Ischemic Changes Research Articles

Differential diagnosis of acute coronary syndrome without ST-segment elevation in a middle-aged patient

Acute Coronary Syndrome (ACS) is an initial diagnosis, which is transformed into the diagnosis of “myocardial infarction”, “unstable angina” or other diagnosis during the diagnostic process. If a patient meets the criteria for myocardial infarction (according to the Fourth Universal Definition of Myocardial Infarction), in the presence of atherothrombosis in the infarct-related coronary artery, Type 1 myocardial infarction is diagnosed. In most of the remaining cases Type 2 myocardial infarction is diagnosed. Acute myocardial injury due to various conditions is separately classified. In the presented case, a 54-year-old patient with a history of arterial hypertension and diabetes mellitus, not adherent to treatment and suffering from obesity, a smoker, was hospitalized with typical new-onset angina pectoris and ischemic changes on the ECG, by ambulance, with the initial diagnosis of “ACS without ST-segment elevation”. The diagnosis changed several times during the examination: “ACS without ST-segment elevation”, “CAD: myocardial infarction without ST-segment elevation”, “Myocardial infarction with non-obstructive coronary arteries (MINOCA)”, “Severe calcified aortic stenosis. Anemia. Type 2 myocardial infarction”. The peculiarity of this case is the debut of high-gradient aortic stenosis in a middle-aged man with clinical manifestations of ACS and high blood troponin level. Causes of severe aortic stenosis manifestation as myocardial infarction with elevation of cardiac-specific troponin in the blood, despite intact coronary vessels, are discussed in this article. The differential diagnosis of myocardial injury is discussed, as the correct diagnostic judgment directly determines the patient’s management strategy.

Functional correlates of ischemic electrocardiographic changes during stress echocardiography. data form stress echo 2030 survey

Abstract Background/Introduction Cardiac stress tests are carried out in populations with a low probability of ischemic heart disease (IHD) much more frequently than in the past. Stress ECG remains a frequently used modality for the diagnosis of IHD in vast areas of the world with limited facilities. Purpose To assess the diagnostic value of stress ECG for diagnosing IHD using inducible regional wall motion abnormalities (RWMA) on stress echocardiography (SE) as the gold standard method of diagnosis. Methods The 12-lead ECG response was retrospectively analyzed in 4317 patients (age 64±13 years, 59.6% males) undergoing SE for chronic coronary syndromes who were prospectively recruited from 39 cardiac centers between March 2021 and February 2024. Exclusion criteria were left bundle branch block or pacemaker rhythm. ECG response was considered ischemic according to standard criteria (if ST-segment deviated >1.0 mm from baseline in ≥2 contiguous leads at 80 ms from J point) during an exercise (n=2980, 69.8%), dobutamine (n = 766, 18.0%), or vasodilator (n=519, 12.2%) SE. All patients underwent a comprehensive SE protocol with an assessment of wall motion score index (WMSI), B-lines (4-site simplified score), left ventricular contractile reserve (LVCR) based on force, coronary flow velocity reserve (CFVR) in the mid-distal left anterior descending artery (LAD), and heart rate reserve (HRR). Results ECG changes occurred in 641 patients (14.8%, Group 1) for the overall studied population. Compared to patients without ECG changes (Group 2, n=3676, 85.2%), patients with ECG changes showed higher values of peak WMSI and lower values of CFVR and LVCR (see table).Amongst patients without inducible RWMA (n=3553), there were 392 (11%) patients with an ischemic ECG at stress (89% specificity). Of 764 patients with inducible RWMA during SE, 249 had an ischemic ECG trace (sensitivity 33%). In patients without inducible RWMA, those with ischemic ECG changes showed similar abnormal stress B-lines (23% vs. 21%, p=0.719), LVCR (61% vs. 63%, p=0.602), CFVR (31% vs 33%, p=0.607) and HRR (37% vs 41%, p=0.097) compared to those without ECG changes. Amongst patients with inducible RWMA and ECG changes, CFVR was significantly lower in patients with ECG changes (39.2% and 60.8%, respectively, p<0.001). Conclusions Simple standard stress ECG diagnostic value in the current era in populations with a low probability of IHD seems to be low. However, during SE, stress-induced ischemic ECG changes are associated with more extensive RWMA and blunted global LVCR, with reduced CFVR in the LAD. Therefore, analysis of ST segment changes during stress imaging studies can offer additional, significant information.

