Diagnosis Of Ischemic Heart Disease Research Articles

Immunohistochemical analysis of vimentin expression in myocardial tissue from autopsy cases of ischemic heart disease

Vimentin is a type III intermediate filament cytoskeletal protein that is expressed mainly in cells of mesenchymal origin and is involved in a plethora of cellular functions. In this study, myocardial tissues from patients with ischemic heart disease and a mouse model of acute myocardial infarction were subjected to immunohistochemistry for vimentin. We first examined 26 neutral formalin-fixed, paraffin-embedded myocardial tissue samples from autopsies of patients that were diagnosed with ischemic heart disease within 48 h postmortem. Myocardial cells were negative for vimentin, whereas non-myocardial cells, including vascular endothelium, vascular smooth muscle, fibroblasts, nerve fibers, adipocytes and mesothelial cells, showed positivity. Elevated vimentin expression was observed around myocardial cells undergoing remodeling, suggesting fibroblastic and endothelial proliferation in these locations. By contrast, myocardial foci that were completely fibrotic did not show upregulated vimentin expression. Inflammatory foci including macrophages and neutrophils were clearly visualized with vimentin immunostaining. The same vimentin expression phenomena as those found in human samples were observed in the mouse model. Our study indicates that immunostaining of vimentin as a marker for myocardial remodeling and the dynamics of all non-myocardial cell types may be useful for supplementing conventional staining techniques currently used in the diagnosis of ischemic heart disease.

483 Minoca in a young patient with elevated platelet count

Abstract Aims Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulin-dependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12–16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000–400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies.

Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.

Machine Learning for Ischemic Heart Disease Diagnosis Aided by Evolutionary Computing.

Heart disease is the leading cause of death from chronic diseases in the developing countries. The difficulty of making an accurate and timely diagnosis is exacerbated by a lack of resources and professionals in some areas, which contributes to this reality. Medical professionals may benefit from technological advancements that aid in the accurate diagnosis of patients. In light of these findings, a hybrid diagnostic tool has been developed that combines several computational intelligence (machine learning) techniques capable of analyzing clinical histories and images of electrocardiogram signals and indicating whether or not the patient has ischemic heart disease with up to 97.01% accuracy. Working with medical experts and a database containing clinical data on approximately 1020 patients and their diagnoses was required for this project. Both were put to use. A picture database containing 92 images of electrocardiogram signals was also used in this project for the analysis of the Artificial Neural Network. After extensive research and testing by the medical community, which supported the project and provided positive feedback, a successful tool was developed. This demonstrated the tool's effectiveness.

Abstract 12872: Adherence to Guidelines for Heart Rate in Stable Ischemic Heart Disease in the Primary Care Setting

Per 2012 ACC/AHA Guidelines, patients with stable ischemic heart disease (IHD) should be treated with beta-blockers (BB) to target a resting heart rate (HR) of 55-60 bpm due to associations of higher HR with all-cause mortality. We sought to determine adherence to this in the resident primary care (PC) clinic at our institution. Two hundred twenty-nine patients with a medication list in the electronic medical record (EMR) that includes metoprolol succinate or tartrate or carvedilol who were seen in PC clinic in January 2020 were identified. Of these, 100 had a diagnosis of IHD, and their EMR were reviewed for vital signs; medication changes; and contraindications (CI) to BB titration such as hypotension, bradycardia, and max dosing; during their PC and cardiology visits. We found that 10% (10 of 100) had HR within goal during their PC visit, whereas 6 and 84 had HR below and above goal, respectively. Of the 90 whose HR was not at goal, 24 had some perceivable CI to BB titration. Of those without CI to titration, 9% (6 of 66) had their BB increased, 4.5% (3 of 66) had their BB switched to a different medication, and 85% (56 of 66) did not have their BB changed. Of those whose BB was unchanged, 79% (44 of 56) had no other antihypertensive changed. Moreover, 88% (74 of 84) of those with HR above goal had a HR also above goal at their last two PC visits. Sixty-eight of the 100 patients with IHD were also managed by cardiology, and in contrast, 18% (8 of 45) of those with HR not at goal and without CI to titration had their BB dose adjusted at their last cardiology visit. A chi-square test was performed to examine the relation between BB titration and clinic setting with no statistical significance, X 2 (1, N = 106) = 1.18, p = 0.28. In sum, adherence to guidelines for HR in stable IHD were poor and not significantly different in the PC and cardiology settings. Lack of provider initiative, perhaps due to trainee unfamiliarity with guidelines, may be one of many factors and warrants more investigation to improve quality of care.

