Major Coronary Arteries Research Articles

Association of perivascular fat attenuation on computed tomography and heart failure with preserved ejection fraction.

Heart failure with a preserved ejection fraction (HFpEF) is associated with chronic inflammation. We aimed to investigate the association between pericoronary adipose tissue attenuation (PCATA) on coronary computed tomography angiography as a novel noninvasive marker of pericoronary inflammation and the presence of HFpEF. This retrospective study included 607 outpatients (median age, 65years; 50% male) who underwent both echocardiography and coronary computed tomography angiography. Patients with obstructive coronary artery disease were excluded from this study. PCATA was compared between patients with and without HFpEF, which was diagnosed according to the Heart Failure Association (HFA)-PEFF score. PCATA was assessed at the proximal 40-mm segments of all three major coronary arteries on coronary computed tomography angiography. Patients with HFpEF had higher PCATA in all coronary arteries compared to the control participants: left anterior descending artery (LAD), -65.2±6.9 Hounsfield units (HU) vs. -68.1±6.7 HU; left circumflex artery (LCX), -62.7±6.8 HU vs. -65.4±6.6 HU; and right coronary artery (RCA), -63.6±8.5 HU vs. -65.5±7.7 HU (P<0.01). Multivariate logistic regression analysis, including conventional risk factors, revealed that PCATA per standard deviation in the LAD (odds ratio [OR], 1.449; 95% confidence interval [CI], 1.152-1.823), LCX (OR, 1.634; 95% CI, 1.283-2.081), and RCA (OR, 1.388; 95% CI, 1.107-1.740) were independently associated with HFpEF. The association between PCATA and HFpEF was mostly consistent across various patient clinical characteristics. The left ventricular mass and left atrial volume index showed a mild correlation with LAD-PCATA (ρ=0.13 [P<0.01] and ρ=0.24 [P<0.01]) and LCX-PCATA (ρ=0.16 [P<0.01] and ρ=0.23 [P<0.01]). High PCATA score was significantly associated with the presence of HFpEF. Our results suggest that inflammation in the pericoronary artery adipose tissue is one of the underlying mechanisms of HFpEF.

Association between CZT‑SPECT myocardial blood flow and coronary stenosis: A cross‑sectional study.

The association between the quantitative and semi-quantitative parameters of myocardial blood flow obtained using cadmium-zinc-telluride single photon emission computed tomography (CZT-SPECT) and coronary stenosis remains unclear. Therefore, the objective of the present study was to evaluate the diagnostic value of two parameters obtained using CZT-SPECT in patients with suspected or known coronary artery disease. A total of 24 consecutive patients who underwent CZT-SPECT and coronary angiography within 3 months of each other were included in the study. To evaluate the predictive ability of the regional difference score (DS), coronary flow reserve (CFR), and the combination thereof for positive coronary stenosis at the vascular level, receiver operating characteristic (ROC) curves were plotted and the area under the curves (AUCs) were calculated. Comparisons of the reclassification ability for coronary stenosis between different parameters were assessed by calculating the net reclassification index (NRI) and the integrated discrimination improvement (IDI). The 24 participants (median age: 65 years; range: 46-79 years; 79.2% male) included in this study had a total of 72 major coronary arteries. When stenosis ≥50% was defined as the criteria for positive coronary stenosis, the AUCs and the 95% confidence interval (CI) for regional DS, CFR, and the combination of the two indices were 0.653 (CI, 0.541-0.766), 0.731 (CI, 0.610-0.852) and 0.757 (CI, 0.645-0.869), respectively. Compared with single DS, the combination of DS and CFR increased the predictive ability for positive stenosis, with an NRI of 0.197-1.060 (P<0.01) and an IDI of 0.0150-0.1391 (P<0.05). When stenosis ≥75% was considered as the criteria, the AUCs were 0.760 (CI, 0.614-0.906), 0.703 (CI, 0.550-0.855), and 0.811 (CI, 0.676-0.947), respectively. Compared with DS, CFR had an IDI of -0.3392 to -02860 (P<0.05) and the combination of DS and CFR also enhanced the predictive ability, with an NRI of 0.0313-1.0758 (P<0.01). In conclusion, both regional DS and CFR had diagnostic values for coronary stenosis, but the diagnostic abilities differed in distinguishing between different degrees of stenosis, and the efficiency was improved with a combination of DS and CFR.