Coronary physiology: no complete diagnosis without acteylcholine

Abstract Introduction In up to 40% of patients with pectanginous symptoms, no obstructive coronary artery disease (NOCAD, no stenosis > 50%) can be detected as the cause, so that the terms ANOCA (angina with no obstructive CAD) or INOCA (ischemia with no obstructive CAD) have been defined. In patients with acute myocardial infarction, 5-20% are diagnosed with MINOCA (myocardial infarction with no obstructive CAD). Microvascular dysfunction (CMD) or coronary spasm has been identified as one of the leading causes of these entities. Further clarification by determining the coronary flow reserve (CFR) an microvascular resistance (IMR) is used to diagnose CMD and is also included in the ESC guidelines. The indices can be determined using thermodilution or ultrasound/doppler wires methods. According to current recommendations, the acteylcholine provocation test is administered in cases of suspected coronary spasm. Despite extensive studies on the safety of ACh testing, many clinics refrain from testing for vasoconstriction disorder although microvascular coronary spasm has been shown to be the leading subgroup of CMD in registry studies. Purpose We want to investigate the necessity of a complete coronary physiological examination, consisting of CRF/IMR and ACh provocation test, when compared to testing without ACh. Methods All 299 patients who underwent complete physiological testing in our clinic between 2021 and 2024 due to ANOCA, INOCA or MINOCA were evaluated retrospectively. Patients completed a coronary physiological examination using thermodilution and an acetylcholine provocation test. The IMR, CFR, fractional flow reserve (FFR), resting full-cycle ratio (RFR) and the ACh test (defined as epicardial spasm >90% reduction in coronary diameter with symptoms and/or ischemic electrocardiographic changes, respectively no epicardial spasm >90% reduction in coronary diameter with symptoms and and ischemic electrocardiographic changes for microvascular spasm) are thus routinely measured. Results Of the total of 299 patients included, 244 (81%) were found to have impaired vasoconstriction with pathologic ACh testing, either alone or in combination with pathologic indices CFR/IMR. The leading finding of pathological spasms was microvascular coronary spasm (66%). 119 patients with normal CFR/IMR had a diagnosis of microvascular (72 patients) or macrovascular spasm (47 patients). 40% of the total patient cohort would have not had a compete diagnosis without the use of Ach testing. Conclusion Physiological testing without the systematic use of ACh testing will misdagnose a significant amout of patients with ANOCA/MINOCA/INOCA. ACh testing should be always performed to complete the diagnosis for these patients

The trends of arterial hypertension and ischemic heart disease in Lithuanian population (1983-2023)

Abstract Background During the past two decades, in Lithuania, the morbidity and mortality from circulatory system diseases such as ischemic heart disease (IHD) have been increasing. The increasing incidence of IHD can be linked to the IHD prevention program implemented in Lithuania, which was launched in 2005. This study aimed to determine and evaluate the prevalence of IHD, their risk factors, and trends among middle-aged (45-64 years) urban males and females in Lithuania over the last 40 years. Methods During our study, the changes in the prevalence of arterial hypertension (AH) and IHD, among Kaunas city inhabitants aged 45-64 years in six population-based cohorts (1982-1983 (n = 1660), 1986-1987 (n = 1152), 1992-1993 (n = 824), 2001-2002 (n = 978), 2006-2008 (n = 4604) and 2023 (n = 554)) were analyzed. AH was defined when the arterial blood pressure was ≥140/90 mmHg or a person had taken antihypertensive drugs during 2 weeks. IHD was defined when a person had a previous myocardial infarction (MI) and/or ischemic changes on electrocardiogram (ECG) were assessed by Minnesota codes. The prevalence of AH and IHD changes were evaluated using regression analysis. Results During 1983-2023, the prevalence of AH among males aged 45-64 significantly increased from 58.7% (1982-1983) to 72.7% (2023) (p = 0.04), but among females aged 45-64 the prevalence of AH tended to decrease from 63.0% (1982-1983) to 50.9% (2023) (p = 0.18). The prevalence of IHD among males aged 45-64 was without significant changes and was from 14.4% (1982-1983) to 13.6% (2023) (p = 0.7), but among females aged 45-64 the prevalence of IHD significantly decreased from 21.7% (1982-1983) to 16.6% (2023) (p = 0.04). Conclusions From 1983 to 2023, among Lithuanian middle-aged urban males, the prevalence of AH significantly increased, but the prevalence of IHD was stable, meanwhile, among Lithuanian middle-aged urban females the prevalence of AH tended to decrease, but the prevalence of IHD significantly decreased. Key messages • From 1983 to 2023, among Lithuanian middle-aged urban males, the prevalence of AH significantly increased, meanwhile among females - tended to decrease. • Over 40 years, the prevalence of IHD among Lithuanian males was without significant changes, but among females - significant decreased.

Myocardial Bridging: a bridge to spasm?

