Extensive CAD Research Articles

Frequency of NAFLD among Patients of Coronary Artery Disease

Objective: The purpose of this study was to assess the prevalence of NAFLD in coronary artery disease patients. Study Design: Prospective study Place and Duration: Department of General Medicine, Khyber Teaching Hospital, MTI Peshawar in the duration from June, 2022 to November, 2022. Methods: Total 125 patients of both genders with age 25-75 years were presented. Patients were included if they had a verified diagnosis of CAD and stenosis in either of the main coronary arteries or one of the branches. Hepatic steatosis was diagnosed with ultrasound of the liver in all individuals. Likewise, steatosis severity was ranked from 0 (no steatosis present) to 3 (moderate steatosis present) (severe steatosis). At last, the patients' NAFLD prevalence was calculated. The data was analyzed using SPSS 23.0. Results: In all, 73 (58.4%) patients were males and 52 (41.6%) cases were females. Mean age of the patients was 44.6±18.37 years and had mean BMI 26.9±11.65 kg/m2. Most common comorbidity was hypertension, followed by diabetes mellitus, obesity and hyperlipidemia. There were 60 (48%) smokers among all cases. Frequency of NAFLD was found in 62 (49.6%) cases. Among 62 cases of NAFLD, 40 cases were had normal NAFLD (grade 1) and 22 cases were had mild NAFLD (grade 2). Majority of the NAFLD patients were had hyperlipidemia, obesity and hypertension. Conclusion: We found that obese, HTN, and hyperlipidemic NAFLD individuals were more common. The prevalence and severity of NAFLD were also independently linked with CAD. Normal vascular and NOB patients had mild NAFLD, while extensive CAD patients with multi-vessel disease had severe NAFLD. Keywords: CAD, NAFLD, Obesity, Hyperlipidemia, HTN

Angiographic Severity of CAD in Diabetic Versus Non-Diabetic Patients Presenting with STEMI

Objective: To determine the angiographic severity of CAD in diabetic versus non-diabetic patients undergoing primary PCI for STEMI. Methodology: This cross-sectional observational study was carried out in the Cardiology unit of Hayatabad Medical Complex Peshawar from January, 2021 to August 2021. All patients undergoing primary PCI for STEMI at cardiology unit of HMC were included in the study after a thorough history, examination and informed consent. Patients were divided into two categories on the basis of diabetes status. Furthermore, patients were also classified on the basis of number of vessels with significant coronary stenosis. Continuous variables were described as means and standard deviations whereas categorical variables were described as frequencies and percentages. Chi-square test was applied to determine the significance of categorical variables. Results: A total of 68 patients with a mean age of 52±4.5 years were included in the study. Of these, 49 were males and 27 patients had diabetes. In the diabetes group, 20 patients had a history of anterior wall MI whereas 19 patients had history of anterior wall MI in the non-diabetes group. Similarly, 15 patients in the diabetes group and 11 patients in the non-diabetes group had inferior wall MI (p: 0.095). Furthermore, the number of patients who had TVCAD, DVCAD and SVCAD in the diabetic group was 15, 5 and 7 compared to 7, 15 and 19 in the non-diabetic group respectively (X2=11.039, p:<0.01). Two patients in the diabetes group had stent thrombosis whereas only 1 patient had stent thrombosis in the non-diabetes group. One patient died in the cath lab in the diabetic group whereas there was no mortality in the non-diabetic group. Conclusion: Diabetic patients presenting with STEMI is having more severe and extensive CAD during primary PCI as compared to non diabetic patients.

Transient ischemic dilation or transient RV visualization in patients with normal SPECT stress myocardial perfusion imaging: Correlation with CT coronary artery calcium scoring and coronary angiography