Coronary artery disease is associated with impaired atrial function regardless of left ventricular filling pressure

BackgroundLeft atrial (LA) strain is impaired in left ventricular (LV) diastolic dysfunction, associated with increased LV end diastolic pressure (LVEDP). In patients with preserved LV ejection fraction (LVEF), coronary artery disease (CAD) is known to impair LV diastolic function. The relationship of LVEDP with CAD and impact on LA strain is not well studied. Methods and resultsPatients with LVEF >50% (n = 37, age 61 ± 7 years) underwent coronary angiography, high-fidelity LV pressure measurements and cardiac magnetic resonance imaging. LA volumes, LA emptying fraction (LAEF), LA reservoir strain (LARS) and LA long-axis shortening (LALAS) were measured. By coronary angiography, patients were assigned into 3 groups: severe-CAD (n = 19, with obstruction of major coronary arteries >70% and/or history of coronary revascularization), mild-to-moderate-CAD (n = 10, obstruction of major coronary arteries 30–60%), and no-CAD (n = 8, obstruction of major coronary arteries and branches <30%). Overall, LVEF was 65 ± 8% and LVEDP was 14.4 ± 5.6 mmHg. Clinical characteristics, LVEDP and LV function measurements were similar in 3 groups. Severe-CAD group had lower LAEF, LALAS and LARS than those in no-CAD group (P < 0.05 all). In regression analysis, LARS and LALAS were associated with CAD severity and treatment with Nitrates, whereas LAEF and LAEFactive were associated with CAD severity, treatment with Nitrates and LA minimum volume (P < 0.05 all). LAEFpassive was associated with LVED volume (P < 0.05). ConclusionsLA functional impairment may be affected by coexistent CAD severity, medications, in particular, Nitrates, and loading conditions, which should be considered when assessing LA function and LA-LV interaction. Our findings inspire exploration in a larger cohort.

Role of Dual-Acquisition Noninvasive Cardiac CT Imaging for the Detection of Vasospastic Angina.

Vasospastic angina (VSA) is characterized by chest pain at rest with transient ischemic electrocardiographic changes in the ST segment, and a prompt response to nitrates. Vasospastic angina is among the most frequent of the coronary artery diseases in Asia, and coronary computed tomography angiography (CCTA) may become available as a non-invasive diagnosis method. We prospectively enrolled 100 patients with suspected vasospastic angina at two centers from 2018 to 2020. All patients underwent baseline CCTA without a vasodilator in the early morning followed by catheterized coronary angiography and spasm testing. CCTA with intravenous infusion of nitrate (IV) was repeated within 2 weeks of baseline CCTA. Vasospastic angina as detected by CCTA was defined as significant stenosis (≥50%) with negative remodeling without definite plaques or diffuse small diameter (<2 mm) of a major coronary artery with a beaded appearance on baseline CT that completely dilated on IV nitrate CT. We analyzed diagnostic performance of dual-acquisition CCTA for the detection of vasospastic angina. The patients were categorized into three groups according to their provocation test result (negative, n = 36; probable positive, n = 18; positive, n = 31). The diagnostic accuracy in terms of CCTA per patient had a sensitivity of 55% (95% CI, 40-69), specificity of 89% (95% CI, 74-97), positive predictive value (PPV) of 87% (95% CI, 72-95), and negative predictive value (NPV) of 59% (95% CI, 51-67). Dual-acquisition CCTA can support the non-invasive detection of vasospastic angina with relatively good specificity and PPV. CCTA was helpful for non-invasive screening of variant angina.

Prognosis Related to Reperfusion Therapy Post-Acute Coronary Syndrome in Secondary Care: Long-Term Survival Analysis in the ERICO Study.

