Management Of Coronary Artery Disease Research Articles

Nicardia® XL (Nifedipine Extended Release): Technologically Advanced GITS Formulation Ensures Robust Efficacy and Assured Safety

Nifedipine is a classical dihydropyridine calcium channel blocker (CCB) indicated for the management of hypertension, vasospastic angina and chronic stable angina. Prestigious regulatory bodies like USFDA, EMA, CDSCO and TGA have approved long-acting Nifedipine for the management of hypertension and angina. Nifedipine was 1st introduced in United States as Adalat® (Bayer) in 1981 and in India as Nicardia® (J. B. Chemicals & Pharmaceuticals) in 1985.
 Conventional Nifedipine shows the rapid onset and short duration of action which results in prompt and marked hypotensive effect but exhibits reflex SNS activation leading to flushing, tachycardia, worsening myocardial ischemia, and cerebrovascular ischemia. Nifedipine gastrointestinal therapeutic system (GITS) formulation addresses many of the concerns surrounding the older formulations of Nifedipine. Nifedipine GITS is a gold standard once-daily formulation of Nifedipine which allows relatively constant plasma drug concentrations over 24 hours. Nifedipine GITS provides a controlled release and gradual onset of action of Nifedipine, avoiding the reflex SNS activation resulting in improved tolerability and compliance.
 Clinical studies suggest that long-acting formulations of Nifedipine have slightly greater antihypertensive actions than Amlodipine. Nifedipine was also found to be more efficient than other CCBs like Amlodipine, Nicardipine, and Isradipine in resistant hypertensive patients. The addition of Nifedipine GITS to the conventional treatment of angina pectoris is safe and reduces the need for coronary angiography and interventions.
 Several landmark trials have demonstrated that long-acting Nifedipine improves endothelial function and arterial stiffness and reduces albuminuria, LV hypertrophy, atherosclerotic plaques and cardiovascular and cerebrovascular complications.
 This comprehensive review focuses on the superiority of the Nifedipine GITS formulation over the conventional Nifedipine and elaborates on the role of long-acting Nifedipine as a CCB of choice for the management of hypertension, resistant hypertension, angina pectoris and coronary artery disease.
 Keywords – Calcium Channel Blockers, Nifedipine, Long-Acting Nifedipine, Nifedipine GITS, Nifedipine Extended Release, Nicardia XL.

Clinical impact of quantitative [15O] H2O PET/CT myocardial perfusion imaging on decision-making regarding invasive management of coronary artery disease

BackgroundThis study was performed to determine the impact of oxygen-15-labeled water ([15O] H2O) positron emission tomography/computed tomography (PET/CT) myocardial perfusion imaging (MPI) on referral for invasive coronary angiography (ICA) and revascularization. MethodsThis study involved 57 patients who underwent [15O] H2O PET/CT MPI for evaluation of coronary artery disease (CAD). Data of referral for ICA and revascularization, clinical symptoms, and cardiac events within 6 months after MPI were assessed. Logistic regression was used to determine the predictors for referral and revascularization. The diagnostic values of hyperemic myocardial blood flow (MBF) and coronary flow reserve (CFR) were calculated. ResultsNormal and abnormal MPI findings were observed in 18 (32%) and 39 (68%) patients, respectively. The referral rate was significantly different between the normal and abnormal MPI groups (5.6% and 48.7%, respectively; P = .002). Revascularization rate of abnormal MPI group was 40.0%. There were significant differences of hyperemic MBF and CFR between patients with and without referral. Hyperemic MBF was significant predictor for referral (OR 15.24, 95% CI 3.39-68.55, P < .005) and revascularization (OR 28.57, 95% CI 3.08-265.33, P < .005). Conclusion[15O] H2O PET/CT MPI showed a clinical impact on decision-making regarding invasive procedure for management of CAD.

Cardiac risk factors limiting survival to liver transplantation in patients with nonalcoholic fatty liver disease.