Abstract Introduction Myocardial bridges (MBs) represent a congenital anomaly where a segment of a coronary artery passes through the myocardium, resulting in systolic compression. The role of MBs in causing chest pain has been debated, as coronary blood flow occurs primarily in diastole. MBs are generally considered benign, there is growing evidence implicating them in the pathogenesis of coronary artery spasm (CAS). However, the prevalence of CAS in patients in Europe with MBs, particularly assessed through acetylcholine (ACh) testing, remains poorly defined. Methods We conducted a retrospective analysis of consecutive patients with angina with no obstructive CAD (ANOCA), ischemia with no obstructive CAD (INOCA), or myocardial infarction with no obstructive coronary arteries (MINOCA) undergoing ACh testing between 2021 and 2024 at our centre. Patients with documented MBs on coronary angiography were included. The presence of epicardial CAS, defined as >90% reduction in coronary diameter with symptoms and/or ischemic electrocardiographic changes, was assessed during ACh provocation testing. Clinical characteristics, Fractional flow reserve (FFR), resting full-cycle ratio (RFR), coronary flow reserve (CFR) and the index of microvascular resistance (IMR) were also analyzed. Results From a total of 299 patients who underwent ACh Testing, 21 patients were identified with MBs, (17 Male, 4 Female). The prevalence of focal CAS in the MB among these patients was 90%. None of these patients had abnormal hyperemic (FFR) or non-hyperemic (RFR) measurements. 9 of the 21 patients with MB had increased IMR, and only 1 had a CFR < 2. 1 Patient had both microvascular CAS in addition to focal epicardial CAS. Conclusion This analysis provides valuable insights into the prevalence of CAS in patients with MBs undergoing ACh testing. The findings underscore the importance of considering CAS in the evaluation and management of patients with MBs, particularly during provocative testing. Further prospective studies are warranted to validate these findings and elucidate the clinical implications for risk stratification and treatment strategies in this patient population.

Diagnostic potential of relative changes in high-sensitivity troponin levels during intracoronary acetylcholine provocation testing

Abstract Background Intracoronary acetylcholine (ACh) provocation testing is useful for the diagnosis of vasospastic angina (VSA). However, the positive or negative diagnosis of ACh testing is often challenging when lacking typical anginal symptoms and electrocardiographic changes during provocation tests. We hypothesized that relative changes in cardiac troponin levels during ACh provocation testing may be suggestive of myocardial ischemia and would be helpful for the VSA diagnosis. Purpose To evaluate the diagnostic potential of relative changes in high sensitivity troponin I (hs-TnI) levels during intracoronary ACh provocation test. Methods This preliminary study included a total of 29 patients undergoing invasive coronary angiography with or without ACh provocation tests. Patients were divided into three groups; no ACh provocation tests (i.e. angiography alone), negative ACh tests, and positive ACh tests. Blood samples were obtained twice, before and after angiography, through the arterial sheath to evaluate hs-TnI. The primary measure was relative changes in hs-TnI (i.e. Δhs-TnI). Positive ACh provocation test was defined as total or subtotal coronary occlusion accompanied by chest pain and/or ischemic electrocardiographic changes. Results Of the 29 patients, 10 (34.5%) underwent coronary angiography alone, while ACh provocation testing was performed in 19 (65.5%) patients, of whom 7 (36.8%) and 12 (63.2%) had negative and positive ACh test results. Overall, the mean time interval between the blood sample collections was 76 minutes. Levels of hs-TnI before angiography did not differ significantly in the no, negative, and positive ACh test groups (5.3 [2.8, 8.6] vs. 2.9 [1.3, 8.8] vs. 3.3 [1.6, 8.5] pg/ml, p=0.76), while Δhs-TnI was highest in the positive ACh test group, followed by the negative and no ACh test groups (4.2 [0.5, 8.1] vs. 0.8 [0.4, 4.6] vs. −0.3 [−0.6, 0.3], p=0.002) (Figure). Conclusions In patients undergoing intracoronary ACh testing for the VSA diagnosis, a relative increase in Δhs-TnI during angiography was observed than in those who did not undergo the provocation tests, particularly when the ACh test diagnosis was positive. Our findings suggest that Δhs-TnI has the potential to aid in the positive or negative diagnosis of ACh provocation testing.

Electroencephalographic monitoring in detection and prediction of delayed cerebral ischemia due to non-traumatic subarachnoid hemorrhage

Intensive care of patients with acute non-traumatic subarachnoid hemorrhage primarily relies on diagnostics of delayed cerebral ischemia (DCI). The major difficulty in detecting DCI emerges upon suppression of wakefulness, when clinical assessment of growing neurological deficit becomes complicated. Widely used transcranial dopplerography allows solely to verify a vasospasm development not always leading to DCI exhibiting a multifactorial underlying mechanism. Electroencephalography (EEG) is the only broadly available instrumental tool ensuring a continuous monitoring of cerebral functional status including in subjects at intensive care unit. To date, non-specific EEG parameters pointing at development of acute cerebral injury were identified that provide varying diagnostic and predictive informative value in DCI. We reviewed publications aimed at assessing the data on visual and quantitative EEG parameters such as regional slowing, alpha rhythm spectral power and relative variability, alpha-to-delta power ratio, and detection of epileptiform activity. Having searched international and Russia-wide medical databases, we found only 7 publications quantitatively assessing diagnostic value of EEG monitoring, which showed that for DCI diagnosis its sensitivity ranged from 76% to 100%, and specificity – from 54% to 100%. We also present a clinical case with a 70-year-old female patient who underwent surgery for non-traumatic subarachnoid hemorrhage due to a ruptured aneurysm of the communicating segment of the right internal carotid artery. During the continuous videoEEG monitoring 2 days before clinical deterioration and appearance of ischemic changes in the right cerebral hemisphere on computed tomography scans, an ictal-interictal continuum pattern was noted to emerge. Future studies should be aimed at clarifying and validating the most informative DCI biomarkers including while recording EEG with intracranial electrodes that may contribute to development of automated algorithms for DCI detection.

