were then classified into two groups according to initiation of antiplatelet therapy after the index procedure. Primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during 5 years of follow-up. Primary safety outcome was any gastrointestinal bleeding. Results After propensity score matching in a 1:1 ratio, there were 1,634 patients in antiplatelet therapy group and 1,634 in no therapy group (total N=3,268). The risk of MACCE was similar between the two groups (24.8% vs. 24.7%; adjusted hazard ratio [aHR], 0.97; 95% confidence interval [CI], 0.84-1.13; P=0.745). However, the risk of any gastrointestinal bleeding was higher in antiplatelet therapy group than no therapy group (2.2% vs. 1.2%; aHR, 2.07, 95% CI, 1.08-4.00). These results were consistently found in subgroup analyses. Conclusions In patients with intermediate coronary artery stenosis with deferred revascularization based on FFR, antiplatelet therapy was not associated with reduced risk of ischemic events but increased risk of gastrointestinal bleeding.

Relationship between diastolic hyperemia-free ratio and fractional flow reserve in patients with aortic valve stenosis

Abstract Background Diastolic hyperemia-free Ratio (DFR) is new resting index and uses a pragmatic definition by including areas below the average aortic pressure with negative slope. Aortic valve stenosis (AS) exhibits left ventricular hypertrophy and impaired microcirculation. The relationship between DFR and fractional flow reserve (FFR) in the patients with AS has not been yet investigated. Purpose We aimed to compare DFR and FFR in each of AS group and Non-AS group and to elucidate a suitable DFR cut-off value predicting less than 0.80 of FFR. Methods We enrolled 761 consecutive patients (1033 vessels) who underwent both DFR and FFR in the intermediate coronary artery stenosis between July 2020 and December 2023 in our hospital. We compared the DFR values with FFR values between AS group and Non-AS group. AS was defined as an aortic valve area of 1.5 cm2 or less, a mean aortic valve gradient of 20 mm Hg or more, or a peak aortic-jet velocity of 3.0 m/s or more. Results AS group consisted of 55 patients and Non-AS group consisted of 706 patients. A good correlation between DFR and FFR was observed in AS group (R=0.713; p &amp;lt; 0.0001) and Non-AS group (R=0.758; p &amp;lt; 0.0001). The patient backgrounds were similar between AS and Non-AS groups (Table). Regarding physiological findings, DFR in AS group was significantly lower than in Non-AS group (0.83 ± 0.12 vs. 0.88 ± 0.11, p &amp;lt; 0.0001), but FFR was similar (0.80 ± 0.07 vs. 0.81 ± 0.10, p = 0.12). Receiver operating characteristic curve showed that a suitable cut off value of DFR for equivalent FFR value of 0.80 was 0.85 in AS group and 0.89 in Non-AS group, respectively (Figure). Conclusion In the patients with AS, DFR may overestimate intermediate coronary artery stenosis and the suitable cut off value was 0.85.2024 ESC AS DFR Table2024 ESC AS DFR Figure

The prognostic value of contrast stress echocardiography in a real-world population of symptomatic patients without known coronary artery disease

