Diseased Coronary Segments Research Articles

Assessment of coronary artery disease and calcified coronary plaque burden by computed tomography in patients with and without diabetes mellitus

PurposeTo compare the coronary atherosclerotic burden in patients with and without type-2 diabetes using CT Coronary Angiography (CTCA).Methods and Materials147 diabetic (mean age: 65 ± 10 years; male: 89) and 979 nondiabetic patients (mean age: 61 ± 13 years; male: 567) without a history of coronary artery disease (CAD) underwent CTCA. The per-patient number of diseased coronary segments was determined and each diseased segment was classified as showing obstructive lesion (luminal narrowing >50%) or not. Coronary calcium scoring (CCS) was assessed too.ResultsDiabetics showed a higher number of diseased segments (4.1 ± 4.2 vs. 2.1 ± 3.0; p < 0.0001); a higher rate of CCS > 400 (p < 0.001), obstructive CAD (37% vs. 18% of patients; p < 0.0001), and fewer normal coronary arteries (20% vs. 42%; p < 0.0001), as compared to nondiabetics. The percentage of patients with obstructive CAD paralleled increasing CCS in both groups. Diabetics with CCS ≤ 10 had a higher prevalence of coronary plaque (39.6% vs. 24.5%, p = 0.003) and obstructive CAD (12.5% vs. 3.8%, p = 0.01). Among patients with CCS ≤ 10 all diabetics with obstructive CAD had a zero CCS and one patient was asymptomatic.ConclusionsDiabetes was associated with higher coronary plaque burden. The present study demonstrates that the absence of coronary calcification does not exclude obstructive CAD especially in diabetics.

Prognostic Value of Coronary Computed Tomographic Angiography in Comparison With Calcium Scoring and Clinical Risk Scores

Several studies have demonstrated a high accuracy of coronary computed tomography angiography (CCTA) for detection of obstructive coronary artery disease (CAD), whereas some studies have also shown a good prediction of cardiac events. However, it remains to be proven whether CCTA is better predictive of events than conventional risk scores or calcium scoring. Therefore, we compared CCTA with calcium scoring and clinical risk scores for the ability to predict cardiac events. Patients (n=2223) with suspected CAD undergoing CCTA were followed up for a median of 28 months. The end point was the occurrence of cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and coronary revascularization later than 90 days after CCTA). Patients with obstructive CAD had a significantly higher event rate (2.9% per year; 95% confidence interval, 2.1 to 4.0) than those without obstructive CAD, having an event rate 0.3% per year (95% confidence interval, 0.1 to 0.5; hazard ratio, 13.5; 95% confidence interval, 6.7 to 27.2; P<0.001). CCTA had significant incremental predictive value when compared with calcium scoring, both with scores assessing the degree of stenosis (P<0.001) and with scores assessing the number of diseased coronary segments (P=0.027). In patients with suspected CAD, CCTA not only detects coronary stenosis but also improves prediction of cardiac events over and above conventional risk scores and calcium scoring. This may result in a reclassification of cardiovascular risk in a substantial proportion of patients.

Is size really all that matters? Remarks on size and necrotic core content of atherosclerotic plaques

Is size really all that matters? Remarks on size and necrotic core content of atherosclerotic plaques

Abstract 4872: Beta Blockers and Acute Release of ET-1 in Response to Anger Recall Stress in Patients With CAD