Abstract 9826: Impact of Ischemic Heart Disease on Inpatient Outcomes of Atrial Fibrillation

Introduction: Comparative outcomes of hospitalizations for Atrial Fibrillation (AF) with and without coexisting ischemic heart disease (IHD) have limited large scale data. Coexistence of AF and IHD is common and exposed patients are at high risk for ischemic/hemorrhagic events. We assess baseline characteristics and outcomes in these hospitalized patients using National Inpatient Sample (NIS). Hypothesis: Ischemic heart disease worsens the inpatient clinical outcomes of atrial fibrillation. Methods: We conducted a retrospective analysis of hospitalizations for AF using data from NIS between 2013 and 2014. International classification of diseases, 9th revision was used to identify the target population. The primary outcome was inpatient mortality, hospital length of stay and cost. Results: A total of 1531704 hospitalizations for AF were identified, of these, 863, 352 hospitalizations were without IHD and 668, 342 hospitalizations were with secondary diagnosis of IHD. AF with IHD cohort was older (mean age, 76.4 vs 74.4, p <0.001), had low proportion of females (41% vs 55%, p <0.001), higher proportion of whites (83.4% vs 81.6%, p <0.001) and high comorbidities such as hypertension, diabetes mellitus, chronic kidney disease and congestive heart failure. AF with IHD had significant higher inpatient mortality (OR 1.02, CI 1.01-1.04), increased length of hospital stay (6 vs 5.8 days, mean difference 0.05, p <0.001) and higher cost of hospital stay (mean difference, 7122 USD, p <0.001). There was higher prevalence of cardiogenic shock (OR 2.97, CI 2.86-3.09), cardiac arrest (OR 1.58, CI 1.53-1.62), complete heart block (OR 1.46 (CI 1.40-1.53) and acute kidney injury (OR 1.10, CI 1.09-1.11) in AF with IHD cohort. Conclusion: AF with coexisting IHD is associated with higher inpatient mortality, increased cost of hospital stays, and prolonged length of hospital stay as well as higher comorbidity burden.

Expression of F0 ATP synthase C subunit in serum of patients with ischemic heart disease and its clinical implications