Abstract Background Coronary artery disease (CAD) is the leading cause of mortality and morbidity worldwide. In addition to diagnosis, non-invasive tests may also provide prognostic information useful in the risk stratification and management of CAD patients. Stress echocardiography (SE) is an accurate, non-invasive method for the detection of obstructive CAD. However, in real-world clinical practice the test performance may vary among different centres, depending on availability, local protocols, and operator expertise. Purpose To evaluate the prognostic value of contrast SE in a real-world population of symptomatic patients without known CAD. Methods This was a cohort follow-up study of patients without known CAD and symptoms of atypical chest pain, unexplained dyspnoea or palpitations who were referred to the echocardiography lab of a tertiary hospital for SE between January 2020 and December 2021. Patients with resting regional wall motion abnormalities were excluded. All patients underwent treadmill exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) if unable to exercise. Contrast agents were used in almost all patients (99%). The study population was followed-up for at least 2 years after SE by phone and/or electronic hospital records. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, acute coronary syndrome (ACS), or cardiac-related death. Results The study comprised 266 patients (mean age 58±12 years, 63% male) who underwent either ESE (58%) or DSE (42%). The patients' details are reported in Table 1. The most common indication for the exam was atypical chest pain, with a prevalence of 73%. SE exams were positive for inducible ischaemia in 14 (5%) patients. Symptoms during the exam were present in 3 (21%) patients with positive SE and 4 patients (2%) with negative SE (p=0.004). No serious complications (sustained ventricular tachycardia, myocardial infarction, or death) were recorded. During the follow-up (median 30, IQR 23–38 months), 264 patients (99%) were successfully contacted. Cardiac outcome occurred in 10 patients. Among 14 patients with positive SE, 8 underwent revascularization due to significant coronary artery stenosis. Among 250 patients with negative SE, 1 underwent revascularization due to significant coronary artery stenosis and 1 presented with ACS 13 months after the test (both patients underwent DSE). Negative predictive value was 99% over a median follow-up of 30 months, corresponding to an annualized event rate of 0.32% per year. A positive SE was significantly associated with cardiac outcome (log-rank test p&amp;lt;0.0001, Figure 1). Conclusion Contrast SE carries significant prognostic implications in symptomatic patients without known CAD. A positive test is strongly associated with the need for revascularization, while a normal test result has an excellent negative predictive value regarding cardiovascular morbidity and mortality.Figure 1

Coronary artery disease polygenic risk score in patients undergoing coronary angiography and risk of future revascularization

Abstract Background Coronary artery disease (CAD) polygenic risk score (PRS) is a strong predictor of incident CAD. The role of CAD PRS in patients with known or suspected CAD already presenting for invasive coronary angiography remains poorly understood. Purpose We aimed to (i) study the association between CAD PRS and coronary angiography traits, and (ii) determine whether CAD PRS can predict risk of future revascularization after an initial coronary angiogram. Methods Patients who underwent coronary angiography at a single hospital and were part of its biobank were included in the study. Participants were classified into 3 risk groups based on CAD PRS distribution–low (0-20%), intermediate (21-80%), and high (81-100%)–computed from a recently reported PRS comprised of 1,296,172 variants (GPSMult, PGS003725). Revascularization was defined as a composite of coronary artery bypass graft and percutaneous coronary intervention with a 3-month blocking window after the initial angiogram. Associations between coronary stenosis severity and burden, and CAD PRS were assessed using multinomial logistic regression adjusted for age, sex, and genetic ancestry. The cumulative incidence of revascularization was tested using Fine-Gray regression accounting for competing risk of all-cause mortality and compared across CAD PRS strata by log-rank test. Results Among 3,518 participants (29.90% female, mean age 63.29±12.14 years), 2,568 (73%) had angiographic evidence of CAD – 340 (13.24%) mild, 346 (13.47%) moderate, and 1,882 (73.29%) severe. Out of those with CAD, 844 (32.87%) presented with acute coronary syndromes (ACS) and 1,724 (67.13%) with stable CAD. CAD PRS was strongly associated with angiographic presence of CAD (OR 2.62, 95%CI 2.08-3.29) and this did not differ among patients presenting with ACS vs. stable CAD (Fig1A). The association was weakest for mild CAD (OR 1.14, 95%CI 0.77-1.68) and strongest for severe CAD (OR 3.04, 95%CI 2.40-3.84). Besides severity, CAD PRS was also strongly associated with angiographic burden of CAD with the strongest association observed for presence of left main coronary stenosis (OR 2.63, 95%CI 1.86-3.73). Each standard deviation increase in CAD PRS was associated with a 10-point increase in the Gensini score, a continuous measure of angiographic burden of CAD (p&amp;lt;2e-16) (Fig1B). Over a mean follow-up period of 9.26±5.81 years, 659 (18.73%) patients required revascularization at a mean period of 5.31±4.69 years. Risk of revascularization varied dramatically by CAD PRS; HR was 1.64 (95%CI 1.28-2.10, p=8.7e-5) for high vs. low CAD PRS (Fig2). CAD PRS remained predictive of future revascularization even after adjusting for the angiographic burden of CAD at baseline (HR 1.41, 95%CI 1.09-1.82, p=7.9e-3). Conclusion CAD PRS is strongly associated with severity and burden of CAD assessed on coronary angiography and is predictive of future risk of revascularization even after accounting for baseline disease burden.Figure 1.CAD PRS and angiographic traitsFigure 2.CAD PRS and revascularization

