Epicardial Stenosis Research Articles

CXCL5 gene polymorphisms and coronary collateralization

BackgroundThe presence of coronary collateralization is heterogenous, even amongst those with similar degrees of epicardial coronary artery stenoses. We hypothesized that genetic variation of CXCL5, a chemokine that mediates angiogenesis, is associated with coronary collateralization. MethodsWe genotyped subjects undergoing coronary angiography for single nucleotide polymorphisms of CXCL5 and determined the presence of spontaneously visible coronary collaterals. ResultsSubjects with collaterals had less angina (46 % vs 59 %, p = 0.006), and prior percutaneous coronary intervention (34 % vs 47 %, p = 0.010), and more hyperlipidemia (90 % vs 82 %, p = 0.018), peripheral arterial disease (25 % vs 17 %, p = 0.041), congestive heart failure (16 % vs 8 %, p = 0.007), and multi-vessel coronary artery disease (41 % vs 24 %, p = 0.0001) compared to those without collaterals. Multi-vessel disease and hyperlipidemia were positive predictors of angiographically visible collaterals while being a carrier of the CXCL5 polymorphism was a negative predictor. ConclusionsCoronary collateralization may, at least in part, be genetically determined.

Coronary sinus reducer device for the treatment of refractory angina therapy. A multicentric initial experience

Abstract Introduction The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting. Methods Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy. Results Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010). Conclusion In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA. Funding Acknowledgement Type of funding sources: None.

Relative monocytosis predicts the presence and severity of coronary artery disease on CT coronary angiography in patients with stable angina symptoms

Abstract Background Monocytes, among other leucocytes, are crucially involved in the pathogenesis of atherosclerosis, but the value of peripheral blood leucocyte counts in predicting the presence or absence of atherosclerotic coronary artery disease (CAD) is unknown. Purpose Investigating whether circulating counts of monocytes, lymphocytes and neutrophils predict CAD on computed tomography coronary angiography (CTCA) in patients presenting with stable chest pain. Methods All patients investigated with CTCA in our centre in the year 2021 were screened (n=1564). Patients presenting via the Rapid Access Chest Pain clinic were retrospectively identified, and those with a Full Blood Count from the 6 months prior to clinic were included (n=330). Traditional cardiovascular risk factors were ascertained from the clinic letter. CAD was defined as any epicardial stenosis >25% on CTCA. Patients with CAD were further classified as having either single or multivessel disease (left main stem disease was considered multivessel), and non-obstructive or obstructive disease (any stenosis >70% was considered obstructive). Results Patients with CAD had significantly higher mean monocyte count than those without CAD (0.61 vs. 0.55x109/L, p=0.004), while no differences were observed between groups in lymphocyte or neutrophil count. Monocyte count increased further with more severe CAD, being higher in patients with multivessel compared to single-vessel disease (0.62 vs. 0.60x109/L; p for trend including no CAD =0.012), and in patients with obstructive compared to non-obstructive disease (0.62 vs. 0.60x109/L; p for trend including no CAD=0.012). The association between monocytes and CAD was most marked among patients with a history of hypercholesterolaemia (monocyte count in CAD vs. no CAD: 0.63 vs. 0.54x109/L, p=0.001), and was absent in those without (0.57 vs 0.56x109/L, p=0.695). In the hypercholesterolaemia subgroup (n=186), a forward conditional logistic regression model including monocyte count alongside traditional risk factors (age, sex, smoking status, diabetes mellitus, hypertension, cholesterol level and family history), showed that only increasing age (p<0.001), male sex (p<0.001) and increasing monocyte count (p=0.01) were independently predictive of CAD. Conclusion Raised monocyte count is associated with both the presence and severity of coronary artery disease in patients presenting with anginal symptoms. In patients with a history of hypercholesterolaemia, monocyte count had a more robust predictive ability than many traditional cardiovascular risk factors. Further work is needed to establish whether patients with a relative monocytosis have a higher cardiovascular risk than would be predicted by traditional risk tools. Funding Acknowledgement Type of funding sources: None.