Relationship between reperfusion therapy post-acute coronary syndrome (ACS) and mortality in secondary care is not well-known. To evaluate the impact of three therapeutic strategies: (1) exclusive medical therapy, (2) percutaneous coronary intervention (PCI) and (3) coronary artery bypass grafting (CABG) on long-term survival of participants in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. Survival analyses for all-cause, cardiovascular (CVD) and coronary artery disease (CAD) mortality were performed according to three therapeutic strategies (exclusive medical therapy, PCI or CABG). Cox regression models were used to estimate the hazard ratio (HR) with respective 95% confidence interval (95%CI) from 180 days to four years of follow-up after ACS. Models are presented as crude, age-sex adjusted and further adjusted for previous CAD, ACS subtype, smoking, hypertension, dyslipidemia, left ventricular ejection fraction and according to the number of obstructed (≥ 50%) major coronary arteries. Among 800 participants, the lowest crude survival rates were detected among individuals who underwent CABG (all-cause and CVD). CABG was correlated to CAD (HR: 2.19 [95% CI: 1.05-4.55]). However, this risk lost significance in the full model. PCI was associated to lower probability of fatal events during four-year follow-up: all-cause [multivariate HR: 0.42 (95% CI: 0.26-0.70)], CVD [HR: 0.39 (95% CI: 0.20-0.73)] and CAD [multivariate HR: 0.24 (95% CI: 0.09-0.63)] compared to those submitted to exclusive medical therapy. In the ERICO study, PCI after ACS was associated to better prognosis, particularly CAD survival.

Systematic coronary physiology improves level of agreement in diagnostic coronary angiography

ObjectiveThe training of interventional cardiologists (ICs), non-interventional cardiologists (NICs) and cardiac surgeons (CSs) differs, and this may be reflected in their interpretation of invasive coronary angiography (ICA) and management plan....

Coronary CT angiography for preoperative evaluation of non-cardiac surgery in patients with thoracic tumors: preliminary exploratory analysis in a retrospective cohort

PurposeNoninvasive coronary CT angiography (CCTA) was used to retrospectively analyze the characteristics of coronary artery disease (CAD) in patients with thoracic tumors and the impact of the results on clinical surgery decision-making, thus increasing the understanding of perioperative cardiac risk evaluation.MethodA total of 779 patients (age 68.6 ± 6.6 years) with thoracic tumor (lung, esophageal, and mediastinal tumor) scheduled for non-cardiac surgery were retrospectively enrolled. Patients were divided into two groups: accepted or canceled surgery. Clinical data and CCTA results were compared between the two groups, and multivariate logistic regression analysis was performed to determine predictors of the events of cancellations of scheduled surgeries.Results634 patients (81.4%) had non-significant CAD and 145 patients (18.6%) had significant CAD. Single‑, 2‑, and 3‑ vessel disease was found in 173 (22.2%), 93 (11.9%) and 50 (6.4%) patients, respectively. 500 (64.2%), 96 (12.3%), 96 (12.3%), 56 (7.2%) and 31 (4.0%) patients were rated as CACS 0, 1–99, 100–399, 400–999 and > 1000, respectively. Cancellations of scheduled procedures continue to increase based on the severity of the stenosis and the number of major coronary artery stenosis. The degree of stenosis and the number of vascular stenosis were independent predictors of cancelling scheduled surgery.ConclusionsFor patients with thoracic tumors scheduled for non-cardiac surgery, the results suggested by CCTA significantly influenced surgery planning and facilitated to reduce perioperative cardiovascular events.

Multi-vessel giant coronary artery aneurysms: An unusual cause of chest pain

We describe an unusual case of multi-vessel giant coronary artery aneurysms complicated by acute coronary syndrome despite escalation of therapy. A 65-year-old man with hypertension and hypercholesterolemia presented to clinic with atypical chest pain over 4 months. Outpatient computed tomography coronary angiography (CTCA) demonstrated giant coronary aneurysms involving all 3 major coronary arteries. Outpatient coronary angiogram findings were in concordance with the CTCA with no definite obstructive coronary disease. Myocardial perfusion imaging was normal. He was commenced on dual antiplatelet therapy (DAPT). At 6 months, he presented with chest pain and non-ST-elevation myocardial infarction. Repeat coronary angiogram demonstrated occluded first septal LAD branch which previously had aneurysmal dilatation. DAPT was changed to long-term oral anticoagulation. He remains well at 18 months. This case highlights the importance of multi-modality imaging in the diagnosis and workup of coronary artery aneurysms and challenges in management; an individualized approach is required.

Successful Management of a Very Unusual Coronary Pattern in Transposition of the Great Arteries.