Diagnostic accuracy of automatic quantitative flow ratio for hemodynamic assessment of coronary artery stenosis: prospective observational study

Abstract Background Quantitative flow ratio (QFR) is a method for evaluating fractional flow reserve (FFR) without the use of an invasive coronary pressure wire or pharmacological hyperemic agent. Automatic QFR (auto QFR) is a recently developed, simpler method of calculating QFR that uses a patient-specific TIMI (Thrombolysis in Myocardial Infarction) frame count, but with automatically specified start and end frames. Although the previous studies demonstrated that contrast QFR is more accurate than fixed QFR, there is no evidence for auto QFR. Purpose The aim of this study was to evaluate the diagnostic performance of auto QFR, fixed QFR, and contrast QFR for the diagnosis of hemodynamically significant coronary stenosis defined by FFR ≤0.80. Methods This prospective, multicentre trial enrolled patients suspected with coronary artery disease undergoing diagnostic coronary angiography with an indication for to perform invasive FFR. QFR was calculated at a blinded core laboratory. The primary endpoint was the diagnostic accuracy of auto QFR, fixed QFR, and contrast QFR to determine hemodynamically significant coronary stenosis using invasive FFR (≤0.80) as a reference standard. Results A total of 325 vessels from 274 patients were analysed. Mean FFR was 0.82±0.09, mean auto QFR was 0.80±0.12, and mean contrast QFR was 0.82±0.11, respectively. The overall diagnostic accuracy for identifying an FFR of ≤0.80 was highest by contrast QFR (81.5%), followed by fixed QFR (79.1%), and auto QFR (77.5%). The AUC was higher for contrast QFR (AUC 0.885; 95% CI: 0.845-0.925) than fixed QFR (AUC 0.856; 95% CI: 0.812-0.900) or auto QFR (AUC 0.854; 95% CI: 0.806-0.901), but did not differ significantly between fixed QFR and auto QFR (Figure). Conclusions There was no significant difference in AUC between fixed and auto QFR, but the accuracy of contrast QFR was significantly higher compared to both QFRs. Auto QFR has the advantage of faster computation time while using patient-specific coronary flow, but accuracy still needs to be improved.

Improved quantification of coronary stenosis in patients with high calcium scores using spectral reconstructions in coronary CT angiography

Abstract Background Coronary CT angiography has demonstrated reduced accuracy in patients with high calcium scores due to blooming artifacts, often resulting in overestimated stenosis. Purpose This study aimed to assess the impact of spectral reconstructions on coronary stenosis quantification in patients with high calcium scores (&amp;gt;500), utilizing invasive coronary angiography as the gold standard. Methods Twenty consecutive patients referred for coronary artery disease assessment underwent both coronary CT angiography and invasivecoronary angiography. Conventional 120 kV images, 100 keV virtual monoenergetic images, and iodine-no-water images were reconstructed. Two blinded operators independently reviewed the images. Lesions were qualitatively classified in both CCTA and invasive angiography as stenosis of 1-24%, 25-49%, 50-70%, and &amp;gt;70%. Results A total of 87 plaques were evaluated. Mean age was 72 years (SD=7.7) and 79% were male. Pre-test probability were low, medium and high in 15.8, 26.3% and 57.9% of patients respectively. Mean calcium score was 1662, with an average dose of 7.5 mSv (67.9% retrospective studies). Nitrates were administered in 89.5% of patients, and 47.4% received intravenous beta-blockers. Sensitivity, specificity, positive predictive value, and negative predictive value to detect lesions &amp;gt; 50% improved from 94%, 57%, 38%, 97% with conventional images to 94%, 82%, 59%, 98% with 100 keV virtual monoenergetic images. Conclusion Spectral reconstructions significantly enhance diagnostic accuracy in coronary CT angiography of severely calcified coronary arteries.