Acute anger is associated with triggered AMI and transient myocardial ischemia. Anger provoked ischemia differs from demand related ischemia with regard to differential epicardial vs. microvascular processes. Use of beta-blockers is standard of care for patients with CAD. Endothelin-1 plays a central role in vascular regulation and homeostasis, particularly in diseased coronary segments, and has been linked to endothelial dysfunction during laboratory emotional stress. Beta-blockade has been reported to reduce plasma levels of ET-1 in patients with marked LV dysfunction/CHF and to inhibit the synthesis and release of ET-1 in cellular preparations. We studied the relationship of beta-blockade use on laboratory anger stress-provoked levels of ET-1 in patients with CAD without marked LV dysfunction/CHF. Methods and results: 104 patients with history of stable CAD underwent sequential 10-min resting baseline (BL) and 6 minute anger-recall stress (AR). Blood samples drawn at the end of rest and stress were assayed for ET-1 by ELISA (fmo/mL) and change from BL to AR calculated. As expected, the hemodynamic response to anger stress was significantly lower (p=0.015) among patients taking beta-blockers (n=81) than those not taking these agents (n=23). These two groups did not differ in ET-1 at BL (2.27±3.77 vs. 1.24±1.89, p = 0.98). Those not taking beta-blockers however, showed a significantly greater % increase in ET-1 from BL to AR (16.12%±29.09% vs. 2.14%±23.85%, p &lt;0.036); this relationship persisted after adjusting for rate pressure product, age, diabetes, HTN, and statin use (p=0.03). Comments: Beta-blocker use was associated with a significantly less anger-stress provoked increase in ET-1. This may be one of the mechanisms behind beneficial effects longitudinally of beta-blocker use on incident coronary events in patients with CAD.

The Effect of Acute Hypoxemia on Coronary Arterial Dimensions in Patients with Coronary Artery Disease

Objectives: To assess the influence of acute hypoxemia on the dimensions of diseased and nondiseased coronary arterial segments in humans. Methods: In 18 subjects (age 53 ± 8 years) with known or suspected coronary artery disease, quantitative coronary angiography was performed before and after being randomly assigned to breathing (1) an inspired oxygen concentration (fraction of inspired oxygen, FIO₂) of 21% (room air, RA) for 20 min (n = 4, controls) or (2) an FIO₂ of 15 and 10% for 10 min each (corresponding to altitudes of 2,500 and 5,500 m, respectively; n = 14). Results: In the control subjects, no hemodynamic, oximetric or angiographic variable changed. In the 14 study subjects, the arterial partial pressure of oxygen averaged 85 ± 13 mm Hg on RA, 65 ± 15 mm Hg on 15% FIO₂ and 44 ± 13 mm Hg on 10% FIO₂. Average arterial segment diameter was 2.52 ± 0.63 mm on RA, 2.55 ± 0.62 mm on 15% FIO₂ (not significant vs. RA) and 2.66 ± 0.66 mm on 10% FIO₂ (p < 0.001 vs. RA). The increase in coronary arterial diameter with 10% FIO₂ occurred only in normal segments (2.74 ± 0.64 vs. 2.97 ± 0.64 mm; p < 0.001), but not in diseased segments (2.34 ± 0.57 vs. 2.38 ± 0.55 mm; not significant). Conclusions: In humans, severe hypoxemia induces vasodilation of angiographically normal coronary arterial segments, whereas it causes no change in diseased segments.

Comprehensive evaluation of coronary arteries by multidetector-row cardiac computed tomography according to the glucose level of asymptomatic individuals

BackgroundEarly detection of atherosclerosis in individuals with diabetes is important because of high cardiovascular mortality in this population. We performed multidetector-row computed tomography (MDCT) in asymptomatic individuals to investigate the status of coronary artery stenosis and plaque characteristics depending on the glucose level. Methods and resultsThe plaque burden (number of diseased coronary segments), severity of stenosis, plaques characteristics, and coronary artery calcium score (CACS) were assessed by MDCT in 1043 asymptomatic individuals. Anthropometric parameters and metabolic profiles were also acquired. Twenty-one percents of subjects had plaques and 5% had significant stenosis. Mean (±S.D.) CACS of study population was 17±81. Subjects with impaired fasting glucose (IFG, n=215, 21%) or diabetes (n=112, 11%) had a greater plaque burden, more coronary stenosis (>50% of diameter stenosis) and higher CACS than normal subjects (all, p<0.01). Noncalcified and mixed plaques were observed more in subjects with diabetes (19%) and IFG (11%) than normal (7%). After adjustment for confounding factors, higher fasting glucose was strongly associated with significant coronary stenosis and a greater plaque burden. ConclusionsMore significant coronary stenosis and multivessel involvement, higher CACS, and greater plaque burden were observed in subjects with IFG or diabetes by MDCT, even they are asymptomatic. Proactive screening, irrespective of the imaging modalities used, in asymptomatic subjects with prediabetes and diabetes is helpful to identify those who have a higher cardiovascular morbidity and mortality. Further studies will guide us with respect to which imaging modality is more appropriate.