Diagnostic value of computed tomography myocardial perfusion to detect coexisting microvascular dysfunction in patients with obstructive epicardial coronary disease

Abstract Background The usefulness of computed tomography myocardial perfusion (CTP) to assess hemodynamically significant epicardial coronary artery lesions has been previously reported. However, the diagnostic value of quantitative evaluation of absolute coronary flow by CTP to detect microvascular dysfunction remains unknown. Purpose The aim of study is to assess the diagnostic value of CTP to evaluate coronary microvascular dysfunction (CMD) in patients with significant epicardial coronary stenosis, and to analyze the predicting factors for lesions with CMD. Methods Sixty-eight chronic coronary syndrome patients with de novo single functionally significant stenosis (Fractional flow reserve [FFR] <0.80) were investigated. CMD was defined by the index of microcirculatory resistance (IMR) ≥25. Clinical characteristics and CTP findings were compared between the two groups with and without CMD (CMD, n=29, non-CMD, n=39, respectively). The computed tomography angiography (CCTA) assessment included CTP findings and quantitative and qualitative assessment of plaques. Results In wire-based analysis, FFR, coronary flow reserve (CFRwire) and IMR were 0.68 (0.59–0.74), 1.71 (1.24–2.88), and 22.6 (15.1–34.5), respectively. In CTP analysis, culprit territory regional absolute myocardial blood flow (MBF) at rest (rest-MBF) and hyperemia (hyperemic-MBF) were evaluated semi-automatically. CTP-derived CFR (CFRCTP) was calculated as hyperemic-MBF divided by rest-MBF. Rest and hyperemic-MBF and CFRCTP were 0.83 (0.64–1.03) ml/min/g, 2.14 (1.30–2.92) ml/min/g, and 2.19 (1.44–3.37). In the lesions with CMD, hyperemic-MBF was significantly lower than those without CMD (1.68 [0.84–2.44] vs 2.31 [1.67–3.34] ml/min/g, p=0.015) and the prevalence of CFRCTP<2.0 was higher in the lesions with CMD than those without CMD (62.1% vs 28.2%, p=0.007). CCTA analysis showed that fibrofatty and necrotic core component (FFNC) volume was greater in the lesions with CMD than in the lesions without CMD (31.8 [19.0–48.9] vs 25.1 [17.2–32.1] mm3, p=0.045). The multivariable logistic regression analysis, hyperemic-MBF and FFNC volume were independent predictors for lesions with CMD (Odds ratio [OR] 0.583 [0.355–0.958], p=0.033 and OR 1.040 [1.010–1.070], p=0.018). Conclusion Quantitative assessment of absolute coronary flow by CTP and comprehensive plaque analysis by CCTA may help detect coexisting subtended microvascular dysfunction in patients with functionally significant epicardial coronary lesions. Further studies are needed to elucidate the clinical significance of coexisting CMD in CCS patients. Funding Acknowledgement Type of funding sources: None.

Coronary tortuosity in patients with acetylcholine-induced coronary microvascular spasm