To investigate the expression and clinical significance of F0 ATP synthase C subunit (Csub) in patients with ischemic heart disease (IHD). The 101 patients with chest pain admitted to the department of emergency of the People's Hospital of Yuhuan from May 2019 to December 2020 were enrolled, including 59 patients with acute myocardial infarction (AMI) and 42 patients with unstable angina pectoris (UAP). At the same time, 50 age-matched healthy subjects in the health examination center were selected as the healthy control (HC). All patients had completed blood sampling before the intervention of drugs or other intervention measures in the emergency room. The content of serum Csub was detected by enzyme linked immunosorbent assay (ELISA), and the relationship between Csub and clinical characteristics was analyzed. At the same time, the contents of hypersensitivity cardiac troponin T (hs-cTnT) and MB isoenzyme of creatine kinase (CK-MB) in blood were detected by electrochemical luminescence. The receiver operator characteristic curve (ROC curve) was drawn to evaluate the value of Csub, hs-cTnT, and CK-MB in the early diagnosis of IHD. The baseline data such as age, gender, and history of the three groups were balanced. There were significant differences in low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), CK-MB, hs-cTnT and B-type natriuretic peptide (BNP), but there were no significant differences in other biochemical indexes. The Csub content in the AMI group and the UAP group were significantly higher than those in the HC group [8.96% (6.37%, 11.53%), 4.27% (3.23%, 6.49%) vs. 1.56% (1.07%, 2.33%), both P < 0.01]. Moreover, the Csub in the AMI group with more severe myocardial ischemia was higher than UAP group [8.96% (6.37%, 11.53%) vs. 4.27% (3.23%, 6.49%), P < 0.01]. A total of 59 patients with AMI were treated with percutaneous coronary intervention (PCI). According to the median of Csub, AMI patients were subdivided into above-median group (29 cases) and below-median group (30 cases). The results showed that there were no significant differences in the number of coronary artery lesion branches, the number of stent implantation and postoperative medication between the two groups. ROC curve analysis showed that the area under the curve (AUC) and 95% confidence interval (95%CI) of Csub, hs-cTnT and CK-MB in the diagnosis of IHD were 0.98 (0.95-1.00), 0.99 (0.99-1.00), 0.94 (0.89-0.99), respectively. The diagnostic efficacy of Csub was slightly lower than that of hs-cTnT but higher than that of CK-MB. When the cut-off value of Csub was 4.74%, the sensitivity and specificity for the diagnosis of IHD were 100% and 87.0%, respectively. Csub increased significantly in the serum of IHD patients, and further increased with the severity of ischemia. It can be used as a new diagnostic biomarker for the diagnosis and evaluation of the development of myocardial ischemia.

Self-Attention Based Virtual Staining for Bright-field Images of Label-free Human Carotid Atherosclerotic Plaque Tissue Section.

Histological analysis of carotid atherosclerotic plaque tissue specimens is a widely used method for studying the diagnosis of ischemic heart disease and stroke. Understanding the physiological and pathological mechanisms of carotid atherosclerotic plaque is of great significance for the effective prevention and treatment of plaque formation and rupture. In this work, we adapted a self-attention generative adversarial model to virtually stain label-free human carotid atherosclerotic plaque tissue sections into corresponding H&E stained sections. The self-attention mechanism and multi-layer structure are introduced into the residual steps of the generator and in the discriminator. Our method achieved the best performance (SSIM, PSNR, and LPIPS of 0.53, 20.29, and 0.30, respectively) in comparison with other state-of-the-art methods.Clinical Relevance - The proposed approach allows for the virtual staining of unlabeled human carotid plaque tissue images. It identifies the histopathological features of atherosclerotic plaques in the same tissue sample which could facilitate the development of personalized prevention and other interventional treatments for carotid atherosclerosis.

Retrospective Detection and Suppression of Dark-Rim Artifacts in First-Pass Perfusion Cardiac MRI Enabled by Deep Learning.

The dark-rim artifact (DRA) remains an important challenge in the routine clinical use of first-pass perfusion (FPP) cardiac magnetic resonance imaging (cMRI). The DRA mimics the appearance of perfusion defects in the subendocardial wall and reduces the accuracy of diagnosis in patients with suspected ischemic heart disease. The main causes for DRA are known to be Gibbs ringing and bulk motion of the heart. The goal of this work is to propose a deep-learning-enabled automatic approach for the detection of motion-induced DRAs in FPP cMRI datasets. To this end, we propose a new algorithm that can detect the DRA in individual time frames by analyzing multiple reconstructions of the same time frame (k-space data) with varying temporal windows. In addition to DRA detection, our approach is also capable of suppressing the extent and severity of DRAs as a byproduct of the same reconstruction-analysis process. In this proof-of-concept study, our proposed method showed a good performance for automatic detection of subendocardial DRAs in stress perfusion cMRI studies of patients with suspected ischemic heart disease. To the best of our knowledge, this is the first approach that performs deep-learning-enabled detection and suppression of DRAs in cMRI.Clinical Relevance- Our approach enables clinicians to provide a more accurate diagnosis of ischemic heart disease by detecting and suppressing subendocardial dark-rim artifacts in first-pass perfusion cMRI datasets.