Coronary artery anatomy is the key to a successful arterial switch operation in transposition of the great arteries. We came across an unusual coronary pattern in a child with transposition in which the three major coronary arteries were seen arising from all three aortic sinuses. This coronary pattern is the first of its kind in transposition, and this case report emphasizes the difficulty in translocating such a rare coronary pattern while performing an arterial switch operation.

IgG4-related disease as a variable-vessel vasculitis: A case series of 13 patients with medium-sized coronary artery involvement

IntroductionIgG4-related disease (IgG4-RD) is a systemic autoimmune fibroinflammatory disease that can affect multiple organ systems. Although large-vessel vasculitis is a well-recognized manifestation of IgG4-RD, this condition is generally not regarded as a vasculitis. We aimed to describe coronary artery involvement (CAI), a vascular distribution about which little is known in IgG4-RD. Material and methodsPatients with IgG4-related CAI were identified from a large, prospective IgG4-RD cohort. CAI was confirmed by imaging evidence of arterial or periarterial inflammation in any coronary artery. We extracted details regarding demographics, features of IgG4-RD, and manifestations of CAI. ResultsOf 361 cases in the cohort, 13 (4%) patients had IgG4-related CAI. All were male and all had highly-elevated serum IgG4 concentrations, with a median value of 955 mg/dL (interquartile range [IQR]: 510–1568 mg/dL; reference: 4–86 mg/dL). Median disease duration at the time of CAI diagnosis was 11 years (IQR: 8.23–15.5 years). Extensive disease in the coronary arteries was the rule: all three major coronary arteries were involved in 11 patients (85%). The coronary artery manifestations included wall thickening or periarterial soft tissue encasement (85%), stenosis (69%), calcification (69%), and aneurysms or ectasia (62%). Five patients (38%) had myocardial infarctions, 2 (15%) required coronary artery bypass grafting, and 2 (15%) developed ischemic cardiomyopathy. DiscussionCoronary arteritis and periarteritis are important manifestations of IgG4-RD, which should be regarded as a variable-vessel vasculitis that is among the most diverse forms of vasculitis known. Potential complications of CAI include coronary artery aneurysms, myocardial infarction, and ischemic cardiomyopathy.

Higher visceral adiposity index and lipid accumulation product in relation to increased risk of atherosclerotic burden in community-dwelling older adults

Background and aimsVisceral adiposity index (VAI) and lipid accumulation product (LAP), as anthropometric indices, have been applied to predict the risk of cardiovascular diseases (CVD). However, few studies investigated the correlation between these two indicators and cardio-cerebro-vascular atherosclerosis in community populations. Our study was to explore the association of VAI and LAP with coronary, intracranial and extracranial atherosclerosis in a community-based asymptomatic middle-aged and older population. MethodsParticipants without a history of CVD in the study of PRECISE (Polyvascular Evaluation for Cognitive Impairment and Vascular Events) were included. The sex-special indicators of VAI and LAP were calculated and stratified by the tertiles. The presence of plaque and coronary segmental stenosis score (SSS) were assessed by coronary computed tomography (CTA), as well as intracranial and extracranial atherosclerotic burden were evaluated by high-resolution magnetic resonance imaging (HR-MRI), respectively. Binary or ordinal logistic regression was conducted to assess the association between each of the indexes and the presence and burden of atherosclerosis. ResultsA total of 2875 subjects were included in the final analysis. The mean age was 60.9 ± 6.6 years and 1329 (46.2 %) participants were males. Compared with the first tertile of VAI, the higher tertile was associated with the presence of plaques (T3 vs T1, OR, 1.49, 95%CI, 1.12–1.98, for males; OR, 1.64, 95%CI, 1.24–2.17, for females) and atherosclerotic burden (T3 vs T1, adjusted cOR, 1.63, 95%CI, 1.24–2.14, for males; adjusted cOR, 1.70, 95%CI, 1.29–2.24, for females) in major coronary arteries. A similar association was found for LAP. VAI level has presented an association with the extracranial atherosclerotic plaques (T3 vs T1, OR, 1.34, 95%CI, 1.02–1.77) and burden (T3 vs T1, adjusted cOR 1.32, 95 % CI 1.00–1.73) only in females. Whereas, for intracranial atherosclerosis, the results failed to show any statistically significant association. ConclusionsAmong community-dwelling asymptomatic older adults, VAI and LAP were associated with the presence and burden of coronary atherosclerotic plaques, while VAI presented a weaker significant association with extracranial atherosclerosis in females.