BACKGROUNDNonalcoholic fatty liver disease (NAFLD) describes the hepatic manifestations of metabolic syndrome, which is estimated to affect 25% of adults, and currently represents the second most common indication for liver transplant in the United States. Studies have shown that patients with NAFLD are at an increased risk for heart failure, arrhythmia, and coronary artery disease (CAD), which may impact outcomes of liver transplantation. However, it remains unclear whether the presence of cardiac disease affects survival prior to liver transplant. If so, this would represent an important opportunity to optimize cardiac status and improve outcomes before liver transplant.AIMTo identify cardiac factors that impact survival to liver transplantation in patients with NAFLD and on the transplant waitlist.METHODSThe aim of this study was to identify cardiac risk factors that limit survival to transplant in patients with NAFLD. We performed a retrospective analysis of patients with NAFLD listed for liver transplant at a tertiary academic medical center in the United States from January 2015 to January 2021, identified through United Network of Organ Sharing registry. Exclusion criteria included a concurrent etiology of liver disease and removal from the transplant list due to chemical dependency, lack of social support, improvement in liver disease, or being lost to follow-up. We manually reviewed patient charts including electrocardiogram, echocardiogram, and cardiac catheterization reports as well as physician notes to identify cardiac disease states (i.e., heart failure, arrhythmia, valvular disease and CAD) and other related diagnoses. We performed a survival analysis by Cox proportional hazards regression model to analyze the association between cardiac factors at the time listed for transplant and death or clinical deterioration prior to transplant.RESULTSBetween January 2015 and January 2021, 265 patients with nonalcoholic fatty liver disease were listed for liver transplant at our institution. Our patient sample had a median age of 63 and an even distribution between sexes. The median Model for End-Stage Liver Disease (MELD) score was 17 and the median body mass index was 31.6. Of these 265 patients, 197 (74.3%) survived to transplant and 68 (25.7%) died or clinically deteriorated prior to transplant. The presence of mild or moderate CAD represented a hazard ratio of 2.013 (95%CI 1.078-3.759, P = 0.029) for death or clinical deterioration when compared to patients without CAD, after adjustment for age, sex, and MELD. MELD represented an adjusted hazard ratio of 1.188. CONCLUSIONMild or moderate CAD represents a hazard for waitlist mortality prior to liver transplant in patients with NAFLD. Aggressive management of CAD may be needed to improve patient outcomes.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Patients With Three Vessel Coronary Artery Disease: A Comparison of Centers in the Same Jurisdiction With Differing Multidisciplinary Heart Team Approaches.

Referral patterns and outcomes of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were compared between 2 centers within 1 jurisdiction wherein only 1 center utilizes multidisciplinary review for all patients. Management of advanced coronary artery disease often involves PCI and CABG for improvements in quality of life and survival. Indications exist for PCI and CABG, with CABG demonstrating benefit in three-vessel disease (TVD). A total of 27,961 patients underwent cardiac catheterization in 2 centers within the same single-payer health jurisdiction (Center A and B) from 2017 to 2018. Rates of PCI, CABG, and outcomes of 1-year mortality, rehospitalization, myocardial infarction, and stroke were compared. More patients in Center A received PCI and less received CABG compared with Center B even among patients with TVD ( P <0.001). Multivariable logistic regression identified Center B as protective for mortality for TVD patients ( P <0.001) and those undergoing PCI ( P =0.004), but not CABG ( P =0.06). Center A's 1-year mortality was increased for all patients ( P =0.004) and those with TVD ( P =0.011). Discordant outcomes exist between these 2 centers. While patients in Center A were more likely to undergo PCI than Center B and experienced decreased 1-year survival, the difference was not significant for CABG. In part, the differences are attributable to contrasting referral practices and the discrepant rates of PCI and CABG between centers. Review of all coronary artery disease patients with a multidisciplinary Heart Team including a surgical opinion may lead to a more evidence-based referral practice aligned with current clinical guidelines.

Colchicine for cardiovascular medicine: a systematic review and meta-analysis.

Aim: Colchicine, a microtubule-disassembling (antitubulin) agent used for centuries for the treatment of gout and autoimmune diseases, is a drug of growing interest in the cardiovascular field. While in the last decades it has become cornerstone of pericarditis treatment, it has also emerged in the last few years as a promising drug in the management of coronary artery disease, atrial fibrillation and heart failure. This systematic review and meta-analysis aimed to assess the efficacy of colchicine in patients with cardiovascular diseases. Methods: Systematic search in electronic databases (MEDLINE/PubMed, Scopus, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, ClinicalTrials.gov, EMBASE, Google Scholar) was performed to identify randomized controlled trials (RCTs) up to February 2021. Random-effects meta-analysis was performed to assess the risk of cardiovascular events, defined according to clinical setting. Results: Among 15,569 pooled patients from 21 RCTs, colchicine was superior to placebo in the reduction of cardiovascular events. In the setting of pericardial diseases, it was associated with a lower risk of recurrent pericarditis (17 vs 34%, RR=0.50, 95% CI: 0.42-0.60, I2=10%). In other studies assessing coronary artery disease patients, colchicine was associated with a reduced risk of major adverse cardiovascular events (MACE) such as myocardial infarction, stroke, cardiovascular death, coronary revascularisation and hospitalization (6.3 vs 9%, RR=0.67, 95% CI: 0.54-0.84, I2=55). Among patients with atrial fibrillation, it was associated with lower rates of recurrence (20 vs 30%, RR=0.68, 95% CI: 0.58-0.81, I2=0). In the single RCT on heart failure, colchicine was not associated with improved NYHA class. Conclusion: Colchicine is a valuable anti-inflammatory agent for the prevention of cardiovascular events in patients with inflammatory cardiac conditions such as pericardial diseases, coronary artery disease and atrial fibrillation.