Abstract Background Angina pectoris in the absence of relevant epicardial stenoses (ANOCA) is frequently caused by coronary microvascular spasm. It has been speculated that the morphology of epicardial coronary arteries is associated with microvascular spasm. One hypothesis is that the vasoconstriction of microvessels leads to intraluminal pressure increase in the vascular segments proximal to the spasm, which may shift the balance of vessel forces toward vessel elongation resulting in coronary tortuosity. Purpose We assessed the relationship between epicardial coronary tortuosity and coronary spasm to elucidate a potential relationship between structural and functional coronary abnormalities. Methods 610 patients (39% male, mean age 61 years) with stable angina yet unobstructed coronary arteries (<50% stenosis) were included in this study. All patients underwent invasive diagnostic coronary angiography followed by intracoronary acetylcholine (ACh) testing according to a standardized protocol. The ACh test was considered “positive” in the presence of (a) angina, ischemic ECG shifts during the test and ≥90% coronary diameter reduction (“epicardial spasm”) or (b) all above without epicardial spasm (“microvascular spasm”). Assessment of coronary tortuosity was performed using left and right coronary images in multiple projections in a blinded fashion. The number and angles of the coronary curves in late diastole determined the severity of coronary tortuosity previously defined by Eleid. Patients were divided into those with at least moderate tortuosity versus those with no or mild tortuosity. Results ACh-testing revealed epicardial spasm in 179 (29%) and microvascular spasm in 172 (28%) patients. The ACh-test was negative/inconclusive in the remaining 259 patients (43%). There were 298 patients (49%) with at least moderate coronary tortuosity. The remaining 312 patients had no or mild coronary tortuosity (51%). Patients with at least moderate tortuosity were more likely to have microvascular spasm (99 patients of 172 with microvascular spasm had at least moderate coronary tortuosity (58%) vs. 76 patients of 179 with epicardial spasm (43%) vs. 126 patients of 259 with negative/inconclusive ACh test (49%), p=0.017). Analysis of coronary tortuosity in patients with positive ACh-test showed that patients with at least moderate coronary tortuosity (n=175) had significantly more microvascular spasm (57%) than epicardial spasm (43%) (p=0.005). We also found that at least moderate coronary tortuosity was significantly more often found in patients with hypertension compared to patients without hypertension (230/438 vs. 71/172, p=0.015). Conclusions In this large cohort of ANOCA patients coronary tortuosity was associated with hypertension and microvascular spasm. Our results provide interesting insights into the relationship of coronary morphology and vasomotor function. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Berthold-Leibinger-Foundation, Ditzingen, Germany

"CIRCLE OF VIEUSSENS": A LIFE-SAVING CORONARY ARTERY ANOMALY IN A PATIENT WITH KAWASAKI DISEASE

"CIRCLE OF VIEUSSENS": A LIFE-SAVING CORONARY ARTERY ANOMALY IN A PATIENT WITH KAWASAKI DISEASE

Invasive evaluation of coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.

Exploring the mechanism of Shexiang Tongxin dropping pill in the treatment of microvascular angina through network pharmacology and molecular docking.

BackgroundMicrovascular angina (MVA) is a group of clinical manifestations of angina pectoris or angina-like chest pain, positive exercise test, and exclusion of epicardial coronary artery spasm, wherein coronary angiography (CAG) does not present obvious epicardial vascular stenosis. Shexiang Tongxin dropping pill (STDP) has the effect of benefiting the Qi and opening the blood vessels, activating blood circulation, and resolving blood stasis. We explored the mechanism of STDP against MVA by network pharmacology and molecular docking.MethodsTraditional Chinese Medicine Systems Pharmacology Database and Analysis Platform (TCMSP), literature search, SwissTargetPrediction database, and high-throughput experiment- and reference-guided database of traditional Chinese medicine (HERB) were applied to identify the active ingredients and targets of STDP. The MVA targets were searched in the databases of GeneCards, Pharmacogenetics and Pharmacogenomics Knowledge Base (PharmGKB), DisGeNET, Online Mendelian Inheritance in Man (OMIM), and Therapeutic Target Database (TTD). The common targets of STDP and MVA were screened. The software RStudio 4.1.3 was used to analyze the enrichment of these targets using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Protein-protein interaction (PPI) network analysis of the common targets was performed using the Search Tool for the Retrieval of Interacting Genes/Genomes (STRING) database. The cytoHubba plug-in of Cytoscape 3.9.1 software was employed to analyze the PPI network and obtain the core targets. Molecular docking was performed to verify the relationship between the core compounds and proteins with AutoDock Tools 1.5.7 and Pymol 2.4.0.ResultsWe identified 93 effective components of STDP, 310 potential targets, 981 MVA targets, and 138 intersectional targets. The potential anti-MVA mechanism of STDP may involve the advanced glycation end products/receptor for advanced glycation end products (AGE-RAGE) signaling pathway in diabetic complications; lipids and atherosclerosis; fluid shear stress; atherosclerosis; the tumor necrosis factor (TNF), interleukin (IL)-17, hypoxia-inducible factor (HIF)-1, and C-type lectin receptor signaling pathways. Further, STDP mainly acts on its targets IL-6, AKT1, STAT3, JUN, and IL-1β to against MVA.ConclusionsThe STDP may exert its therapeutic effects through processes, such as anti-inflammation, promotion of smooth muscle cell proliferation and differentiation, lipid metabolism, immunomodulation, and regulation of cellular autophagy.