BackgroundAncillary findings on MPI, such as transient ischemic dilation (TID) and transient right ventricular visualization (TRV), are recognized as markers of extensive CAD and predictive of adverse outcomes. They usually occur in association with stress-induced regional MPI abnormalities. However, the clinical significance of these ancillary markers in the presence of normal stress MPI is incompletely understood. MethodsFrom a cohort of 564 consecutive patients referred for clinical SPECT stress MPI, 44 patients had normal stress SPECT MPI and either TID (n = 28) or TRV (n = 16). These imaging findings were correlated with CT coronary calcium (CAC), CT coronary angiography (CTA), and invasive coronary angiography (ICA) in patients with severe CAC ≥ 1000 HU. TID and TRV were quantified as stress/rest ratios. Severe CAD was defined as > 70% luminal stenosis on CTA or ICA. ResultsThe median TID ratio was 1.23, with a range of 1.13–1.48; the median TRV ratio was 1.30, with a range of 1.20–1.48. Of 44 patients with TID or TRV, only 9 patients (20.5%) had severe obstructive > 70% CAD by angiography (6 of 28 patients (21.5%) with TID and 3 of 16 patients (19%) with TRV). Severe multi-vessel CAD occurred in only 2 of 44 patients (4.5%). In contrast, of 9 patients with CAC > 1000 HU, 6 (67%) had severe obstructive CAD. ConclusionIn patients with normal stress SPECT MPI and TID or TRV, the incidence of severe obstructive CAD was relatively low and predominantly single-vessel CAD. These findings do not support the concept that TID or TRV with normal stress MPI is predictive of high-risk CAD.

Abstract 13907: Patients With NSTEMI Are at Higher Risk, Have Worse Outcomes, but Less Intense Cardiology Follow-up 1-3 Years Post-discharge: Findings From the TIGRIS Registry

Introduction: Non-ST-elevation myocardial infarction (NSTEMI) patients have more comorbidities and extensive CAD than STEMI patients. However, there is a need for comparative data on the long-term prognosis and resource utilization of stable patients after these MI subtypes. Methods: TIGRIS enrolled 9027 stable patients 1-3 years post-MI (369 centers, 25 countries) with ≥1 risk factor (age ≥65 years, diabetes, 2nd prior MI, multivessel CAD, CKD). The incidence of cardiovascular (CV) events and deaths, and self-reported EQ-D5 score were recorded over 2 years. Multivariable Poisson regression models were used to compare STEMI and NSTEMI patients for relative risks, adjusting for prognostically relevant patient factors. Results: MI subtype was known in 8494 patients (STEMI: 56%; NSTEMI: 44%). At enrollment, NSTEMI patients were more likely to be older, have diabetes, hypertension, hyperlipidemia, and prior CAD compared with STEMI patients. NSTEMI patients had significantly poorer self-rated health and a lower use of dual antiplatelet therapy at discharge and 1-3 years later. NSTEMI patients had a higher incidence of the composite of MI, stroke and CV death over 2 years (5.6% vs 4.0%, p<0.001) and higher all-cause mortality (4.1% vs 2.6%, p<0.001) vs STEMI patients (Figure). These excess risks for the composite outcome attenuated after adjusting for baseline characteristics (adj RR 1.18, 95% CI 0.96-1.45, p=0.11), but remained significant for all-cause mortality (adj RR 1.31, 95% CI 1.02-1.68, p=0.03). Resource utilization over 2 years was higher in NSTEMI patients, although the mean number of cardiologist visits were higher for STEMI patients (4.2 vs 2.8, p<0.001). Conclusions: NSTEMI patients had a less favorable risk profile and experienced more adverse CV events during long-term follow-up than STEMI patients, but had less intense cardiology follow-up. Continued efforts are needed to optimize secondary prevention and care of stable patients after NSTEMI.

P1628ASSESSING CORONARY HEART DISEASE IN SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION - IS THERE SPACE FOR A RISK SCORE MODEL?