Evaluating the use of coronary artery calcium scoring as a tool for coronary artery disease (CAD) risk stratification and its association with coronary stenosis and CAD risk factors: a single-centre, retrospective, cross-sectional study at a tertiary centre in Pakistan

ObjectiveCoronary artery disease (CAD) risk stratification plays a fundamental role in the early detection and optimal management of CAD. The aim of our study is to investigate the use of...

Coronary computed tomography angiography evaluation of plaque morphology and its relationship to HDL and total cholesterol to HDL ratio

BackgroundWhile population studies have demonstrated that high density lipoprotein cholesterol (HDL-C) and the ratio of total cholesterol to HDL (TC/HDL) improve cardiovascular risk prediction, the mechanism by which these parameters protect the cardiovascular system remains uncertain. ObjectiveTo investigate the relationship between the HDL-C level and the total cholesterol to HDL (TC/HDL) ratio with the morphology of coronary artery plaque as determined by coronary computed tomography angiography (CCTA). MethodsThis is a cross-sectional study involving 190 subjects with stable coronary artery disease. Semi-automated plaque analysis software was utilized to quantify plaque and plaque volumes are presented as total atheroma volume normalized (TAVnorm). Multivariate regression models were used to evaluate the association of HDL-C and TC/HDL ratio with coronary plaque volumes. ResultsOf the 190 subjects the average (SD) age was 58.9 (9.8) years, with 63% being male. After adjustment for cardiovascular risk factors, HDL- C (>40 mg/dl) is inversely associated with fibrous (p = 0.003), fibrous fatty (p = 0.007), low attenuation plaque (LAP) (p = 0.007), total non-calcified plaque (TNCP) (p = 0.002) and total plaque (TP)(p = 0.004) volume. Furthermore, the TC/HDL ratio (> 4.0) is associated with fibrous (p = 0.047) and total non-calcified plaque (p = 0.039), but not with fibrofatty, LAP, dense calcified plaque, or TP volume. ConclusionThere is a strong association between low HDL-C levels and increasing TC/HDL ratio with certain types of coronary plaque characteristics, independent of traditional risk factors. The findings of this study suggest mechanistic evidence supporting the protective role of HDL-C and the TC/HDL ratio's clinical relevance in coronary artery disease management.

Lung transplant and severe coronary artery disease: results from a single-centre experience.

The management of severe coronary artery disease at the time of a lung transplant remains a challenge. We analysed the short- and long-term outcomes of lung transplant recipients with severe coronary artery disease. Records of adult patients who received transplants at our institution between April 2010 and February 2021 were reviewed retrospectively. Severe coronary artery disease was defined as coronary stenosis ≥70% (main stem ≥50%) seen on the coronary angiographic scans performed before or at the time of listing. Patient characteristics, perioperative and long-term outcomes were compared between patients with and without severe coronary artery disease. Among 896 patients who received lung transplants who had undergone coronary angiography before the transplant, 77 (8.5%) had severe coronary artery disease; the remaining 819 (91.5%) did not. Patients with severe coronary artery disease were older (p &lt; 0.0001), more often male (p &lt; 0.0001) and received transplants more often for pulmonary fibrosis (p = 0.0007). The median (interquartile range) follow-up was 46 (20-76) months. At the Cox multivariable analysis, severe coronary artery disease was not associated with death. Patients with pretransplant percutaneous transluminal coronary angioplasty and patients with coronary artery bypass graft surgery concomitant to a transplant had survival equivalent to that of patients without severe coronary artery disease (p = 0.513; p = 0.556). Severe coronary artery disease was not associated with decreased survival after a lung transplant. Concomitant coronary artery bypass graft surgery and pretransplant percutaneous transluminal coronary angioplasty can be used for revascularization.