A STUDY TO IDENTIFY THE PRESENCE OF SEVERE CORONARY ARTERY DISEASE IN PATIENTS WITH NO ELECTROCARDIOGRAPHIC, BIOCHEMICAL AND ECHOCARDIOGRAPHIC EVIDENCE OF CAD USING CT CORONARY ANGIOGRAPHY

INTRODUCTION:Acute chest pain is one of the most common reasons for seeking care in the emergency department (ED), accounting for approximately 10% of all visits. The difficulty lies in discriminating patients with ACS or other lifethreatening conditions from those with non-cardiovascular,non-life-threatening chest pain.The diagnosis ofACS is missed in approximately 2%ofpatients.But itis essential to rule out cardiovascular etiology of chestpain to avoidunnecessary cost and complications of investigations and treatment. This study aims at identifying the prevalence of significant coronary artery disease in patients with no electrocardiographic and biochemical evidence of coronary artery disease. AIM OF STUDY: To identifying the presence of severe coronary artery disease in the patients with no electrocardiographic, biochemical and echocardiographic evidence of CAD using CT Coronary Angiography. MATERIAL AND METHODS: The study was conducted on 50 patients during a period of 4 months,admitted with history of chest pain without any ECG evidence of STEMI, negative cardiac markers, no evidence of RWMA on 2D ECHO, or previous history of myocardial infarction.RESULTS: Out of the 50 patients studied, 38 (76%) were males and 12 (24%) were females.A total of 6 patients (12%) were found to have severe stenosis in major coronary arteries (stenosis &gt; 70%) of which 4 were males (10.5%) and 2 were females (16.67%).CADRAD score≥3 was found in 9 patients (18%):6 males (15.78%) and 3 females (12%).Average age of patients who presented with chest pain with no electrocardiographic and biochemical evidence of coronary artery disease was found to be 61.7 years in males and 60.1 in females.66.7% of the female patients and 78.94% of male patients were over the age of 55 years.CONCLUSION: Furtherworkupofpatientswith chestpainwith no electrocardiographic and biochemicalevidenceofcoronaryarterydiseaseisnecessarytoavoidmissingdiagnosisofCAD

Triglyceride glucose index is associated with obstructive coronary artery disease in hypertensive patients

BackgroundHypertension is a leading risk of coronary artery disease (CAD). Triglyceride glucose index (TyG) is a surrogate of insulin resistance (IR). Few studies explore the association between TyG and the incidence of obstructive CAD (OCAD) in hypertensive patients.MethodsWe retrospectively screened 1841 hypertensive subjects who were free of a history of CAD and underwent coronary computed tomography angiography (CCTA) because of chest pain. TyG index was calculated as ln (fasting TG [mg/dL] * fasting glucose [mg/dL]/2). The outcome of this research was OCAD, which was defined as the presence of diameter stenosis ≥ 50% in any of the four major epicardial coronary arteries detected on CCTA.ResultsA total of 310 (16.8%) patients developed obstructive CAD. The restricted cubic spline (RCS) analysis showed a J-shaped relationship between TyG and OCAD and the OR for OCAD increased as the TyG rose over 8.61 (OR perSD) 1.64, 95% CI 1.13–2.54, p = 0.008). After full adjustments for confounding covariates, patients with TyG index in tertile 3 (T3) had 2.12 times (95% CI 1.80 to 3.81) and in T2 had 2.01 times (95% CI 1.40 to 2.88) as high as the risk of OCAD compared with patients in T1 (p for trend = 0.001). When regarding TyG as a continuous variable, 1-SD increase elevated 49% (OR (95%CI), 1.49 (1.30–1.74)) risk of obstructive CAD (p = 0.007). This positive effect was still consistent across the subgroups (p for interaction > 0.05).ConclusionTyG index was associated with the incidence of obstructive CAD in hypertensive patients.

Clinical Characteristics and Prognosis of Patients with Vasospastic Angina Subjected to the Spasm Provocation Test and the Unavoidable Use of Nitroglycerin.