Abstract Background and Aims Type 1 diabetes mellitus (DM1) is associated with an increased risk of coronary heart disease (CHD), which is generally more aggressive and frequently asymptomatic. This risk substantially increases for those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation (SPKT) is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols for silent CHD in this population are still debatable. As so, Gowdak recently developed a simple clinical risk score to determine the pre-test probability of significant CHD in single kidney transplant candidates. Our aim was to identify potential risk factors associated with the presence of significant lesions on pre-SPKT coronary angiography (CA) and test the utility of Gowdak score in SPKT candidates. Method 77 patients submitted to SPKT between 2011 and 2018 were retrospectively included in this study. All subjects underwent CA as screening method for CHD during the eligibility evaluation. Demographic, clinical, laboratory, therapeutic and imaging characteristics were studied. Continuous variables are presented as means or medians; categorical variables as frequencies. Univariate analysis (Qui2 or Fisher test) and multivariate analysis (logistic regression) were performed. Comparison between groups of patients with and without CA injury was performed using SPSS statistics version 23 and a p <0.05 was considered significant. Results In the past 8 years, 99 SPKT were performed; 78% of these patients (N=77) were submitted to preoperative CA; mean age was 36±5.9 years and 64% were male. The mean duration of DM1 was 25 years and 97% had retinopathy, 43% neuropathy, 31% dysautonomia, 19% peripheral arterial disease and 7% cerebrovascular disease. We excluded 1 due to missing data. A minority of SPKT (3%, N=2) was preemptive. The mean time on dialysis was 37 months. Only one patient had angor, wh0 was excluded of Gowdak risk score assessment. Most patients (87%, N=67) were hypertensive; 56% (N=43) were on statin; 48% (N=37) had smoking habits, and 5% (N=4) had a BMI>30 kg/m2. CA identified at least one lesion in 48% (N = 37) of the patients, of which 30% (N=11; 14% of all CA) underwent intervention; none had complaints of angor. Based on Gowdak risk score, mean probability for CHD was 30.8% and 19 patients had a risk >40% - the recommended cut off to pursuit CA as screening method - but only 2 required intervention. In a univariate analysis, we found that the only distinguishing feature between the group of patients with and without CA lesions was smoking (p=0.005). DM1 with 20 or more years of evolution was found to have a significant association with coronary artery disease development (identifiable by any diagnostic test) (p=0.048). In our population of SPKT recipients Gowdak risk score did not predicted those with significant CHD. Conclusion In our study, CA was positive for lesion in almost half of the patients, all of them asymptomatic. Despite the fact that Gowdak probability score failed to identify those with significant CHD before CA (probably because all of our patients were diabetic), in our population for every seven patients submitted to CA, one needed coronary intervention. We highlight that asymptomatic patients with long-term DM and smokers should be carefully evaluated. The task of correctly ascertaining the presence of CAD can be more overwhelming when we take into account that there is a high prevalence of asymptomatic patients with extensive CAD. Facing the importance of an unmissed diagnosis we encourage the use of CA as an initial screening method, even if it is invasive. Further studies should be encouraged to create screening algorithm for SPKT candidates. Finally, medium- and long-term follow-up studies are needed to evaluate the effects of preoperative selection on posttransplant cardiac events and survival rates.

Current Center Line Integration in the Manufacturing Process of the ITER Toroidal Field Coils

The first ITER's European Toroidal Field Coil (TFC) is going to be assembled in 2019. The TFC is composed mainly by the superconducting Winding Pack (WP - manufactured in Europe), and the Coil Cases (TFCC - manufactured in Japan), which provide structural integrity to the magnet and offer interface connections with the rest of the machine. Dimensional measurements and other manufacturing data are taken during the WP manufacture and are used to reconstruct the Current Centre Line (CCL), which is defined as the barycentre of the as-built conductors inside the WP. The CCL is useful to characterize the magnetic field generated by the magnet, and its monitoring and control can minimize the Error Field during ITER operation. Fusion For Energy (F4E) developed a method to calculate the CCL using manufacturing data. Since the CCL represents how different the WP is manufactured from its nominal conductor layout, this deviation can be corrected where there is need of a more controlled magnetic field shape, namely in the straight inboard area of the D-shaped tokamak. That is why each WP position inside its respective TFCCs is optimized, compensating the deviations detected and maintaining an allowable gap between components for the subsequent welding and resin filling operation. This paper presents the strategy followed by F4E to calculate the CCL and optimize the WP position inside the TFCC, by means of extensive CAD and CAE modelling activity. It explains also the data management process developed and followed to ensure configuration control of all the data inputs and outputs, coming from different sources and formats, and details the successful insertion operation on the first ever ITER TFC coil manufactured in Europe, and how in the future the updated CCL coil position will be used to define the final TFC machining, after the welding and gap filling operations.