Predictors and outcomes of ischemia-driven target lesion revascularization in deferred lesion based on fractional flow reserve: a multi-center retrospective cohort study.

BackgroundFractional flow reserve (FFR) has become the gold standard for diagnosing ischemia in angiographically intermediate epicardial coronary artery stenosis. This study investigated the clinical outcomes and predictors of revascularization deferral based on FFR.MethodsIn this retrospective cohort study, we assessed 474 lesions (440 patients) where revascularization was deferred based on the FFR value. Minimum lumen diameter and %-diameter stenosis were measured. Calcification was graded as none, mild, moderate, or heavy. The synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score I was also determined. The primary outcome was ischemia-driven target lesion revascularization (TLR) in deferred lesions within 3 years. Patients were also assigned into two groups based on FFR value.ResultsThe average age of the patients was 69.7±10.4 years. The average FFR value was 0.86±0.05. Stable angina pectoris was noted in 298 (67.7%) cases, and in-stent restenosis (ISR) was present in 28 (5.9%). The average SYNTAX score was 7.2±4.2. The 3-year ischemia-driven TLR was 18 lesions (3.8%). Cox proportional hazard model revealed that the SYNTAX score and ISR were independent predictors for TLR in deferred lesions [hazard ratio (HR) =1.10, 95% confidential interval (CI): 1.01–1.19, P=0.03; HR =6.33; 95% CI: 2.25–17.8, P<0.01, respectively]. The deferral group, with a low FFR value, tended to have higher TLR rates than other groups.ConclusionsLesions with lower FFR values were associated with a higher incidence of ischemia-driven TLR than those with higher FFR values. SYNTAX score and ISR were predictors for ischemia-driven TLR at 3 years in the deferred lesions.

Diagnostic performance of dobutamine stress echocardiography: A South African experience

Background. Dobutamine stress echocardiography (DSE) is a well-established modality for the diagnosis of coronary artery disease, but there are no reported diagnostic data in southern Africa. Objectives. To compare the safety, sensitivity and specificity of a South African (SA) DSE programme with larger, international series. Methods. All patients undergoing DSE from 2019 to 2021 at a single SA centre were included. A new wall motion abnormality (≥2 segments) signified inducible ischaemia. Results. A total of 106 patients (mean (standard deviation) age 61 (11) years, 68% male) were analysed. Six patients (6%) experienced chest pain during DSE and 4 (4%) developed an atrial arrhythmia. The sensitivity and specificity for epicardial coronary stenosis were 77% and 74%, respectively, changing to 82% and 72% when excluding those who had previous coronary artery bypass surgery. Conclusion. The sensitivity, specificity and safety of an SA DSE programme were comparable to international series. A DSE programme is feasible in a resource-constrained environment.

Validity and correlation of quantitative flow ratio with fractional flow reserve for assessment of intermediate coronary lesions

Background The angiographic percent diameter stenosis (%DS) do not assess the physiological significance of epicardial coronary stenosis. The currently practised physiological indices require pressure wires with or without adenosine-induced hyperaemia. Quantitative flow ratio (QFR) is an angiography-based method to determine the functional significance of coronary stenosis. The present study aimed to analyse the diagnostic performance of QFR in comparison to fractional flow reserve (FFR) in intermediate coronary lesions. Materials and methods It was a single centre retrospective study to analyse the diagnostic performance of offline QFR with the previously performed FFR in the last six years. A total of 56 interrogated vessels were included for the analysis. Offline QFR analysis was performed and correlated with FFR values in the intermediate coronary stenoses. Results The mean age of the study population was 62.4 ± 9.1 years, including 81% men. The left anterior descending artery (50%) was the most common analysed vessel followed by left circumflex (27%) and right coronary (21%) arteries. The mean % DS and % area stenosis were 45.25 ± 11.22% and 57.45% ± 16.25%, respectively. The mean FFR and QFR values were 0.83 ± 0.06 and 0.82 ± 0.10, respectively. A strong positive correlation was found between FFR and QFR with a Spearman correlation coefficient of 0.56. Receiver operating curve analysis for QFR and %DS with a FFR cut off value <0.80 showed an area under the curve of 0.97 and 0.77, respectively. The sensitivity, specificity and diagnostic accuracy of QFR were 87.5%, 95% and 92.8%, respectively. There was a discordance in four vessels (7.1%) between QFR and FFR. Conclusion QFR has a good diagnostic performance in comparison to the gold standard FFR for physiological assessment of intermediate lesions. Its performance is significantly better than the anatomical % DS (p < 0.001).

Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis.

More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.

Diagnostic and Clinical Value of FFRCT in Stable Chest Pain Patients With Extensive Coronary Calcification: The FACC Study

BackgroundThe influence of extensive coronary calcifications on the diagnostic and prognostic value of coronary computed tomography angiography–derived fractional flow reserve (FFRCT) has been scantily investigated. ObjectivesThe purpose of this study was to investigate the diagnostic and short-term role of FFRCT in chest pain patients with Agatston score (AS) >399. MethodsThis was a prospective multicenter study of 260 stable patients with suspected coronary artery disease (CAD) and AS >399. FFRCT was measured blinded by an independent core laboratory. All patients underwent invasive coronary angiography (ICA) and FFR if indicated. The agreement of FFRCT ≤0.80 with hemodynamically significant CAD on ICA/FFR (≥50% left main or ≥70% epicardial artery stenosis and/or FFR ≤0.80) was assessed. Patients undergoing FFR had colocation FFRCT measured, and the lowest per-patient FFRCT was registered in all patients. The association among per-patient FFRCT, coronary revascularization, and major clinical events (all-cause mortality, myocardial infarction, or unstable angina hospitalization) at 90-day follow-up was evaluated. ResultsMedian age and AS were 68.5 years (IQR: 63-74 years) and 895 (IQR: 587-1,513), respectively. FFRCT was ≤0.80 in 204 patients (78%). Colocation FFRCT (n = 112) showed diagnostic accuracy, sensitivity, and specificity to identify hemodynamically significant CAD of 71%, 87%, and 54%. The area under the receiver-operating characteristics curve (AUC) was 0.75. When using the lowest FFRCT (n = 260), per-patient accuracy, sensitivity, and specificity were 57%, 95%, and 32%, respectively. The AUC was 0.84. A total of 85 patients underwent revascularization, and FFRCT was ≤0.80 in 96% of these. During follow-up, major clinical events occurred in 3 patients (1.2%), all with FFRCT ≤0.80. ConclusionsMost patients with AS >399 had FFRCT ≤0.80. Using ICA/FFR as the reference revealed a moderate diagnostic accuracy of colocation FFRCT. Compared with the lowest per-patient FFRCT, colocation FFRCT measurement improved diagnostic accuracy and specificity. The 90-day follow-up was favorable with few coronary revascularizations and no major clinical events occurring in patients with FFRCT >0.80. (Use of FFR-CT in Stable Intermediate Chest Pain Patients With Severe Coronary Calcium Score [FACC]; NCT03548753)

Wnt is coming: A role for serum Wnt2 and 4 in fibrotic remodeling following acute myocardial infarction.

Wnt is coming: A role for serum Wnt2 and 4 in fibrotic remodeling following acute myocardial infarction.

Correlation Between Retinopathy and Coronary Microcirculation Dysfunction in Patients with Type 2 Diabetes Mellitus.