Myocardial revascularization in dextrocardia with situs inversus totalis

Dextrocardia with situs inversus totalis occurs with an incidence of 1 in 10,000 and the pattern of susceptibility to coronary disease is similar to the general population. An adult male patient with situs inversus-dextrocardia who underwent percutaneous intervention for a discrete lesion in the right coronary artery presented two years later with rapid progression of lesions in the left coronary system. Off pump endarterectomy of the obtuse marginal branch and revascularization of the left anterior descending and obtuse marginal branch in this patient are discussed. In addition an outline of the natural history of normal appearing or mildly diseased coronary artery segments at follow-up angiography is presented.

Comparison of 64-slice multi-detector computed tomography coronary angiography between asymptomatic, type 2 diabetes mellitus and impaired glucose tolerance patients

Cardiovascular disease is the most frequent cause of death and disability for diabetic patients, and patients with diabetes are more likely to have silent ischemia. Multi-detector computed tomography (MDCT) allows non-invasive assessment of coronary artery stenosis and plaque properties. In this study, we investigated whether 64-slice MDCT can non-invasively identify significant coronary artery stenosis in asymptomatic, type 2 diabetes mellitus (T2DM) and impaired glucose tolerance (IGT) patients. The study population consisted of 154 consecutive asymptomatic patients [IGT (n=93), T2DM (n=61)]. All patients underwent contrast-enhanced 64-slice MDCT. The number of diseased coronary segments was classified as showing obstructive (> or = 50% luminal narrowing) disease or not. Significant coronary stenosis was detected in 43 (27.9%) of 154 enrolled patients. Patients with T2DM showed significantly more coronary stenosis than patients with IGT (41% vs. 19.4%; p<0.01). Twenty-three patients [14.9%; IGT (n=9), T2DM (n=14)] underwent percutaneous coronary intervention (PCI) for severe stenosis. Patients with T2DM showed significantly more calcified plaque than IGT (47.5% vs. 29%; p<0.05), but not significantly more soft plaque (19.7% vs. 15.1%; ns), or significantly different remodeling index (1.05+/-0.18 vs. 1.04+/-0.21; ns), respectively. 64-Slice MDCT can non-invasively identify significant coronary artery stenosis in asymptomatic, T2DM and IGT patients.

What is behind the calcium? The relationship between calcium and necrotic core on virtual histology analyses: reply

In our recent study, the ratio of necrotic core to calcification (NC/DC ratio) detected by virtual histology intravascular ultrasound (VH-IVUS) in diseased coronary segments was related to known risk factors for sudden coronary death (SCD) in men, in line with previous observations that vulnerable plaques have more NC and less DC than stable plaques.1 We also demonstrated in a previous publication, also from the VH-IVUS registry, that the NC/DC ratio separated high-risk non-ST elevation ACS patients from low-risk patients.2 This new IVUS-derived imaging method allows spectral analysis of backscattered radiofrequency (RF) ultrasound signal for the characterization of four basic plaque components: fibrous, …

In vivo virtual histology intravascular ultrasound correlates of risk factors for sudden coronary death in men: results from the prospective, multi-centre virtual histology intravascular ultrasound registry