SESCAS: A System for Mitigating Forwarding Misbehaviour in Wireless Sensor Networks

Remote Sensor arrange is the most standard administrations utilized in business and modern applications because of its specialized advancement in the processing, communication and low-control utilization of installed PC equipment. Due to open sent nature, the attackers effectively attack the node, so there is an absence of security. To avoid this, Selective sending approach is actualized. This paper aims to establish a simple countermeasure Scalable and Energy efficient Single Check Point based Acknowledgement Scheme; SESCAS is to detect and isolate the misbehaviour node in a wireless sensor network based on time out and retransmission. We carry out extensive simulation experiments to evaluate and compare performance with the extensive CHEMAS, CAM and CAD. The result of the simulation shows that the proposed mechanism can diminish the false recognition rate, collision of packets, energy utilization rate, propagation delay; we likewise enhance the packet delivery ratio and identification rate.

ESC/EAS clinical guidance recommendations: impact on patient eligibility for PCSK9 inhibitor therapy

Background: The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been demonstrated to significantly reduce the risk of recurrent adverse vascular events in high-risk patients with a history of coronary, cerebral, or peripheral artery disease. The primary barrier to the use of these drugs is their cost. Use of these drugs in the highest-risk patients would improve their cost-effectiveness. A clinical guidance for the use of these drugs based on vascular risk was recently published.Objectives: To determine how clinical guidance recommendations would impact the numbers of patients eligible to receive PCSK9 inhibitor therapy.Methods: 2000 consecutive patients admitted to an academic medical center referred to a cardiology consult service with documented atherosclerotic cardiovascular disease (ASCVD) were evaluated for PCSK9 inhibitor eligibility using the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) clinical guidance recommendations. Any patient with ASCVD with an LDL-C >140 mg/dl was considered eligible for PCSK9 inhibitor therapy. Patients with an LDL-C >100 mg/dl had to meet additional criteria to be eligible. These criteria included (1) diabetes with target organ damage or another risk factor; (2) severe or extensive CAD; or (3) progressive/accelerated ASCVD, ischemic stroke, or revascularization in the coronary, cerebral, or peripheral arterial system within 2 years of a previous ASCVD event.Results: Mean age was 64.9 ± 12.7 years; 66% were men and 34% were women; 80% were white, 9% were black, 10% were Latino and 1% other. Eligibility for PCSK9 inhibitor therapy included 163 patients with LDL-C >140 mg/dl and 892 patients with LDL-C >100 mg/dl with additional risk factors. Additional risk factors were diabetes plus comorbidity in 318 patients; severe or extensive CAD in 317 patients; and progressive/accelerated ASCVD in 257 patients. The total number of patients eligible for PCSK9 inhibitor therapy using the ESC/EAS criteria was 1055 (53%).Conclusions: Previous studies have estimated 15 to 25% of patients with a history of vascular disease to be eligible for PCSK9 inhibitors. In this high-risk cardiac population, over 50% of patients would be PCSK9 inhibitor eligible. The cost to treat this proportion of patients would represent an overwhelming burden to any health system using current drug costs. Medication access coordinators need to play a critical role in the selection and evaluation of patients eligible for PCSK9 inhibitor therapy to maximize cost-efficiency of this therapy.

Is the epicardial adipose tissue area on non-ECG gated low-dose chest CT useful for predicting coronary atherosclerosis in an asymptomatic population considered for lung cancer screening?

The purpose was to determine whether the epicardial adipose tissue (EAT) area on low-dose chest CT (LDCT) could be used to predict coronary atherosclerosis in an asymptomatic population considered for lung cancer screening. Subjects aged 55-80 years with smoking history who underwent both LDCT and coronary CT angiography (CCTA) were retrospectively enrolled. Correlation between the EAT volume in CCTA and EAT area in LDCT was evaluated. Coronary risk factors including the body surface area (BSA) indexed EAT area were compared between coronary plaque negative and positive groups. Significant factors for predicting coronary atherosclerosis were analyzed with logistic regression analysis. Receiver-operating characteristic curve analysis was performed to determine the cutoff value. A total of 438 subjects were enrolled, including 299 subjects with coronary atherosclerosis. There was a good correlation between the EAT volume in CCTA and EAT area in LDCT (ρ = 0.712, p < 0.001). There were significant differences in age, systolic blood pressure, all BSA indexed EAT area, sex, and hypertension between plaque negative and positive groups. In multivariate logistic regression for the BSA indexed EAT area in LDCT at the RCA level, sex (OR: 11.168, 95% CI: 2.107-59.201, p = 0.005), systolic blood pressure (OR: 1.021, 95% CI: 1.005-1.036, p = 0.009), hypertension (OR: 1.723, 95% CI: 1.103-2.753, p = 0.017), and EAT area (OR: 1.273, 95% CI: 1.154-1.405, p < 0.001) were significant. The area under the curve of the BSA indexed EAT area in LDCT at the RCA level for coronary atherosclerosis was 0.657, and the cut-off value was 7.66 cm2/m2. The EAT area in LDCT could be used to predict coronary atherosclerosis in an asymptomatic population considered for lung cancer screening. • To quantify EAT, the EAT area in LDCT can be used instead of the EAT volume in CCTA. • The EAT area measured in LDCT can be used as a predictor of coronary artery disease. • The extensive CAD group tended to have a greater EAT area than the non-extensive CAD group.