Assessing chiasm perfusion and postoperative visual function with superior hypophyseal artery indocyanine green angiograms during endoscopic endonasal surgery.

To date, there are no validated intraoperative tools to predict postoperative visual function following endoscopic endonasal surgery (EES). Assessment of post-surgical vision during surgery can help in postoperative planning and disposition and inform surgical decisions in real-time. The objective of this study was to evaluate the capability of intraoperative endoscopic indocyanine green (ICG) angiography to measure optic chiasm perfusion and determine its relationship with postoperative visual function. A retrospective review was performed on patients undergoing EES for sellar andsuprasellar lesions. ICG was injected prior to surgical closure at a time when the optic chiasm and anterior circulation were visible. Luminescence of the superior hypophyseal artery (SHA) branches enveloping the optic chiasm was registered 10seconds after ICG penetration into the anterior cerebral arteries (ACAs). Pre and post-operative visual acuity and field exams were used to assess visual function. Patients with and without new deficits were compared to examine statistical association with intraoperative ICG findings. Twenty patients were included (mean age 49years, 55% female). Eighteen patients displayed stable or improved vision after resectionand demonstrated luminescence of all chiasmatic branches within 10s of ACA fluorescence. Two patients experienced new postoperative visual deficits. Upon review, their ICG administrations showed no fluorescence of the SHA branches enveloping the chiasm. A lack of chiasm fluorescence within ten seconds of ACA fluorescence was associated with new postoperative vision deficits (p = 0.005). This study shows that the lack of ICG fluorescence of SHA branches at the chiasm correlates with ischemic changes and new post-operative bitemporal hemianopsia. Lack of chiasm fluorescence after 10seconds of observation reflects compromised chiasm perfusion and likely new post-surgical visual deficits.

Trends over time in oral anticoagulation and stroke rates in atrial fibrillation: A community-based study

ObjectivesOver the last decade, direct oral anticoagulants (DOAC) have become preferred over warfarin for stroke prevention in atrial fibrillation (AF). The objectives of this study were to quantify the shift over time from warfarin to DOACs and parallel changes in ischemic and hemorrhagic stroke rates in AF. Materials and methodsThis community-based retrospective study was undertaken within a single integrated health care network from 2011 to 2021. Changes over time in warfarin and DOAC use were quantified by year, both overall and stratified by CHA2DS2-VASc score. Ischemic and hemorrhagic stroke rate changes over time were evaluated by Poisson regression. Stroke rates were evaluated in different time eras: 2011–2015 and 2016–2021. ResultsAmong 31,978 AF patients followed an average of 5.5 years, any OAC use increased from 50.2 % (2011) to 59.4 % (2020) (p < 0.001). Warfarin use decreased from 49.3 % to 30.8 %, while DOAC use increased from 2.0 % to 30.8 % (both p < 0.001). In 2020, patients with CHA2DS2-VASc 0–1 and 2–5 were more likely to use DOACs than warfarin (18.6 % vs. 6.7 %; 33.0 % vs. 28.2 %), whereas in CHA2DS2-VASc 6–9 DOACs were used less frequently (30.0 % vs. 40.8 %). Ischemic stroke rates significantly increased by 19 % (95 % CI: 7 %, 32 %) from 2011 to 2015, but significantly decreased by 18 % (10 %, 26 %) from 2016 to 2021. Hemorrhagic stroke rates stabilized in 2016–2021 (+3 %; −18 %, 30 %) after increasing in 2011–2015 (+36 %; 4 %, 78 %). ConclusionImprovements in ischemic and hemorrhagic stroke rates coincided temporally with increased uptake of OACs and a shift toward increased uptake of DOACs relative to warfarin.