Multi-vessel spasm (MVS) has a prognostic impact in patients with vasospastic angina (VSA). Thus, the presence of coronary spasm in both the left coronary artery (LCA) and right coronary artery (RCA) should be assessed through the spasm provocation test (SPT). Nitroglycerin (NTG) is used to avoid SPT-related complications; however, this unavoidable use of NTG may decrease the detection of MVS. Therefore, we investigated the frequency of the unavoidable use of NTG during SPT and clarified the clinical characteristics in patients with VSA who underwent the unavoidable use of NTG during STP. A total of 141 patients with positive SPT were evaluated. A positive SPT was defined as &gt; 90% constriction in epicardial coronary arteries in response to acetylcholine, accompanied by the usual chest symptoms and/or ischaemic ST-T changes on electrocardiography. When a coronary spasm occurred, we usually wait for the spontaneous relief of the coronary spasm. However, if a prolonged coronary spasm or unstable haemodynamics occurred, 0.3 mg NTG was administered intracoronarily to promptly relieve the coronary spasm and this was defined as the unavoidable use of NTG. Even when the unavoidable use of NTG was administered in one coronary artery, an additional SPT was performed on another coronary artery. If a coronary spasm occurred in another coronary artery, a positive SPT was diagnosed. In contrast, if a coronary spasm was not induced after the unavoidable use of NTG, the judgement was classified as undiagnosed. The patients were divided into two groups according to the unavoidable use of NTG: U-NTG (n = 42) and the final use of NTG: F-NTG (n = 99). The clinical characteristics and frequencies of MVS (≥2 major coronary arteries in which a coronary spasm was provoked) and complications (malignant arrhythmia and unstable haemodynamics requiring catecholamines) during the SPT were compared between the groups. Except for smoking status, all other clinical characteristics did not differ significantly between the groups. More current smokers were observed in the U-NTG group (29%) than in the F-NTG group (12%, p = 0.02). The frequency of MVS did not vary significantly between the groups (p = 0.28), with 64% for U-NTG and 55% for F-NTG. No significant difference was found between the groups in the frequency of severe complications during SPT (p = 0.83), with 2% for U-NTG and 3% for F-NTG. In the U-NTG group, the positive induction rate of coronary spasm in another coronary artery was 40% (17/42). Conclusions: The unavoidable use of NTG occurred in ~30% of patients with VSA, most of whom were current smokers. It did not decrease the detection of MVS and potentially prevented severe complications during SPT. Therefore, the unavoidable use of NTG is acceptable during SPT. However, an additional test may need to be performed to assess the presence of MVS.

Elevated Lp(a) Levels Correlate with Severe and Multiple Coronary Artery Stenotic Lesions.

The role of Lipoprotein(a) (Lp(a)) in increasing the risk of cardiovascular diseases is reported in several populations. The aim of this study is to investigate the correlation of high Lp(a) levels with the degree of coronary artery stenosis. Two hundred and sixty-eight patients were enrolled for this study. Patients who underwent coronary artery angiography and who had Lp(a) measurements available were included in this study. Binomial logistic regressions were applied to investigate the association between Lp(a) and stenosis in the four major coronary arteries. The effect of LDL and HDL Cholesterol on modulating the association of Lp(a) with coronary artery disease (CAD) was also evaluated. Multinomial regression analysis was applied to assess the association of Lp(a) with the different degrees of stenosis in the four major coronary arteries. Our analyses showed that Lp(a) is a risk factor for CAD and this risk is significantly apparent in patients with HDL-cholesterol ≥35 mg/dL and in non-obese patients. A large proportion of the study patients with elevated Lp(a) levels had CAD even when exhibiting high HDL serum levels. Increased HDL with low Lp(a) serum levels were the least correlated with stenosis. A significantly higher levels of Lp(a) were found in patients with >50% stenosis in at least two major coronary vessels arguing for pronounced and multiple stenotic lesions. Finally, the derived variant (rs1084651) of the LPA gene was significantly associated with CAD. Our study highlights the importance of Lp(a) levels as an independent biological marker of severe and multiple coronary artery stenosis.

Coronary Cameral Fistula: A Rare Entity

The existence of an anomalous connection between any of the cardiac chambers and a major coronary artery is the characteristic feature of coronary cameral fistula. This is a case of an 8-year-old child with a congenital coronary cameral fistula from the left circumflex to the right atrium. The fistula was surgically ligated. The postoperative course was uneventful with a good outcome.