Sex differences in left main coronary artery stenting: Different characteristics but similar outcomes for women compared with men

BackgroundThe clinical outcomes for women compared with men undergoing left main PCI were sparse. We compared the characteristics and long-term outcomes in women versus men after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main CAD. MethodsWe identified 2328 patients (545 women; 1783 men) with unprotected left main CAD who received PCI with DES between January 2007 and December 2013 in the Interventional Cardiology Research In-cooperation Society-left MAIN revascularization (IRIS-MAIN) registry. The primary outcome was a composite of death from any cause, myocardial infarction, or stroke. ResultsThe median follow-up time was 2.9years (interquartile range: 1.0–4.1years). Women were older, had a higher incidence of insulin-requiring diabetes mellitus and hypertension, and more commonly presented with acute coronary syndrome than men. Left main ostial lesion was more common in women, whereas left main bifurcation lesion with more extensive CAD was more common in men. The incidence of primary outcome was similar between the two groups (10.8% vs. 10.8%, respectively, log-rank p=0.587). The results were similar after adjustment for baseline variables and consistent across major subgroups. The need for target lesion revascularization was significantly higher in women than in men (8.8% vs. 5.7%, respectively, p<0.05) but the sex bias was not confirmed after adjusting for confounders. ConclusionsWomen, as compared to men, had different clinical and lesion characteristics but similar long-term outcomes after PCI with DES for left main CAD.

Cardiovascular risk factors profile in patients with acute coronary syndrome with particular reference to left ventricular ejection fraction

BackgroundAcute coronary syndrome (ACS) remains a leading cause of death in the United States. Numerous studies have shown that the degree of LV systolic dysfunction is a major if not the most important determinant of long-term outcome in ACS. ObjectivesTo identify the most important risk factors and other clinical predictors which might have impact on left ventricular ejection fraction in patients with ACS. ResultsThe total patients (299) admitted to our center from July, 2015 till December, 2015; with established diagnosis of ACS were classified in to two groups: Group I: 193 patients with impaired LVEF <40% (64.5%), Group II: 106 patients with LVEF equal or >40% (35.5%). The patients of group I were significant elderly compared to those of group II (60.9±11.2 vs 56.9±10.6; p=0.002), had significant history of DM and CKD (66.3% and 31.1% VS 49.1% and 19.8%; p=0.004 and 0.036 respectively), presented mainly with STEMI- ACS (51.3% VS 28.3% respectively; p<0.001) with +v cardiac biomarker (troponin) (90.2% VS 66.0%; p<0.001). Moreover, patients of group I had more significant ischemic MR compared to the patients of group II (24.9% VS 3.8% respectively; p<0.001) with higher rate of LV thrombus discovered by echocardiography (25.4% VS 1.9%; p<0.001). Extensive significant CAD disease was observed to be higher among patients of group I (69.4% VS 57.5%; p=0.039) and those patients treated mainly with PCI revascularization therapy (68.9% VS 52.8%; p=0.002) compared to patients of group II who mainly treated medically (34.9% VS 17.6 %; p<0.001). Multiple logistic regression analysis demonstrated that DM (odd ratio (OR): 2.64, 95% confidence interval (CI): 1.45-4.79, P=0.01), presence of significant ischemic MR (OR: 13.7, 95% CI:2.84-66.1, p=0.001)and presence of significantly diseased coronary vessels (odd ratio (OR): 5.06, 95% confidence interval (CI): 1.14-22.6, P=0.033,) all were independent predictors for significant LV dysfunction (LVEF <40%) which predict poor outcome in ACS patients. ConclusionWe concluded that DM, presence of significant ischemic MR, and increased number, severity of diseased coronaries all were independent predictors of LV dysfunction (LVEF <40%) which is known to predict poor outcome. Identification of those risk predictors upon patient evaluation could be helpful to identify high risk-patients, in need of particular care, aggressive therapy and close follow-up to improve their poor outcome.