Utility of the AngelMed Guardian System in myocardial bridging: a case report

BackgroundMyocardial bridging (MB) is a known congenital anomaly in which a segment of the coronary artery transverses from the epicardium through the myocardium. MB may clinically manifest as recurrent angina, acute coronary syndrome, ventricular dysrhythmia, and even sudden cardiac death. On electrocardiogram (EKG), MB can present with findings consistent with significant ST-segment changes. The AngelMed Guardian System (the Guardian device) was developed in an effort to optimize the time from the onset of myocardial ischemia to intervention. The device analyzes myocardial electrical changes and alerts the patient to seek emergent medical evaluation if an acute ST-segment deviation is detected. We describe the first documented case of the Guardian device detecting acute ST-segment changes secondary to myocardial bridging.Case PresentationA 50-year-old male, with a history of percutaneous coronary intervention of the proximal left anterior descending (LAD) artery, presented to his cardiologist’s office with reports of recurrent, atypical chest pain. The Guardian device was implanted. One month after implantation, the patient experienced chest pain and was alerted by the Guardian device to seek emergent medical evaluation. Initial EKG and high-sensitivity troponins were negative for acute ischemia. Guardian device interrogation revealed significant ST depressions, encouraging further ischemic evaluation. The exercise myocardial perfusion imaging revealed an apical reversible defect. Left heart catheterization revealed a large segment of mid-LAD MB with the patient’s previous LAD stent noted to be widely patent along with no evidence of new obstructive coronary disease. Following the identification of the MB, medication regimen adjusted and the patient denied recurrence of chest pain or Guardian alerts.ConclusionsWe describe the first documented case of the Guardian device detecting acute ST-segment changes that were secondary to myocardial bridging. The Guardian device appropriately documented an ischemic event not appreciated with initial EKG or troponin testing. With the assistance of the Guardian device, we were able to rapidly identify MB as the cause for the ischemic EKG changes and subsequent abnormal stress test, optimize medical management, and prevent recurrent atypical chest pain along with office and hospital visits.

Dual Energy CT for Deep Learning-Based Segmentation and Volumetric Estimation of Early Ischemic Infarcts.

Ischemic changes are not visible on non-contrast head CT until several hours after infarction, though deep convolutional neural networks have shown promise in the detection of subtle imaging findings. This study aims to assess if dual-energy CT (DECT) acquisition can improve early infarct visibility for machine learning. The retrospective dataset consisted of 330 DECTs acquired up to 48h prior to confirmation of a DWI positive infarct on MRI between 2016 and 2022. Infarct segmentation maps were generated from the MRI and co-registered to the CT to serve as ground truth for segmentation. A self-configuring 3D nnU-Net was trained for segmentation on (1) standard 120kV mixed-images (2) 190keV virtual monochromatic images and (3) 120kV + 190keV images as dual channel inputs. Algorithm performance was assessed with Dice scores with paired t-tests on a test set. Global aggregate Dice scores were 0.616, 0.645, and 0.665 for standard 120kV images, 190keV, and combined channel inputs respectively. Differences in overall Dice scores were statistically significant with highest performance for combined channel inputs (p < 0.01). Small but statistically significant differences were observed for infarcts between 6 and 12h from last-known-well with higher performance for larger infarcts. Volumetric accuracy trended higher with combined inputs but differences were not statistically significant (p = 0.07). Supplementation of standard head CT images with dual-energy data provides earlier and more accurate segmentation of infarcts for machine learning particularly between 6 and 12h after last-known-well.

6657 A rare case of a composite pheochromocytoma and ganglioneuroma in a 47-year-old male

Abstract Disclosure: C. Ekladios: None. M.J. Levine: None. Introduction: Pheochromocytoma is a rare tumor that originates from adrenal chromaffin cells. It remains a diagnostic challenge due to its diverse clinical manifestations. We present a case of pheochromocytoma, shedding light on its atypical presentation and diagnostic complexity.Case reportA 47-year-old male was referred to our clinic with a recent diagnosis of pheochromocytoma. Patient started having symptoms approximately two months prior to referral to our office. He initially presented to the emergency department (ED) with generalized weakness for three days, accompanied by feelings of “rushing of blood to the head” and a “rush of blood in the arms” every time he laid down. Symptoms would last for a few seconds and resolve without intervention. Vitals signs and physical examination (PE) were within normal limits. He had basic laboratory studies including BMP and CBC without any abnormalities. He was discharged home with instructions to follow-up outpatient. He returned to the ED two days after with a chief complaint of left sided chest pain associated with palpitations, pain was non-persistent, lasting a few seconds. On presentation his blood pressure was 142/89 mmHg, Pulse: 66 bpm, Temperature: 98.4 °F, and oxygen Saturation 100%. On PE, he had clear bilateral air entry and regular heart rate with no murmurs noted, EKG demonstrated no ischemic changes. Chest Xray showed no evidence of cardiopulmonary disease. A CTA revealed no pulmonary embolism, pleural effusion, or pneumothorax. However, a large heterogeneous adrenal mass was partially visualized, measuring 8.3 cm anteroposteriorly concerning for adrenal cortical carcinoma. His labs were pertinent for Metanephrine level of 0.52 nmol/L (nl:0-0.49) and Normetanephrine of 4.22 nmol/L (nl:0-0.89). Aldosterone level is 16.2 ng/dL and Renin activity was 0.1ng/mL. An abdominal CT scan confirmed a left adrenal mass measuring approximately 9.2 x 8.8 cm transaxially and 9.9 cm craniocaudal. He was seen in our office after discharge, at that time he was still experiencing tingling in both lower extremities that sometimes would wake him up from sleep. His blood pressure at the office was 125/83 mm Hg. In preparation for the surgery, we started treatment with Prazosin, followed by addition of Metoprolol succinate. Further work-up included a dexamethasone suppression test that ruled out Cushing’s syndrome and a negative RET proto-oncogene, ruling out MEN 2. Patient underwent laparoscopic left adrenalectomy without complications. Pathology results interestingly showed a composite pheochromocytoma and ganglioneuroma constituting 5 % of the mass volume, Ki-67 proliferative index was less than 1% for the pheochromocytoma and overall findings were consistent with a benign tumor.ConclusionOur case report emphasizes the necessity of a high index of suspicion for diagnosing pheochromocytoma in the absence of the classic symptoms. Presentation: 6/2/2024