The global effect of Covid-19 on acute coronary syndromes management

AimCovid-19 has had a dramatic impact on the healthcare systems globally. Despite efforts to maintain systems of cardiovascular care during the pandemic, public health responses to the virus have contributed to adverse cardiovascular outcomes. Herein, we summarize current evidence detailing the impact of Covid-19 on interventional cardiology.MethodsAccording to PRISMA criteria, a systematic review was performed through Medline, Embase, and Cochrane databases, to identify reports on the impact of Covid-19 on interventional cardiovascular procedures. We identified 50 published studies that met the prespecified inclusion and exclusion criteria.ResultsIn the acute setting, several datasets report a reduction of acute coronary syndrome (ACS) admission by 40% globally (−40%, 95% CI 37–43 from the National Health Service hospital trusts in England). Most surveys and registries reported a numerically higher impact on NSTEMI/unstable angina cases compared to STEMI (−42%, 95% CI 38–46 and −23%, 95% CI 16–30 respectively, from the National Health Service hospital trusts in England).In STEMI care pathways, several studies report increased delays between symptom onset and first medical contact (105 min, 95% CI 45–222 during the pandemic vs 71 min, 95% CI 30–180 before it, p<0.001, from the National STEMI registry in Spain), with a subsequent increased duration of the ischaemic period (200 min, 95% CI 140–332 during the pandemic vs 233 min, 95% CI 150–375 before it, p<0.001, from the National STEMI registry in Spain). Importantly, hospital “door-to-balloon” times were unchanged.Most studies suggest similar in-hospital mortality for STEMI during the pandemic compared to historic controls (1.7% vs 1.8%, p=0.67 from British National Institute of Cardiovascular Outcomes Research database). An increased incidence of mechanical complications were observed (41.2% vs 19.6%, p=0.030, from an Italian monocentric experience).In the United States (New York city), overall mortality from ischemic heart diseases depicted a 2-fold increase during the pandemic (relative change 2.39, 95% CI 1.39–4.09). Of note, in the same city home deaths increased from 35/day in 2013–2017 to 200/day during the pandemic. These data suggest that ACS incidence has not decreased, but more likely patients presenting ischemic symptoms may have not contacted health care services, and have died at home.ConclusionsThe Covid-19 pandemic has adversely impacted outcomes in patients with ischemic heart disease (IHD). The diagnosis and treatment of IHD should be designated a health system priority that remains intact during pandemic events as the magnitude of harm induced by its interruption is substantial.FUNDunding AcknowledgementType of funding sources: None.

Unshielded magnetocardiography contributes to non-invasively rule-out ischemic heart disease in patients with chest pain of uncertain origin