The aim of this study is to evaluate the correlation between retinopathy and coronary microcirculation dysfunction (CMD) in type 2 diabetes mellitus (T2DM) patients. 198 T2DM patients with left ventricular ejection fraction (LVEF)>50%, no epicardial coronary artery stenosis diagnosis by coronary angiography (CAG) and successfully completed coronary blood flow reserve (CFR) test and laboratory examination were enrolled, and fundus examination was performed on all participants. Two groups were divided according to CFR value, including 86 patients with CMD (CFR≤2.5) in study group and 112 patients without CMD (CFR>2.5) in control group. The composition of various retinopathy in two groups was observed, and the correlation between retinopathy and CMD was analyzed using ordered logistic regression. There were 13 cases with arteriovenous (A/V) nicking, 4 cases with proliferative diabetic retinopathy (PDR), 14 cases with non-proliferative diabetic retinopathy (NPDR), 17 cases with diabetic retinopathy (DR) with A/V nicking, 38 cases without retinopathy in study group, and 18 cases, 7 cases, 20 cases, 4 cases and 63 cases for each in control group. After adjustment for age, gender, hypertension, diabetes duration, dyslipidemia, glycosylated hemoglobin (HbA1c), body mass index (BMI), A/V nicking, PDR and NPDR, the diference of DR with A/V nicking between study and control group remained statistically signifcant (OR 2.0, 95% CI 0.79 to 3.21, p = 0.001). DR with A/V nicking could be used as an independent predictor of T2DM patients with CMD. CFR testing should be performed on patients with this kind of eye sign, even if they do not have any symptoms of heart disease. Meanwhile, DR with A/V nicking might be served as a reference indicator of CMD in T2DM patients with chest pain who were unable to be tested for CFR.

High remnant cholesterol level is relevant to diabetic retinopathy in type 2 diabetes mellitus

BackgroundDiabetic retinopathy (DR) is the primary oculopathy causing blindness in diabetic patients. Currently, there is increasing interest in the role of lipids in the development of diabetic retinopathy, but it remains controversial. Remnant cholesterol (RC) is an inexpensive and easily measurable lipid parameter; however, the relationship between RC and DR in type 2 diabetes mellitus (T2DM) has not been elucidated. This research investigates the relevance between RC levels and DR severity while building a risk prediction model about DR.MethodsIn this single-centre retrospective cross-sectional study. Each hospitalised T2DM patient had no oral lipid-lowering drugs in the past three months, and coronary angiography showed epicardial coronary artery stenosis of less than 50% and completed seven-field stereo photographs, fluorescein fundus angiography, and optical coherence tomography detection. The RC value is calculated according to the internationally recognised formula. Binary logistic regression was used to correct confounding factors, and the receiver operating characteristic (ROC) analysis was used to identify risk factors and assess the nomogram’s diagnostic efficiency.ResultsA total of 456 T2DM patients were included in the study. The RC levels in the DR team was higher [0.74 (0.60–1.12) mmo/l vs 0.54 (0.31–0.83) mmol/l P < 0.001] in the non-DR team. After adjusting for confounding elements, RC levels are still associated with DR risk (OR = 5.623 95%CI: 2.996–10.556 P < 0.001). The ratio of DR in every stage (except mild non-proliferative diabetic retinopathy) and DME in the high RC level team were further increased compared to the low-level team (all P < 0.001). After ROC analysis, the overall risk of DR was predicted by a nomogram constructed for RC, diabetes duration, and the neutrophil-lymphocyte ratio as 0.758 (95%CI 0.714–0.802 P < 0.001).ConclusionsHigh RC levels may be a potential risk factor for diabetic retinopathy, and the nomogram does better predict DR. Despite these essential findings, the limitation of this study is that it is single-centred and small sample size analysis.

Fractional Flow Reserve and Instantaneous Wave-Free Ratio Predict Pathological Wall Shear Stress in Coronary Arteries: Implications for Understanding the Pathophysiological Impact of Functionally Significant Coronary Stenoses.