Safety and Usefulness of Intracoronary Acetylcholine 200 μg Into the Left Coronary Artery as Vasoreactivity Testing: Comparisons With Intracoronary Acetylcholine Maximum 100 μg.

We retrospectively analyzed the usefulness and safety of intracoronary acetylcholine (ACh) 200 μg into the left coronary artery (LCA) as vasoreactivity testing compared with intracoronary ACh 100 μg. We recruited 1433 patients who had angina-like chest pain and intracoronary ACh testing in the LCA, including 1234 patients with a maximum ACh 100 μg and 199 patients with a maximum ACh 200 μg. ACh was injected in incremental doses of 20/50/100/200 μg into the LCA. Positive spasm was defined as ≥ 90% stenosis, usual chest pain, and ischemic electrocardiogram (ECG) changes. The incidence of coronary constriction ≥ 90%, usual chest pain, and ischemic ECG changes with a maximum ACh of 100 μg was markedly higher than that with a maximum ACh of 200 μg. The frequency of unusual chest pain in patients with a maximum ACh of 200 μg was higher than that in those with a maximum ACh of 100 μg (13% vs. 3%, p < 0.001). In patients with rest angina, positive spasm of maximum ACh 100 μg was significantly higher than that of maximum ACh 200 μg, whereas there was no difference regarding positive spasm in patients with atypical chest pain between the two ACh doses. Major complications (1.38% vs. 1.51%, p = 0.8565) and the occurrence of paroxysmal atrial fibrillation (1.81% vs. 2.63%, p = 0.6307) during ACh testing in the LCA were not different between the two maximum ACH doses. Intracoronary ACh 200 μg into the LCA is clinically useful and safe for vasoreactivity testing when intracoronary ACh 100 μg dose not provoke spasms.

A case of gastrointestinal perforation following transarterial embolization for an intramural hematoma after cold snare polypectomy of an adenoma in the transverse colon.

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

In vivo revascularization and tissue effects of uterine artery embolization with starch microspheres in sheep.

In uterine artery embolization (UAE) for the treatment of fibroids, nondegradable particles permanently occlude the uterine artery (UA). These particles remain in the vessels and can cause secondary undesirable effects, such as severe pain after embolization and fertility issues. In this prospective experimental study, we aimed to evaluate the angiographic recanalization, local and systemic reactions, and uterine damage occurring after performing UAE with newly developed degradable starch microspheres (DSMs) in sheep. Under general anesthesia, eight nonpregnant sheep underwent bilateral UAE using DSMs to achieve stasis. Angiographic evaluation was performed on days 1, 3 and 7 after embolization to assess in vivo recanalization. In addition, the angiographic series were scored via a modified embolization score. A postmortem tissue examination was performed to determine whether DSMs and foreign body inflammatory reactions were present and to assess uterine necrosis. Complete bilateral embolization of the UA and cervicovaginal branches was achieved in all treated animals. Recanalization of the occluded arteries was evident in 25 of 27 arteries during the angiographic evaluation. In all sheep, there were multifocal areas of uterine necrosis, and some uterine vessels contained intraluminal material consistent with DSMs. The average weight of both uterine horns was significantly correlated with both the number of microspheres needed for complete embolization (r = 0.69, ρ<0.01) and the average percentage of necrosis in both uterine horns (r = 0.64, ρ<0.05). Our findings demonstrated the efficacy of vascular embolization with DSM by inducing ischemic changes in the uterus and subsequent recanalization of previously occluded arteries.