Abstract Background Out of millions of patients (pts) screened every year for chest pain in emergency departments (EDs) only 10% to 20% are affected by an acute coronary syndrome (ACS) or angina due to ischemic heart disease (IHD). Unless ECG recording and serum markers are clearly positive, most of them must undergo complete clinical workout to exclude IHD prior to discharge. Moreover, since even effort-ECG and echocardiography don't exhaustively rule-out IHD, second-level exams are frequently needed, enhancing hospitalization time and related costs. Magnetocardiography (MCG) is increasingly reported as a sensitive, non-invasive, radiation-free method with high negative predictive value (PV) to rule out IHD. Purpose Retrospective cohort study to evaluate the reliability likelihood of unshielded MCG (uMCG) as a tool for rapid rule-out of IHD. Method Rest uMCG data of 263 patients (pts), all chest-pain free at the moment of MCG scan, were retrospectively analyzed. uMCG was recorded with a 36-channel SQUID system (intrinsic sensitivity 30 fT/√Hz, above 1Hz), for 90 seconds. With proprietary software, 13 MCG parameters were automatically calculated from T-wave magnetic field (T-MF): 5 parameters quantifying the dynamics of the MF extrema and eight, obtained from inverse solution with the equivalent magnetic dipole (EMD) model, quantifying the spatial dynamics of the T-wave effective magnetic vector (T-EMV). Pts were stratified as follows: – Group A, chest pain pts, with IHD confirmed by subsequent SPECT and coronary angiography (mean age 66±11 years, 36.7% female); – Group B, chest pain pts, with IHD excluded by subsequent SPECT or coronary angiography (mean age 59±10 years, 28.8% female); – Group C, healthy control subjects (mean age 25±7 years, 48.6% female). Only 60 pts in each group were randomly selected for the analysis. Non-parametric Kruskal-Wallis tests were used to compare the 13 MCG predictors among groups. Linear discriminant analysis was employed to assess likelihood ratios (LHR) and PVs, considering a mean IHD prevalence of 13% (range 10–20%) in chest-pain pts. Results Positive LHR was 9, while the negative LHR was 0.3, resulting in a helpful reduction of the pre-test probability of IHD. Whereas positive PV ranges from 51 to 70%, hardly confirming IHD diagnosis, negative PV ranges from 92 to 96%, giving confidence for a safe IHD rule-out. Conclusions Automatic analysis of T-MF and of T-EMV dynamics from rest MCG provided impressive negative LHR and PV values that, if confirmed in prospective multicenter trials, would rank MCG as a useful tool for quick and early triage of pts with acute chest pain and still non-diagnostic ECG and enzyme patterns, to rule-out those whose symptoms are of non-ischemic origin. Interestingly, a similar high negative PV has been recently reported using MCG QRS predictors. Thus, even better results could be expected by combining algorithms for automatic assessment of both T-wave and QRS predictors. Funding Acknowledgement Type of funding sources: None.

565 Predictors of Single Versus Multi-Level Lumbar Spinal Fusion: A Retrospective Cohort Study

Abstract Aim Degenerative spine disease (DSD) of the lumbar spine is a common disorder among the aging population in the world, with a substantial humanistic and economic burden. Although lumbar spinal fusion is currently the mainstay surgical management of DSD, surgery is also associated with adjacent segment disease due to the modification of spinal biomechanics. Therefore, it is important to identify potential risk factors of DSD in order to prevent progressive deterioration and provide early intervention before the surgical option is absolutely necessary. Method Adult patients who underwent posterior lumbar spinal fusion from 2006-2016 were identified via OPCS-4codes. Smoking status, weight, age of operation, gender, diagnosis of ischaemic heart disease (IHD) were obtained via TrakCare®. The degree of deprivation was extrapolated using the Scottish Index of Multiple Deprivation (SIMD) 2020 quintile score. Data were analysed using logistic regression. Results In total, 313 met inclusion criteria and had data available, of which 205 and 108 patients underwent single and multi-level lumbar fusion respectively. Within the study population, 66.8% (206) and 33.2% (104) were female and male. Adjusted for all outcome measures, age of operation achieved statistical significance (p = 0.040). There was a 1.021-fold increase in risk of multi-level spinal fusion with each additional year of age. Weight was approaching statistical significance (p = 0.068). Conclusions Lumbar spinal health declines over time, but some patients experience more progressive deterioration. While some components of the spine are irreparable, early prescription of regimented exercise programs may strengthen spinal musculature to maintain a healthy sagittal balance, particularly in older, overweight, female patients.

Variation in preoperative stress testing by patient, physician and surgical type: a cohort study

ObjectivesTo describe variation in and drivers of contemporary preoperative cardiac stress testing.SettingA dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018.ParticipantsA cohort...