BackgroundThe pathophysiological mechanism behind adverse outcomes associated with ischemia‐inducing epicardial coronary stenoses and microcirculatory dysfunction remains unclear. Wall shear stress (WSS) plays an important role in atherosclerotic plaque progression and vulnerability. We aimed to evaluate the relationship between WSS, functionally significant epicardial coronary stenoses, and microcirculatory dysfunction.Methods and ResultsPatients undergoing invasive coronary physiology testing were included. Fractional flow reserve, instantaneous wave‐free ratio, and the index of microcirculatory resistance were measured. Quantitative coronary angiography was used to obtain the lesion percentage diameter stenosis. Computational fluid dynamics analysis was performed to calculate WSS parameters. Multiple regression analysis was performed to calculate the standardized regression coefficient (β) for the coronary physiology indices.A total of 107 vessels from 88 patients were included. Fractional flow reserve independently predicted the total area of low WSS (β=−0.44; 95% CI, −0.62 to −0.25; P<0.001) and maximum lesion WSS (β=−0.53; 95% CI, −0.70 to −0.36; P<0.001) after adjusting for percentage diameter stenosis and index of microcirculatory resistance. Similarly, instantaneous wave‐free ratio also independently predicted the total area of low WSS (β=−0.45; 95% CI, −0.62 to −0.28; P<0.001) and maximum lesion WSS (β=−0.58; 95% CI, −0.73 to −0.43; P<0.001). The index of microcirculatory resistance did not predict either low or high WSS.ConclusionsFractional flow reserve and instantaneous wave‐free ratio independently predicted the total burden of low WSS and maximum lesion WSS in coronary arteries. No relationship was found between microcirculatory dysfunction and WSS.

Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology.

Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.

Development and Management of No-Reflow in a Patient Performed Coronary Angiography for Acute Coronary Syndrome: Case Report

Despite eliminating epicardial coronary artery stenosis or occlusion, insufficient myocardial perfusion is called “no-reflow.” While the no-reflow phenomenon is defined as coronary flow below increased thrombolysis (TIMI) 3 in myocardial infarction in some sources, TIMI is defined as 0–1 flow in some sources. In addition, some publications refer to TIMI 2 flow as slow coronary flow. However, the general view is that TIMI 0–1 coronary flow without severe residual stenosis, spasm, thrombus, or dissection is called no-reflow. The no-reflow phenomenon is a condition in which blood flow is significantly reduced in the ischemic myocardium despite percutaneous coronary intervention. So far, no standard treatment has been established to cure this condition. In this case, we present an interesting case that demonstrates a practical approach to the no-reflow phenomenon.

Assessment of risk factors, clinical presentation and angiographic profile of coronary slow flow phenomenon

Background: Primary coronary slow flow phenomenon (PCSFP) is a clinical entity that causes attacks of mild to severe chest pain. It is characterized by delayed coronary vessel opacification in the absence of epicardial stenosis. This work aimed for the assessment of predictors, clinical presentation, and angiographic profile of PCSFP. Subjects and Methods: This cross-sectional case–control study was done between February 2019 and January 2020, including 150 patients who presented by ST-segment myocardial infarction, non-ST segment myocardial infarction, unstable angina, chronic coronary syndrome, or atypical chest pain. The patients were divided into two groups: group 1: consisted of 100 patients who had PCSFP and Group 2: consisted of 50 patients who had normal coronary flow (NCF). Results: PCSFP was significantly more prevalent in young male patients. Among the traditional risk factors, there was significantly more prevalence of hypertension (63.0% vs. 28.0%, P = 0.001), obesity (body mass index ≥30 kg/m2 (47.0% vs. 4.0%, P = 0.001), and history of smoking (66.0% vs. 40.0%, P < 0.002) in PCSFP patients as compared to NCF patients. Triglyceride (TG), cholesterol, low-density lipoprotein, high-sensitivity C-reactive protein (hs-CRP), and hemoglobin all were higher in patients with PCSFP. Low high-density lipoprotein levels were associated with PCSFP. In multivariable analysis, PCSFP was significantly independently associated with male sex, high TG, cholesterol, and hs-CRP. TG (odds ratio [OR]: 14.427, 95% confidence interval [CI]: 3.514–59.226) and cholesterol (OR: 11.739, 95% CI, 2.439–56.513) are the strongest independent predictors for PCSFP. Conclusion: PCSFP is more common in young smoker males, is associated with hypertension, obesity, high hs-CRP, TG, and cholesterol levels. High cholesterol and TG and male sex are the strongest risk factors for PCSFP. Furthermore, inflammation plays an important factor in the pathogenesis of PCSFP due to the association of high hs-CRP level in those patients.