EXPLORING THE ROLE OF NGS IN GENETIC PROFILING FOR UNDERSTANDING NON-VIOLENT SUDDEN CARDIAC DEATH IN ASTANA

Sudden cardiac death is an unexpected and often unpredictable event that can have serious consequences for the health and lives of individuals not only in middle age but also in young individuals. Mutations, particularly in genes associated with cardiovascular disease, may play a main role in the development of such events, but their exact role and impact require detailed study and prevention of the development of new mutations by using the Next-generation sequencing (NGS). To evaluate the diagnostic importance of next-generation sequencing (NGS) by using our developed cardiogenetic panel in molecular autopsy in sudden non-violent deaths. A prospective study was conducted from 2018 to 2023 focusing of young individuals aged 18 to 45 years resigning in Astana who died of non-violent CVD. The data were analyzed from RSCE "Forensic Expertise Centre of the Ministry of Justice of the Republic of Kazakhstan" "Research Institute of Forensic Expertise" in Astana, blood samples were obtained from SCD victims for further DNA extraction. We implemented a next-generation sequencing (NGS) using the customized panel to target enrichment of coding sequences of 96 candidate genes in molecular autopsies of young adults who died of SCD. All identified genetic variants were classified according to ACMG guidelines in cases with non-diagnostic and diagnostic cardiac abnormalities (ischemic heart disease postmortem). Targeted sequencing and stepwise filtering of annotated variants identified 251 unique variants in 86 genes out of 96 in the entire group of cases studied. In patients with SCD with ischemic changes in the heart postmortem, the most frequent mutations were identified in the TTN, MYBPC3, LAMA2, MYH6 and GAA genes. Pathogenic variants in the genes of ion channels KCNQ1, KCNJ2, SCN5A, RYR2 were detected in individuals with non-diagnostic structural anomalies of the heart. Genetic screening of individuals who died of SCD identified variants with likely pathogenic functional effects with high frequency in 63% and 35% of SCD cases with non-diagnostic and diagnostic cardiac abnormalities, respectively, showing the high diagnostic value of genetic screening using a panel of genes for targeted NGS. Data from our prospective study have shown that genetic testing using NGS in young Astana victims with SCD results in a significant number of mutations, consequently, may allow genetic counselling of relatives to prevent SCD due to coronary heart disease and arrhythmias and may support differential diagnosis postmortem. Supported by Committee of Science of the of Science and Higher Education of Republic of Kazakhstan (AP1486990) and Nazarbayev University CRP(211123CRP1608).

B - 3 The Role of Artificial Intelligence: Utilization of the Meyers Battery for Diagnostically Differentiating a Complex Neuropsychological Case

Abstract Objectives As medical technology progresses, artificial intelligence (AI) is becoming a common method for providing diagnostic information to patients. In neuropsychology, the Meyers Neuropsychological Battery (MNB) provides impartial data through artificial intelligence. The following case illustrates how AI provided diagnostic clarity and aided in treatment planning. Method A 65-year-old female was referred by her neurosurgeon due to cognitive decline, delusions and hallucinations, and episodes of aggression toward her caretaker. A full, comprehensive neuropsychological examination was administered. Her medical history was remarkable for hypertension, hypercholesterolemia, thyroid cancer, two cerebrovascular accidents, traumatic brain injury, and multiple ischemic strokes. The patient’s most recent imaging was remarkable for chronic encephalomalacia involving the R basal ganglia, mild chronic small vessel ischemic changes, a ventricular shunt within the anterior horn of the R lateral ventricle, and post-coil embolization of a right supraclinoid artery. Results The patient was administered the MNB along with psychological measures. Results were consistent with diffuse and lateralized (RCH &amp;gt; LCH) neuropsychological impairment. Employing the MNB algorithms and AI, this patient’s data matched statistically with Multi-Infarct Dementia, Hydrocephalus, and Lewy Body Dementia. Conclusion These independent applications and AI enable neuropsychologists to respond beyond the “referral question” and provide an objective perspective unique to the patient’s neuropsychological profile. AI is not applied as the only diagnostic approach but rather provides the patient’s medical team with an alternative perspective regarding the entire neuropsychological picture. MNB’s AI not only aids in “matching” neurological conditions to the patient’s profile but also excludes proposed diagnoses in question and underscores a realistic treatment plan.

The treatment effect across ASPECTS in acute ischemic stroke: Analysis from the AcT trial.