The recent advances, drawbacks, and the future directions of CMRI in the diagnosis of IHD

Ischemic heart disease (IHD), also known as coronary artery disease (CAD), is a leading cause of morbidity and mortality in adults. The aims of this research were to study the recent advances on the prognostic and diagnostic value, drawbacks, and the future directions of cardiac magnetic resonance imaging (CMRI) in the diagnosis of IHD. One hundred patients with IHD who had been clinically diagnosed were enrolled in this study prospectively. CMRI; Siemens Magnetom Sola 1.5 T MRI scanner was used to examine the patients. To confirm the diagnosis, conventional coronary angiography was used. CMRI revealed that the left ventricular (LV) volumes and systolic function of male and female patients differed by age decile were 28.9 ± 3.5%; 32 ± 1.7%, 53.3 ± 11.2; 58 ± 6.6 ml, 100.6 ± 7.1; 98.3 ± 14.7 bpm, 5.4 ± 1.4; 5.8 ± 1.5 L/min, 189 ± 14.3; 180 ± 10.9 ml, and 136 ± 3.1; 123 ± 4.4 ml for the left ventricle ejection fraction (LVEF), stroke volume (SV), heart rate, cardiac output, end diastolic volume (EDV), and end systolic volume (ESV), respectively. CMRI has sensitivity, specificity, and accuracy of 97%, 33.33%, and 95.15%, respectively. Finally, CMRI provides a comprehensive assessment of LV function, myocardial perfusion, and viability, as well as coronary anatomy.

Severe Triple Vessel Disease Presenting As a Negative Electrocardiogram Stress Test: Temptations and Pitfalls in the Management of HIV-Associated Cardiometabolic Disease

A 61-year-old male with human immunodeficiency virus was admitted for non-ST elevation myocardial infarction. He reported a three-year history of stable angina and was previously evaluated one year prior with an electrocardiogram exercise stress test, during which he was able to reach greater than 10 metabolic equivalents. Coronary angiography one year after this benign stress test revealed severe triple vessel disease. Here we describe unique considerations for the diagnosis of ischemic heart disease in patients with HIV-associated cardiometabolic disease.

Apixaban Is Safe and Effective Thromboprophylaxis in Myeloma Patients Treated with Immunomodulatory Therapy