We hypothesized a relationship between virtual histology intravascular ultrasound (VH-IVUS) findings and risk factors histopathologically associated with sudden coronary death (SCD) in men: cigarette smoking and an increased total cholesterol-to-high-density lipoprotein cholesterol (HDL-C) ratio (TC/HDL > 5). We assessed volumetric VH-IVUS parameters in a consecutive series of 473 male patients: fibrous, fibro-fatty, dense calcium (DC), necrotic core (NC), and a calculated NC/DC ratio. Patients' age was 61 ± 11 years, with 27% smokers and 69% having a lipid disorder. The NC/DC ratio was the only VH-IVUS parameter related to both TC/HDL ratio (r = 0.18, P= 0.0008) and low-density lipoprotein cholesterol levels (r = 0.17, P= 0.002); had a negative correlation with HDL-C levels (r = -0.11, P= 0.03); and was higher for smokers [median 1.98 (1.35-3.18)] vs. non-smokers [median 1.70 (1.23-2.53), P= 0.006]. An NC/DC value >3 was the threshold that best identified smokers and/or patients presenting TC/HDL >5 (odds ratio 3.0, 95% CI 1.7-4.9, P= 0.0001), and receiver-operator curves showed the superiority of the NC/DC ratio [area under curve (AUC) 0.64, P < 0.0001] over %DC (AUC 0.58, P= 0.006) or %NC (AUC 0.51, P= 0.43) to identify these patients. The ratio of NC to calcification detected by VH-IVUS in diseased coronary segments is related to known risk factors for SCD and, thus, may be associated with a worse prognosis.

Necrotic Core and Its Ratio to Dense Calcium Are Predictors of High-Risk Non–ST-Elevation Acute Coronary Syndrome

Increased creatine kinase-MB levels and ST-segment depression are well-known prognostic factors in the setting of non-ST-elevation acute coronary syndrome (ACS). We hypothesized a relationship between virtual histology intravascular ultrasound (VH-IVUS) findings and these prognostic factors. We performed "whole vessel" VH-IVUS analysis in culprit arteries of 225 patients with ACS and measured the 4 basic VH-IVUS coronary plaque components--fibrous, fibrofatty, dense calcium (DC), and necrotic core (NC)--and calculated a NC/DC ratio. Patients' age was 62 +/- 11 years; 72% were men and 23% had diabetes. Only the NC/DC ratio had a positive association with creatine kinase-MB levels (r = 0.21, p = 0.03), and it was significantly higher for patients with ST-depression compared with those with non-ST-depression ACS (1.97 +/- 1.46 vs 1.58 +/- 1.10, p = 0.02). Sensitivity and specificity curves determined that a NC/DC value > or =2 (odds ratio 3.8, p = 0.01) and percentage of NC > or =6 (odds ratio 3.1, p = 0.04) were thresholds that best separated patients with high-risk non-ST-elevation ACS from those without abnormal creatine kinase-MB or ST depression. Patients with both predictors had significantly higher total cholesterol (204.7 +/- 60.5 vs 173.6 +/- 44.3 mg/dl, p = 0.01), higher low-density liprotein cholesterol (132.5 +/- 49.8 vs 101.3 +/- 33.2 mg/dl, p = 0.02), and more myocardial injury (creatine kinase-MB value of 42 +/- 38 vs 12 +/- 21, p = 0.01) than patients with no predictors. In conclusion, VH-IVUS analysis showed that the percentage of NC and its ratio to DC in diseased coronary segments are positively associated with a high-risk ACS presentation.

Characteristics of coronary plaques before angiographic progression determined by Multi-Slice CT