MY APPROACH to outpatients with suspected CAD

The history and physical will direct the initial step. If there is an important murmur on exam, I would start with an echocardiogram to make sure that the patient did or does not have aortic stenosis or obstructive hypertrophic cardiomyopathy. Most often, however, the physical exam will be normal, and the initial step will be to assess for CAD and the answers to the questions above. In contemporary practice, we have many choices available to us for testing in this situation. One can categorize testing broadly into functional testing (stress ECG or imaging tests) or anatomic testing (cardiac computed tomographic angiography; CCTA). Each has strengths and weaknesses. CCTA gives a more direct answer about CAD and has a very high negative predictive value. If severe and extensive CAD is found, we also have answers. However, if intermediate-severity stenoses are seen, we certainly know the patient has CAD but not whether the symptoms are related, and, if there is a degree of coronary calcium (commonly found with increasing age), the angiography aspect is more uncertain. The functional tests provide

Inappropriate testing for the diagnosis of coronary artery disease

In the last three decades also in our country it has been a huge growth of the use of non invasive testing for diagnosis of CAD. Therefore, appropriateness of prescription in diagnostic testing is crucial. Clinical evaluation is mandatory before a diagnostic test, including the evaluation of pre-test probability of the disease based on symptoms, age, sex and cardiovascular risk factors. The main benefit of testing is in patients with an intermediate pre-test probability. Testing for diagnosis of CAD is rarely appropriate in asymptomatic subjects, except for ECG exercise test in intermediate and high risk individuals, while stress or anatomic imaging is preferable in higher risk individuals. Coronary calcium score should not be used as screening test in asymptomatic subjects, except for excluding CAD in those with low pre-test probability. As far as diabetic patients is concerned, available evidence indicates an unfavorable risk-benefit ratio of extensive CAD screening, except in the presence of high clinical suspicion.

The significance of automatically measured transient ischemic dilation in identifying severe and extensive coronary artery disease in regadenoson, single-isotope technetium-99m myocardial perfusion SPECT

BackgroundThe critical threshold and clinical significance of transient ischemic dilation (TID) for regadenoson, single-isotope 99mTc SPECT myocardial perfusion imaging (MPI) are not defined. MethodsFrom 100 patients with low likelihood of CAD, we derived the abnormal TID threshold (mean + 2 SD). We validated the threshold in a cohort of 547 patients who received one-day, rest/regadenoson-stress, 99mTc-tetrofosmin SPECT-MPI followed by coronary angiography within 6 months. Patients were classified into three CAD severity strata: no significant CAD, mild to moderate CAD, and severe and extensive CAD. ResultsThe abnormal TID threshold was determined to be 1.31. Though mean TID ratios were different between the three CAD severity groups and the derivation cohort (P < .001), there was no difference in the mean TID ratios between the categories of CAD severity or in the prevalence of severe CAD between TID+ and TID− groups (P = .74). By ROC analysis, TID had a poor discriminatory capacity in identifying severe and extensive CAD [AUC of 0.55 (95% CI 0.47-0.62, P = .25)]. Stepwise multivariate logistic analysis demonstrated that adding TID to clinical and perfusion data did not provide incremental diagnostic value (P = .87). ConclusionsThe clinical utility of TID with regadenoson-stress MPI in this era of declining CAD burden is questionable.

Coronary artery disease in patients with atypical chest pain with and without diabetes mellitus assessed with coronary CT angiography

IntroductionCoronary artery disease (CAD) in diabetes mellitus (DM) is often widespread when diagnosed. Non-invasive coronary calcium scoring and coronary CT angiography (CAC-score/CCTA) are accurate in the detection of CAD. This...

Distal vs. non-distal lesions in patients with unprotected left main coronary artery stenosis treated by PCI: does location matter?