Machine learning-based marker for coronary artery disease: derivation and validation in two longitudinal cohorts

Binary diagnosis of coronary artery disease does not preserve the complexity of disease or quantify its severity or its associated risk with death; hence, a quantitative marker of coronary artery disease is warranted. We evaluated a quantitative marker of coronary artery disease derived from probabilities of a machine learning model. In this cohort study, we developed and validated a coronary artery disease-predictive machine learning model using 95 935 electronic health records and assessed its probabilities as in-silico scores for coronary artery disease (ISCAD; range 0 [lowest probability] to 1 [highest probability]) in participants in two longitudinal biobank cohorts. We measured the association of ISCAD with clinical outcomes-namely, coronary artery stenosis, obstructive coronary artery disease, multivessel coronary artery disease, all-cause death, and coronary artery disease sequelae. Among 95 935 participants, 35 749 were from the BioMe Biobank (median age 61 years [IQR 18]; 14 599 [41%] were male and 21 150 [59%] were female; 5130 [14%] were with diagnosed coronary artery disease) and 60 186 were from the UK Biobank (median age 62 [15] years; 25 031 [42%] male and 35 155 [58%] female; 8128 [14%] with diagnosed coronary artery disease). The model predicted coronary artery disease with an area under the receiver operating characteristic curve of 0·95 (95% CI 0·94-0·95; sensitivity of 0·94 [0·94-0·95] and specificity of 0·82 [0·81-0·83]) and 0·93 (0·92-0·93; sensitivity of 0·90 [0·89-0·90] and specificity of 0·88 [0·87-0·88]) in the BioMe validation and holdout sets, respectively, and 0·91 (0·91-0·91; sensitivity of 0·84 [0·83-0·84] and specificity of 0·83 [0·82-0·83]) in the UK Biobank external test set. ISCAD captured coronary artery disease risk from known risk factors, pooled cohort equations, and polygenic risk scores. Coronary artery stenosis increased quantitatively with ascending ISCAD quartiles (increase per quartile of 12 percentage points), including risk of obstructive coronary artery disease, multivessel coronary artery disease, and stenosis of major coronary arteries. Hazard ratios (HRs) and prevalence of all-cause death increased stepwise over ISCAD deciles (decile 1: HR 1·0 [95% CI 1·0-1·0], 0·2% prevalence; decile 6: 11 [3·9-31], 3·1% prevalence; and decile 10: 56 [20-158], 11% prevalence). A similar trend was observed for recurrent myocardial infarction. 12 (46%) undiagnosed individuals with high ISCAD (≥0·9) had clinical evidence of coronary artery disease according to the 2014 American College of Cardiology/American Heart Association Task Force guidelines. Electronic health record-based machine learning was used to generate an in-silico marker for coronary artery disease that can non-invasively quantify atherosclerosis and risk of death on a continuous spectrum, and identify underdiagnosed individuals. National Institutes of Health.

Coronary artery disease among patients admitted with atrial fibrillation and chest pain.

Patients who present to the emergency department with chest pain during an episode of atrial fibrillation (AF) impose a clinical challenge regarding the source of pain - being coronary artery disease (CAD) or AF in origin. The aim of this study was to identify clinical, imaging or laboratory markers which can predict significant CAD among patients with an AF episode and chest pain. We included 57 consecutive patients admitted to our hospital with AF and chest pain. All patients underwent coronary evaluation. Significant CAD was defined as >50% stenosis in a major coronary artery by coronary angiography or cardiac CT. We compared CAD and non-CAD groups and analyzed risk factorsby regression analysis. Twenty-four patients (42%) were diagnosed with- and 33 patients (58%) without obstructive CAD. In a multivariate analysis of regional wall motion abnormality (RWMA), elevated troponin and hypertension were found to be predictors for CAD [odds ratio (OR), 22.4 (confidence interval (CI), 1.8-272.4; P = 0.02); OR, 5.6 (CI, 1-31.0; P = 0.05) and OR, 21.4 (CI, 1.6-284.6; P = 0.02), respectively]. There were no significant differences regarding the rate of typical chest pain at presentation in the CAD vs. the non-CAD group [13 (54%) vs. 20 (60%), P = 0.374], or in ECG ST-changes [12 (50%) vs.9 (27%), respectively; P = 0.08]. In patients who present acutely with chest pain and AF, troponin elevation and RWMA appear to be highly predictive of obstructive CAD, whereas clinical symptoms and ECG changes are not predictive. These findings may be helpful for guiding the management of patients admitted with AF and chest pain.