The aim of the present study was to characterize coronary plaques by Multi-Slice Computed Tomography (Siemens sensation 16, Forcheim, Germany) before significant angiographic progression occurred and to compare them to non-progressing lesions. The MSCT-morphology of coronary plaques leading to a rapid angiographic disease progression is not yet studied. In a series of 68 patients who were scheduled for surveillance angiography 6 months later, MSCT-angiography was done shortly after the baseline catheterisation-procedure. After surveillance angiography rapid progressive lesions with an increase of the stenosis severity of >20% were identified and analysed on the baseline MSCT-scan and were compared to non-progressing lesions. Six months after coronary stenting we observed significant progression of de novo stenoses in 10/438 coronary segments. The progression of four lesions lead to angina pectoris symptoms and the remaining six lesions progressed silently. Analysis of the lesion morphology by MSCT revealed that 5/10 (50%) progressing lesions were non-calcified 3/10 (30%) were predominantly non-calcified and 2/10 (20%) were mainly calcified on the baseline MSCT-scan. In the 428 segments without disease progression atherosclerotic lesions were found in 225 segments on MSCT. Non-calcified plaques were identified in 46 (20%), predominantly non-calcified lesions in 58 (26%) and predominantly calcified lesions in 121 (54%) segments. The average number of diseased coronary segments between patients with and without lesion progression was not significantly different between progressors and non-progressors with a higher prevalence of non-calcified segments in the progressor group (1.1 vs. 0.63). Rapid progression of the angiographic stenosis severity during a 6 months period occurs most frequently in coronary segments revealing non-calcified or predominantly non-calcified plaques as determined by MSCT, whereas lesion progression is rare in predominantly calcified segments. This represents first evidence that non-calcified lesions may be involved in the process of plaque rupture.

Abstract 1982: In Vivo Virtual Histology Intravascular Ultrasound Correlates of Risk Factors for Sudden Coronary Death in Men: Results from the Prospective, Global, Multi-center VH-IVUS Registry

Background: Histopathological data shows that cigarette smoking and a total-cholesterol-to-high-density-lipoprotein ratio (TC/HDL) &gt;5 are associated to sudden coronary death (SCD) in men. We hypothesized a relationship between virtual histology intravascular ultrasound (VH-IVUS) findings and these risk factors. Methods and Results: We performed whole pullback VH-IVUS analyses in a consecutive series of 473 male pts and measured the four basic VH-IVUS coronary plaque components - fibrous (FI), fibro-fatty (FF), dense calcium (DC) and necrotic core (NC) - as well as calculated a NC/DC ratio. Pts age was 61±11years, with 27% current smokers and 69% with a lipid disorder. Among VH-IVUS parameters, the NC/DC ratio was the only parameter related both to the TC/HDL ratio (r=0.18, p=0.0008) and LDL-C levels (r=0.17, p=0.002); it had a negative correlation with HDL-C levels (r=0.11, p=0.03), and was significantly higher for smokers [median: 1.98 (1.35, 3.18)] vs. non-smokers [median: 1.70 (1.23, 2.53), p=0.006]. A NC/DC value &gt;3 was the threshold that best identified smokers with a TC/HDL&gt;5 (odds ratio 3.0, p=0.0001). ROC curves showed superiority of the NC/DC ratio (A 2 : 0.64, p&lt;0.0001) over %DC (A 2 : 0.58, p=0.006) or %NC (A 2 : 0.51, p=0.43) as isolate parameters to identify pts with a risk profile for SCD (Figure ). Conclusions: In diseased coronary segments the ratio of necrotic core to calcification detected by VH-IVUS is related to previously-published pathologic risk factors for SCD.

New Technology for Noninvasive Evaluation of Coronary Artery Disease

Cardiac computed tomography (CT) and positron emission tomography (PET) are emerging as powerful noninvasive imaging tools for the evaluation of atherosclerosis in patients with known or suspected coronary artery disease (CAD). Unlike invasive coronary angiography, CT coronary angiography (CTA) not only assesses disease within the coronary lumen but can also provide direct qualitative and quantitative information about nonobstructive atherosclerotic plaque burden within the vessel wall. Thus, it is possible that CTA-based patient evaluation may provide more clinically relevant information on which to base risk assessments compared with conventional “lumenography.” On the other hand, PET is rapidly growing as a powerful and efficient alternative to conventional single-photon emission CT (SPECT) imaging to evaluate regional myocardial perfusion and metabolism in patients with CAD. In addition, PET scanners are now being converted to hybrid PET/CT devices, which, in the setting of CAD, offer the potential for a comprehensive noninvasive cardiac evaluation of anatomy and function. This review will discuss current and potential future applications of cardiovascular CT, PET, and hybrid PET/CT, with a particular focus on ischemic heart disease. The information provided by noninvasive imaging generally falls into 1 of 3 categories: myocardial perfusion, left ventricular (LV) function, or coronary artery anatomy. The clinical utility, value, and role of a noninvasive modality are based on 2 test characteristics: What type of information is provided (eg, stress perfusion, stress and/or rest LV function, coronary anatomy), and what is the accuracy of the information provided. For example, SPECT and PET both provide stress and rest perfusion information, but the latter will be a superior clinical tool if the imaging data better represent the actual defect size and are subject to less artifact. The advantage of PET over SPECT will be further enhanced, as will be discussed later, if it provides additional clinically relevant information not …