Early ischemic changes on baseline imaging are commonly evaluated for acute stroke decision-making and prognostication. We assess the association of early ischemic changes on clinical outcomes and whether it differs between intravenous tenecteplase and Alteplase. Data are from the phase 3, Alteplase compared to Tenecteplase (AcT) trial. Subjects with anterior circulation stroke were included. Early ischemic changes were assessed using the Alberta Stroke Program Early CT score (ASPECTS). Efficacy outcomes included modified Rankin scale (mRS) 0-1, mRS 0-2, and ordinal mRS at 90 days. Safety outcomes included 24-h symptomatic intracerebral hemorrhage (sICH), any hemorrhage on follow-up scan, and 90-day mortality rate. Mixed-effects logistic regression was used to assess the association of ASPECTS (continuous and categorical (0-4 vs 5-7 vs 8-10)) with outcomes and if these associations were modified by thrombolytic type after adjusting for age, sex, and baseline stroke severity. Of the 1577 patients in the trial, 901 patients (56.3%; median age 75 years (IQR 65-84), 50.8% females, median National Institute of Health Stroke Scale (NIHSS) 14 (IQR 17-19)) with anterior circulation stroke were included. mRS 0-1 at 90 days was achieved in 1/14 (0.3%), 43/160 (14.7%), and 252/726 (85.1%) in the ASPECTS 0-4, 5-7, and 8-10 groups respectively. Every one-point decrease in ASPECTS was associated with 2.7% and 1.9% decrease in chances of mRS 0-1 and mRS 0-2 at 90 days, respectively, and 1.9% chances of increase in mortality at 90 days. Subgroup analysis in endovascular thrombectomy (EVT)-treated population showed similar results. Thrombolytic type did not modify this association between ASPECTS and 90-day mRS 0-1 (P-interaction 0.75). There was no significant interaction by thrombolytic type with any other outcomes. Similar to prior studies, we found that every one-point decrease in ASPECTS was associated with poorer clinical and safety outcomes. This effect did not differ between alteplase and tenecteplase. Data shall made available on reasonable request from the PI (BMM).

Effect of Coronary Collateral Supply on Left Ventricular Global Longitudinal Strain after Recanalization of Chronic Total Occlusion.

Percutaneous coronary intervention (PCI) to chronic total occlusion (CTO) is still a subject of debate. The primary goal of revascularization is to provide symptomatic relief and enhance left ventricular (LV) functions. Global longitudinal strain (GLS) is proven to be more sensitive than the ejection fraction (EF), especially for subtle ischemic changes. The purpose of this study was to investigate the improvement in LV GLS after revascularization of symptomatic stable coronary patients with single-vessel CTO, categorized according to their collateral supply grades. Sixty-nine patients with successful CTO-PCI were grouped, according to their collateral supply grades, as well-developed (WD) and poor collateral groups and followed-up for 3 months. Basal characteristics were similar for both groups, except for a lower EF (p = 0.04) and impaired GLS (p < 0.0001) in the poor collateral group. At the end of 3 months follow-up, symptomatic relief was similar in both groups (p = 0.101). GLS improvement reached statistical significance only for the poor collateral, not for the WD group (p < 0.0001 and p = 0.054, respectively). The EF did not change significantly in both groups. Poorly collateralized CTO lesions may not only result in baseline LV dysfunction, but also appear to carry potential for recovery after revascularization. This may not be the case for WD collaterals.

Deep Learning-Based ASPECTS Algorithm Enhances Reader Performance and Reduces Interpretation Time.

ASPECTS is a long-standing and well documented selection criteria for acute ischemic stroke treatment, however, the interpretation of ASPECTS is a challenging and time-consuming task for physicians with significant interobserver variabilities. We conducted a multi-reader, multi-case study in which readers assessed ASPECTS without and with the support of a deep learning (DL)-based algorithm in order to analyze the impact of the software on clinicians' performance and interpretation time. A total of 200 NCCT scans from 5 clinical sites (27 scanner models, 4 different vendors) were retrospectively collected. Reference standard was established through the consensus of three expert neuroradiologists who had access to baseline CTA and CTP data. Subsequently, eight additional clinicians (four typical ASPECTS reader and four senior neuroradiologists) analyzed the NCCT scans without and with the assistance of CINA-ASPECTS (Avicenna.AI, La Ciotat, France), a DLbased FDA-cleared and CE-marked algorithm designed to automatically compute ASPECTS. Differences were evaluated in both performance and interpretation time between the assisted and unassisted assessments. With software aid, readers demonstrated increased region-based accuracy from 72.4% to 76.5% (p<0.05), and increased ROC AUC from 0.749 to 0.788 (p<0.05). Notably, all readers exhibited an improved ROC AUC when utilizing the software. Moreover, use of the algorithm improved the score-based inter-observer reliability and correlation coefficient of ASPECTS evaluation by 0.222 and 0.087 (p<0.0001), respectively. Additionally, the readers' mean time spent analyzing a case was significantly reduced by 6% (p<0.05) when aided by the algorithm. With the assistance of the algorithm, readers' analyses were not only more accurate but also faster. Additionally, the overall ASPECTS evaluation exhibited greater consistency, less variabilities and higher precision compared to the reference standard. This novel tool has the potential to enhance patient selection for appropriate treatment by enabling physicians to deliver accurate and timely diagnosis of acute ischemic stroke. ASPECTS = Alberta Stroke Program Early Computed Tomography Score; DL = Deep Learning; EIC = Early Ischemic Changes; ICC = Intraclass Correlation Coefficient; IS = Ischemic Stroke; ROC AUC = Receiver Operating Characteristics Area Under the Curve.