Effects of intensive blood pressure lowering in patients with diabetes: A pooled analysis of the STEP and ACCORD-BP randomized trials.

To determine whether intensive systolic blood pressure (SBP) lowering can benefit hypertensive patients with diabetes. We performed a pooled analysis of individual patient data from two randomized trials to compare intensive and standard SBP targets in hypertensive patients with diabetes (STEP diabetes subgroup and ACCORD-BP standard glycaemic group, n=1627 and n=2362, respectively). We defined a modified primary outcome as a composite of stroke, major coronary artery disease (myocardial infarction and unstable angina), heart failure, and cardiovascular death. The secondary outcomes were individual components of the primary outcome and death from any cause. A Cox proportional hazards regression model was used in the main analysis. We conducted one-stage mixed-effect models and two-stage analyses as sensitivity and supplementary analyses to verify the robustness of the findings. A total of 3989 patients were randomized to undergo intensive (n=1984) or standard SBP treatment (n=2005). After a median follow-up of 3.83 years, the primary outcome occurred in 193/1984 patients in the intensive group and in 247/2005 patients in the standard group (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.64-0.93). The incidence rates for secondary outcomes were lower in the intensive group than in the standard group, but were not significantly different, except for stroke (intensive vs. standard: 32/1984 vs. 58/2005; HR 0.56, 95% CI 0.36-0.86). These results remained consistent in the additional sensitivity and supplementary analyses. An intensive SBP-lowering target of 110 to <130 mmHg reduces the cardiovascular outcomes compared with a standard SBP-lowering target of 130 to <150 mmHg. The findings of this study support the favourable effects of intensive SBP lowering in hypertensive patients with diabetes.

Evaluating the relationship between endostatin and cognition in mild cognitive impairment (MCI), coronary artery disease (CAD), and Alzheimer’s disease (AD)

AbstractBackgroundEndostatin is an endogenous angiogenesis inhibitor that can regulate pro‐and anti‐angiogenic factors, notably vascular endothelial growth factor. Research shows that endostatin levels in the brain are associated with amyloid plaque formation in Alzheimer’s disease (AD), and may contribute to AD pathogenesis. Hence, endostatin may be relevant to the broad range of cognitive impairments, namely people with mild cognitive impairment (MCI), AD, and/or coronary artery disease (CAD) who are at risk for cognitive impairment. We examine associations between serum endostatin and global cognition.MethodsParticipants with MCI, AD, or CAD (with or without MCI) were recruited. Serum endostatin concentrations were measured and analyzed using enzyme‐linked immunosorbent assays. MCI was diagnosed using either the Petersen criteria or the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) criteria. AD was diagnosed using DSM‐5 criteria. CAD was defined as at least 1 of previous hospitalization for acute myocardial infarction, coronary angiographic evidence of ≥ 50% blockage in ≥ 1 major coronary artery or a prior revascularization procedure. Global cognition was assessed by the Montreal Cognitive Assessment (MoCA). Linear regression analyses were used to assess the association between endostatin levels and global cognition with and without covariates. Endostatin levels were log‐transformed prior to analyses due to significant departure from normality in Shapiro‐Wilk tests.ResultsIn 119 participants, 94 (79.0%) were male, 102 (85.7%) had CAD, and 23 (19.3%) had MCI or AD; the mean(SD) age was 65.6(7.5), years of education were 16.4(3.3), and endostatin levels were 156.3(38.6) ng/mL. Endostatin was associated with global cognition alone [F(1,117) = 11.39, p &lt;.001, R2 = .089] and also when considering covariates: age, sex, body mass index (BMI), education, MCI/AD diagnosis, and CAD diagnosis [F(7,111) = 11.27, p&lt; .001, R2 = .415]. All variables except age, sex, BMI, and CAD diagnosis added significantly to the association (p&lt; .05). Controlling for other variables, one log endostatin unit was associated with a total MoCA score 5.08 (SE= 2.52) points lower.ConclusionIn this sample, lower serum endostatin concentrations were associated with higher cognitive performance. This relationship may support the involvement of endostatin in cognitive functions and neurodegenerative diseases.