Background and objectives: PCI is an increasingly utilized mode of revascularization of patients with unprotected left main coronary artery disease (ULMCA). Distal left main (DLM) interventions are more technically challenging compared with non-distal LM (NDLM) interventions. We sought to compare the twelve months cumulative risk of major adverse cardiac events (MACE) of patients with DLM with those of NDLM disease. Methods: We identified 182 consecutive patients who underwent PCI in ULMCA. Patients were divided according to location of their LM lesion, DLM, 81 patients vs. NDLM, 101 patients. Patients with cardiogenic shock were excluded. Outcome parameters included: Cardiac mortality, MI, repeated target vessel revascularization (TVR), CABG and MACE at 12 months after the index procedure. Results: The baseline clinical characteristics were similar in both groups. Patients with DLM disease had higher rates of two or three vessel disease (77% NDLM, vs. 92% DLM, p=0.09). DES use was not significantly different in NDLM and DLM locations (60% vs. 72%, p=0.1). There were similar rates of cardiac mortality (6.7% NDLM vs. 14.9% DLM, p=0.07), MI (4% vs. 0%, p=0.07), CABG (2% vs. 5%, p=0.3) and TVR (8.9% NDLM vs. 7.9% in DLM, p=0.8). DES deployment significantly and similarly reduced the TVR rates in both locations as compared with BMS use (4.9% NDLM vs. 5.2% DLM, p=0.9). There was no difference in the MACE rates (19.8% NDLM vs. 27.2% DLM, p=0.7) Conclusions: Patients with DLM and NDLM lesions have similar short term outcome despite more extensive CAD. DES use in ULMCA is effective in reducing short term TVR rate unrelated to lesions location.

Leptin-adiponectin ratio and the extent of CAD in pre-diabetic patients undergoing PCI

Background: The obesity-related hormones leptin and adiponectin are independently and oppositely associated with insulin resistance, an important risk factor for coronary artery disease and restenosis after coronary intervention. In this report, we set out to determine the role of the leptin-adiponectin ratio (LAR) in non-diabetic patients with or without impaired glucose tolerance (IGT) undergoing a percutaneous coronary intervention (PCI). Methods: After obtaining informed consent, three hundred unselected PCI patients were enrolled in this prospective single center study. In both stable and acute subjects, assessment was done on the day of discharge and included a fasting glucose and insulin, leptin, adiponectin, and an oral glucose tolerance test (OGTT) in the non-diabetic patients. IGT, or prediabetes, was defined as 2h-glycemia between 140 and 200 mg/dL during an OGTT. For this analysis, known diabetic patients (n=50) and newly diagnosed diabetic patients (2h OGTT>200 mg/dL, n=25) were excluded. Results: Of the 225 PCI patients without a history of diabetes or newly diagnosed diabetes, 141 had a normal OGTT, while 81 were diagnosed with pre-diabetes (IGT). Pre-diabetic patients were older (67±1 vs 63±1, p=0.002) and had a higher BMI (28.0±.5 vs 26.8±.4, p=0.023) and HbA1c (5.89±.04 vs 5.67±.02, p<0.001). LAR was significantly higher in prediabetic patients (4.57±0.48) vs normoglycemic patients (3.45±0.33, p=0.050). LAR was found to be numerically higher in prediabetic vs normoglycemic patients with two and three vessel disease (VD), but not among patients with single vessel disease (VD) (figure 1). In prediabetic patients, LAR was found to be significantly increased with more advanced CAD (p=0.021), independently of stable vs unstable presentation. We did not observe a significant correlation between LAR and the Duke CAD index (p=0.108). More extensive CAD resulted in worse outcome including revascularization rates during a median follow-up of 2.1y in pre-diabetic but not in normoglycemic patients (Log-rank p=0.004). Conclusion: The leptin-adiponectin ratio is related to the extent of CAD in pre-diabetic patients but not in normoglycemic patients. This finding might in part explain the poorer outcome in revascularized patients with impaired glucose tolerance.

Combining Dynamic Modeling With Geometric Constraint Management to Support Low Clearance Virtual Manual Assembly

This research presents a novel approach to virtual assembly that combines dynamic modeling with geometric constraint-based modeling to support low clearance manual assembly of CAD models. This is made possible by utilizing the boundary representation solid model data available in most contemporary CAD representations, which enables (a) accurate collision/physics calculations on exact model definitions, and (b) access to geometric features. Application of geometric constraints during run-time, aid the designer during assembly of the virtual models. The feasibility of the approach is demonstrated using a pin and hole assembly example. Results that demonstrate the method give the user the ability to assemble parts without requiring extensive CAD preprocessing and without over constraining the user to arrive at predetermined final part orientations. Assembly is successful with diametral clearance as low as 0.0001 mm, as measured between a 26 mm diameter hole and pin.