Noninvasive Assessment of Plaque Characteristics With Multislice Computed Tomography Coronary Angiography in Symptomatic Diabetic Patients

Cardiovascular events are high in patients with type 2 diabetes, whereas their risk stratification is more difficult. The higher risk may be related to differences in coronary plaque burden and composition. The purpose of this study was to evaluate whether differences in the extent and composition of coronary plaques in patients with and without diabetes can be observed using multislice computed tomography (MSCT). MSCT was performed in 215 patients (86 [40%] with type 2 diabetes). The number of diseased coronary segments was determined per patient; each diseased segment was classified as showing obstructive (> or = 50% luminal narrowing) disease or not. In addition, plaque type (noncalcified, mixed, and calcified) was determined. Plaque characteristics were compared in patients with and without diabetes. Regression analysis was performed to assess the correlation between plaque characteristics and diabetes. Patients with diabetes showed significantly more diseased coronary segments than nondiabetic patients (4.9 +/- 3.5 vs. 3.9 +/- 3.2, P = 0.03) with more nonobstructive (3.7 +/- 3.0 vs. 2.7 +/- 2.4, P = 0.008) plaques. Relatively more noncalcified (28 vs. 19%) and calcified (49 vs. 43%) and less mixed (23 vs. 38%) plaques were observed in patients with diabetes (P < 0.0001). Diabetes correlated with the number of diseased segments and nonobstructive, noncalcified, and calcified plaques. Differences in coronary plaque characteristics on MSCT were observed between patients with and without diabetes. Diabetes was associated with higher coronary plaque burden. More noncalcified and calcified plaques and less mixed plaques were observed in diabetic patients. Thus, MSCT may be used to identify differences in coronary plaque burden, which may be useful for risk stratification.

The pathobiology of the vessel wall: Implications for imaging

Recent advances in molecular and cell biology have enhanced our understanding of the vascular pathophysiology, leading to the development of many novel therapeutic approaches. However, this progress has been much less represented in our diagnostic approaches to vascular disease, which remains a major cause of morbidity and mortality, not only in developed, but also in developing, countries. A number of factors, some inherent to the vessel wall, impede progress in this direction. The vessel wall is relatively small, less than 1-mm thick (limit of resolution for nuclear imaging) in many cases. The endothelium, the most natural and easily accessible target for imaging given its presence at the interface of the bloodstream and vessel wall, is only 10- to 12-μm thick. Technical challenges raised by the target size are augmented by cardiac motion. As such, any single-modality imaging may lack many technical requirements, and successful vascular imaging may depend on hybrid and/or intravascular imaging. Enhanced uptake, detected by molecular imaging as a hot spot, will need to have an anatomic coregistration system, such as computed tomography or magnetic resonance imaging angiography. Species-specific differences in pathology, prevalent in the case of vascular disease, render translation from animal studies to human beings more difficult and unpredictable. Thus, the challenges facing vascular imagers are enormous, both biological and technical. What is (are) the best imaging target(s) for different phases of the disease? Which animal model best represent the human pathology? Can we start with a stationary target (eg, carotid artery) and then move to coronaries? Can we image coronary arteries noninvasively? Do we need to localize the diseased coronary segment or is the detection of a hot spot sufficient? What is the role of intravascular detection and/or imaging? In the presence of, and perhaps despite, these challenges, improved understanding of the vessel wall biology continues to support the identification and validation of novel molecular imaging targets (or combination of targets) (Table 2), and ultimately will lead to the development of novel diagnostic approaches for the most common vasculopathies.