IntroductionPatients with myeloma are at increased risk of venous thromboembolism (VTE) and arterial thrombosis, particularly when treated with immunomodulatory drugs (IMiDs) such as thalidomide or lenalidomide. The optimal approach to prevent such potentially fatal complications has not been determined. Despite routine thromboprophylaxis with aspirin, low molecular weight heparin (LMWH) or warfarin, thrombosis rates of thrombosis of 2-8% are reported in the literature. Current agents have limited efficacy with significant associated burdens such as repeated INR monitoring or subcutaneous administration. Direct oral anticoagulants are promising due to their convenience and effectiveness in preventing VTE in other settings. They have not been extensively studied in myeloma therapy.Our baseline audit of 82 consecutive myeloma patients treated with IMiD-containing regimens and receiving thromboprohylaxis with aspirin had VTE rates of 11%. Of 31 patients treated with heparins 6.5% had VTE. These rates are consistent with data in the literature. Apixaban is cheaper than LMWH therapy in our centre.In November 2014 our policy was changed such that apixaban became standard thromboprophylaxis; the effect of this change is reported here.AimAssess the safety and efficacy of apixaban as thromboprophylaxis in patients with multiple myeloma undergoing first line therapy with IMID-containing regimens.MethodConsecutively presenting patients between 1st November 2014 and 31st December 2016 with multiple myeloma undergoing first-line therapy with IMiD-containing regimens were included in this retrospective study. All patients received apixaban 2.5mg twice daily for the first 4 months of therapy or until treatment cessation. Patients with severe renal failure (CrCl <15ml/min) or thrombocytopenia <50x10^9/L received alternative anticoagulants and were excluded from this audit. Patients already on warfarin continued on warfarin and were excluded. The primary outcome was the occurrence of arterial or venous thromboembolism. We also recorded incidence of clinically significant bleeding episodes.Results70patients were identified. 45 (64%) were male, the median age was 66 years, range 43-86. Previous thrombosis: 2 PE, 1 stroke, 1 TIA, 3 myocardial infarction. Treatment (n): Cyclophosphamide-Thalidomide-Dexamethasone (19), Bortezomib-Thalidomide-Dexamethasone (27), Lenalidomide-Dexamethasone (3), Carfilzomib-Cyclophosphamide-Lenalidomide-Dexamethasone (8), Melphalan-Prednisolone-Thalidomide (n=9), Lenalidomide-Cyclophosphamide-Dexamethasone (4).There were no DVTs or PEs within 6 months of treatment initiation. Two patients (2.9%) had arterial thrombosis. One patient had a non-haemorrhagic stroke at day 19 with no identified embolic source and she had no cardiovascular comorbidities. One patient had a non-ST elevation myocardial infarction at day 23 with no previous diagnosis of ischaemic heart disease. He had stopped both thalidomide and apixaban 21 days previously due to drug-induced rash. One patient (1.4%) had major bleeding. He had melaena during his 4th cycle of MPT that resolved on apixaban cessation. His platelet count had dropped to 21x10^9/L during this episode. He required hospital admission for blood transfusion, but no bleeding point was identified at endoscopy.Conclusion - We studied the use of apixaban for preventing IMiD-induced thrombosis in front line myeloma therapy. Rates of thrombosis appear to be very low with no cases of VTE identified and only 2 cases of arterial thrombosis. There was one episode of major bleeding in a patient with coexistent thrombocytopenia. These toxicity rates compare favourably to historical and published data with other anticoagulants. The drug is suitable for ambulatory treatment even in frail patients, and avoids the logistical and acceptability problems of subcutaneous injection of LMWH. Apixaban appears to be an attractive and safe option for thromboprophylaxis in this setting. DisclosuresNo relevant conflicts of interest to declare.

Myocardial perfusion imaging using computed tomography: Current status, clinical value and prognostic implications

AbstractCombined anatomical and functional evaluation of coronary artery disease (CAD) using computed tomography (CT) has recently emerged as an accurate, robust, and non-invasive tool for the evaluation of ischemic heart disease. Cardiac CT has become a one-stop-shop imaging modality that allows the simultaneous depiction, characterization, and quantification of coronary atherosclerosis and the assessment of myocardial ischemia. Advancements in scanner technology (improvements in spatial and temporal resolution, dual-energy imaging, wide detector panels) and the implementation of iterative reconstruction algorithms enables the detection of myocardial ischemia in both qualitative and quantitative fashion using low-dose scanning protocols. The addition of CT perfusion (CTP) to standard coronary CT angiography is a reliable tool to improve diagnostic accuracy. CTP using static first-pass imaging enables qualitative assessment of the myocardial tissue, whereas dynamic perfusion imaging can also provide quantitative information on myocardial blood flow. Myocardial tissue assessment by CTP holds the potential to refine risk in stable chest pain or microvascular dysfunction. CTP can aid the detection of residual ischemia after coronary intervention. Comprehensive evaluation of CAD using CTP might therefore improve the selection of patients for aggressive secondary prevention therapy or coronary revascularization with high diagnostic certainty. In addition, prognostic information provided by perfusion CT imaging could improve patient outcomes by quantifying the ischemic burden of the left ventricle. The current review focuses on the clinical value of myocardial perfusion imaging by CT, current status of CTP imaging and the use of myocardial CTP in various patient populations for the diagnosis of ischemic heart disease.