Comparison of Non-Invasive Methods for the Detection of Coronary Atherosclerosis

BACKGROUND:Non-invasive detection of atherosclerosis is critical for its prevention.Objective:To correlate non-invasively detectable indicators of coronary atherosclerosis, or Coronary Artery Disease (i.e., classical risk factors, hs-CRP test results, carotid intima-media thickness, endothelial function, ankle-brachial index and calcium score by computed tomography) with the extent of coronary disease assessed by the Friesinger index from conventional coronary angiography.METHODS:We conducted a prospective study of 100 consecutive patients, mean age 55.1 ± 10.7 years, 55% men and 45% women. Patients with acute coronary syndrome, renal dialytic insufficiency, collagen disease and cancer were not included. All patients were subjected to clinical evaluation and laboratory tests. Endothelial function of the brachial artery and carotid artery were evaluated by high-resolution ultrasound; ankle-brachial index and computed tomography for coronary determination of calcium score were also performed, and non-HDL cholesterol and TG/HDL-c ratio were calculated. All patients were subjected to coronary angiography at the request of the assistant physician. We considered patients without an obstructive lesion (< 29% stenosis) demonstrated by coronary angiography to be normal.RESULTS:Univariate analysis showed that calcium score, HDL-c, TG/HDL ratio and IMT were significantly correlated with the Friesinger index. However, multivariate analysis indicated that only calcium score and low HDL-c levels correlated significantly with the extension of CAD. On the other hand, hs-CRP, LDL-c, flow-mediated dilation, and Framingham score did not correlate with the Friesinger index. ROC analysis showed that calcium score, HDL-c and TG-HDL ratio accurately predicted extensive CAD in a statistically significant manner.CONCLUSION:It is possible to approximately determine the presence and extent of CAD by non-invasive methods, especially by calcium score, HDL-c and TG/HDL-c ratio assays.

Total Arterial Off-Pump versus On-Pump Coronary Revascularization:. Comparison of Early Outcome

To assess differences in the early outcome after complete arterial myocardial revascularization with (ONCAB) or without cardiopulmonary bypass (OPCAB). Out of 870 consecutive CABG procedures 58 OPCAB and 91 ONCAB patients receiving exclusive arterial grafts were analyzed. OPCAB patients had more single-vessel (p < 0.0001), less triple-vessel (p < 0.0001) or left main disease (p = 0.0021), higher angina class (p = 0.003), unstable angina (p < 0.0001) or previous PTCAs (p < 0.0001). ONCAB was associated with longer operations (182.5 +/- 38 vs. 147 +/- 56 min; p = 0.0001) and more anastomoses/patient (3.2 +/- 1 vs. 2 +/- 0.9; p < 0.0001), but incomplete revascularization was similar in both groups (11% vs. 17%; p = ns). ITA use was identical, whereas single left internal thoracic artery (LITA) use (25.9% vs.1%; p < 0.0001) and LITA jump anastomoses (10.3% vs. 7.7%; p < 0.0001) were more frequent in OPCAB. Radial artery (RA) use (89% vs. 46.6%; p < 0.0001) and RA jump anastomoses (57.1% vs. 12.1%; p < 0.0001) were more frequent in ONCAB. Mortality, arrhythmias, cerebro-vascular accidents (CVA), and renal failure were similar, but ventilatory support shorter (8.8 +/- 11.8 vs. 15.6 +/- 9.4 h; p < 0.0001) and cardiac enzyme release smaller (p < 0.0001) after OPCAB with a trend toward less myocardial infarction (1.7% vs. 7.7%; p = 0.12) and low output (1.7% vs. 8.8%; p = 0.089), and more respiratory complications (10.3% vs. 2.2%; p = 0.056). Arterial OPCAB patients have less extensive CAD, but more severe symptoms. Early outcome is similar concerning mortality, arrhythmias, CVA, renal failure, or ICU and hospital stay, but with shorter ventilatory support and lower cardiac enzymes with a trend toward lower myocardial infarction and low output, but higher respiratory complication rates after OPCAB.