Noninvasive Assessment of Coronary Plaque Burden Using Multislice Computed Tomography

We performed coronary plaque imaging with 16-row multislice computed tomography in 85 patients who had stable angina pectoris and a high pretest likelihood of having coronary plaque to evaluate plaque burden, i.e., extent (number of diseased coronary segments) and size (small vs large) of plaque. We also assessed type of plaque (calcified, noncalcified, or mixed) and its anatomic distribution. Of 85 patients included, 78 (92%) had fully evaluable multislice computed tomograms that allowed assessment of coronary plaque burden, including major and side branches (>or=2 mm), yielding a total of 855 segments. These 78 patients (92% men; mean age +/- SD 58 +/- 11.5 years) were in sinus rhythm, with heart rates of <70 beats/min (spontaneous or induced by beta blocker). Plaque was detected in 57% of all segments (487 of 855). The mean number of segments with plaque per patient +/- SD was 6.2 +/- 3.9. Plaque was classified as large in 33% of segments and small in 67%. Overall, 65% of plaques were calcified, 24% were noncalcified, and 11% were mixed. Plaques were predominantly located in the proximal and middle segments of the main coronary vessels.

Complete myocardial revascularization: between myth and reality

Myocardial revascularization in patients with multi-vessel coronary artery disease may be accomplished, by percutaneous interventions or surgery, either on all diseased lesions or directed to selectively targeted coronary segments. The extent of planned revascularization is often a major determinant of treatment strategy. Revascularization of all diseased coronary segments-complete myocardial revascularization-has a potential long-term benefit, but is more complex and may increase in-hospital untoward events. Revascularization may otherwise be incomplete, either because of the operator's inability to treat all diseased coronary segments or by choice of deciding to selectively revascularize only large areas of myocardium at risk. Although incomplete revascularization may negatively affect long-term outcomes, it may be, when wisely chosen, the preferred treatment strategy in selected patient categories because of its lower immediate risks. The patient's clinical status, ventricular function, and the presence of co-morbidities may orient clinical decisions in favour of incomplete revascularization.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization

The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD). Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%). The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

Coronary anatomy predicts presence or absence of renal artery stenosis. A prospective study in patients undergoing cardiac catheterization for suspected coronary artery disease.

This study aimed to determine the prevalence of renal artery stenosis (RAS) and associated risk factors in patients undergoing cardiac catheterization for suspected coronary artery disease (CAD). One hundred and seventy-seven consecutive patients (62 females) with a serum creatinine concentration <2.0mg.dl(-1) were studied. Abdominal aortography followed cardiac catheterization to screen for RAS. In 110 patients (62%) CAD and in 19 patients (11%) significant RAS (luminal narrowing of >or=50%) were detected, 12 of whom had high grade (>or=70%) RAS, and two subjects had significant RAS without CAD. Patients with RAS were older (67+/-8 vs 61+/-11 years, mean+/-SD;P =0.004), had higher systolic blood pressure (150+/-15 vs 138+/-20 mmHg;P =0.005), a lower glomerular filtration rate (GFR; 61+/-16 vs 80+/-22 ml.min(-1), P<0.001) and more often diabetes mellitus (69% vs 30%; P=0.004). In multivariate analysis a low GFR and the extent of CAD were independent predictors of RAS. The presence of >2 significant coronary lesions predicted RAS (sensitivity 0.84, specificity 0.77, positive predictive value 0.30, negative predictive value 0.98). Screening for RAS in patients with >2 diseased coronary segments has a high diagnostic yield, which is even greater in the presence of a reduced GFR, diabetes mellitus, and elevated systolic blood pressure.