Problems of diagnosis and treatment of chronic ischaemic heart disease combined with chronic obstructive pulmonary disease according to retrospective analysis

Ischaemic Heart Disease (IHD) and Chronic Obstructive Pulmonary Disease (COPD) are common diseases that rank highest in the Global Burden of Disease Study (2019). IHD and COPD are often combined, making diagnosis and treatment of patients difficult in actual clinical practice. The aim of the study was to identify problems in the diagnosis and treatment of patients with a combination of chronic IHD and COPD, based on a retrospective analysis of medical records. Patient’s adherence to treatment was also assessed with the Morisky Scale (MMAS-8). The analysis of 108 inpatient charts with a combination of chronic IHD and COPD was carried out. The quality of diagnosis and treatment of IHD was evaluated in accordance with the order of the Ministry of Health of Ukraine N152 dated March 02 2016, considering the recommendations of the European Society of Cardiology (2019). It was found that smoking history was in 23.1% of patients, a body mass index (BMI) was calculated in 51,9%, and a carotid ultrasound examination was carried out in 7.4% of cases. The total cholesterol level was determined in 59.2% of patients, while the level of low-density lipoprotein cholesterol (LDL-C) was determined in only 43.5%. Transthoracic echocardiography (TTE) was performed in 62.9 % of patients, but stress-echocardiography and exercise ECG were not performed. Daily ECG monitoring was performed in 60.2% of cases. The levels of brain natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) were not detrmined to precise etiology of dyspnea. It was also found that beta-blockers (29.6% of patients), ivabradine (11.1% of patients) and statins (65.7% of patients) are seldom administered to patients with IHD and COPD. The targeted doses of these drugs are not reached. Fixed combinations of long-term bronchodilalarors were insufficiently used in therapy of COPD. However, patients' adherence to basic IHD and COPD therapy is weak. 45.4 % of patients were non-adherent to treatment, 43.5% were medium-adherent, and only 11.1% of patients were adherent to treatment.

Protocolo de utilización de pruebas intervencionistas en la cardiopatía isquémica crónica

Invasive coronary arteriography (ICA) is the most important test for the diagnosis of ischaemic heart disease. It is essential to know its indications and the different additional tests that can be performed during cardiac catheterisation. The indications for ICA are a very high clinical likelihood of ischaemic heart disease with high-risk characteristics or extensive areas of ischaemia on non-invasive tests. Invasive functional testing is indicated for angiographically borderline lesions, such as fractional flow reserve. If there are no angiographically significant lesions, we must rule out microvascular dysfunction with tests such as coronary flow reserve. We must also rule out vasospastic angina with vasospasm provocation testing.

Immunohistochemical analysis of thrombomodulin expression in myocardial tissue from autopsy cases of ischemic heart disease

Thrombomodulin is a transmembrane glycoprotein that is ubiquitously expressed on the surface of vascular endothelial cells. Thrombomodulin exerts its anticoagulant effects by combining with thrombin, activating protein C, and inactivating the coagulation factors FVa and FVIIIa. Clinically, thrombomodulin is also known as a marker of vascular injury because it circulates freely in response to endothelial injury. In this study, myocardial tissue from cases of ischemic heart disease was subjected to immunohistochemistry by thrombomodulin. We examined 40 neutral-formalin-fixed, paraffin-embedded myocardial tissue samples from autopsy cases that were diagnosed with ischemic heart disease (within 48h postmortem). Thrombomodulin expression was observed in vascular endothelial cells between myocardial cells and in mesothelial cells of the epicardium. In necrotic myocardium, diffusion of thrombomodulin, which reflected endothelial injury, was observed. Upregulated thrombomodulin expression was observed around myocardial cells under ongoing remodeling, which suggested endothelial proliferation in these locations. Completed fibrotic foci of the myocardium did not show upregulated thrombomodulin expression. In a mouse model of acute myocardial infarction, the same phenomena as that found in human samples were observed by immunohistochemistry of thrombomodulin. Immunostaining of thrombomodulin, as a marker for endothelial injury or myocardial remodeling, may be useful for supplementing conventional staining techniques in the diagnosis of ischemic heart disease in forensic pathology.