Non-traditional factors affecting referral for coronary angiography following SPECT myocardial perfusion imaging

BackgroundThe use of myocardial perfusion imaging (MPI) in the management of coronary artery disease (CAD) is well established. Although prior studies have shown disparities in the use of invasive angiography in patients with acute MI, data on factors affecting referral to angiography post-MPI are lacking. We sought to evaluate the primary determinants of referral to invasive angiography post-MPI and specifically assess the role of non-traditional non-clinical factors such as race/ethnicity, socioeconomic factors, insurance status, and marital status. MethodsAll patients without known CAD who underwent stress SPECT MPI over 15 years were reviewed and the performance of coronary angiography within 90 days of their MPI was recorded. Multiple factors were analyzed for an association with referral to angiography, including exercise and MPI results, baseline demographics, traditional cardiac risk factors, and non-traditional factors such as ethnicity, insurance, marital and socioeconomic status. In a secondary analysis, these factors were assessed with regard to abnormal MPI results. ResultsOut of 27,895 total patients, 2,150 (7.7%) underwent invasive coronary angiography. On multivariate analysis, inpatient location, positive ECG response, and abnormal MPI results were the strongest predictors of angiography. Non-traditional factors such as race/ethnicity and insurance status had a significant association with referral to angiography with Caucasians (OR 1.42, 95% CI 1.18-1.71, P < .0001) and those with private insurance (OR 1.35, 95% CI 1.13-1.62, P = .001) or Medicare (OR 1.30, 95% CI 1.08-1.56, P = .006) having higher rates of angiography despite controlling for traditional risk factors and test results. ConclusionOur study results indicate that non-traditional factors such as race/ethnicity and insurance status influence patient management decisions and impact the performance of downstream cardiac invasive testing after stress MPI. Higher rates of angiography in Caucasians, privately insured and Medicare patients were seen despite controlling for traditional risk factors and abnormal test results. Further research is needed to better understand these disparities, especially in the current healthcare environment.

Use of a novel multi-disciplinary meeting to aid decision making for cardiac implantable electronic devices and the management of patients with arrhythmias

Abstract Funding Acknowledgements Type of funding sources: None. Background Heart team meetings are well established for the management of coronary artery disease. We recently developed a novel weekly multi-disciplinary meeting (MDM) to aid decision making in the selection of patients suitable for treatment with cardiac implantable electronic devices (CIEDs) and the management of patients with arrhythmias. In this study, we present the results of an audit of the service. Purpose To illustrate the workload, range of conditions and decisions, and electronic communication used in the MDM. Methods Patients from all of Northern Ireland can be listed for discussion at the meeting using the Northern Ireland Electronic Clinical Record (NIECR). The same electronic record is used to log the result of the discussion (Figure 1). These records were analyzed for all patients discussed at the meeting from August 2019 to March 2021. Demographic and outcome (decision and mortality) data were recorded. Results A total of 614 patients were discussed (median age 63.0 years, 68.2% male). The mean weekly number of patients discussed was 7.5 per week. A total of 621 decision outcomes were made. 37 patients (6.0%) had died at the time of data collection. A summary of the major disease for discussion and outcome from discussion is shown in Figure 2. Conclusion A wide variety of patients, diseases and issues were discussed over this period. Conduction system disease was the most common disease, highlighting the challenges in treating this population. Furthermore, the most common outcome from discussion was conservative management. This may reflect the fact that arrhythmias are now frequently detected in asymptomatic patients without structural heart disease. This small study clearly demonstrates that there is interest in such a meeting to help in the management of these complex patients.

Operative and Long-term Outcomes of Combined and Staged Carotid Endarterectomy and Coronary Bypass: A Medicare-linked VQI/VISION Analysis

Optimal temporal surgical management of significant carotid stenosis (CS) and coronary artery disease (CAD) remains unknown. Carotid endarterectomy (CEA) and coronary bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative (VQI)-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network (VISION)-Medicare linked dataset, this study compared operative and long-term outcomes following CCAB and staged approaches.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Managing diffusely diseased coronary arteries – place of endarterectomy in today's scenario

Introduction: Surgical management of diffuse coronary artery disease (CAD) requires aggressive techniques for complete revascularization. Coronary endarterectomy (CE) coupled with coronary artery bypass grafting (CABG) is a valuable technique for this subset. The aim is to evaluate the perioperative and early results following CE. Materials and Methods: Three hundred and eighty patients of diffuse CAD undergoing off-pump CABG were included in the study. CE was performed in 204 patients. The mean age of the patients was 62 ± 16.32 years. The male-to-female ratio was 1.43, and the mean SYNTAX score was 33.12 ± 6.42. The mean stay in the intensive care unit was 4.94 ± 2.72 for patients undergoing CABG with CE. The perioperative mortality was 4.9%. The patients were followed up at 3 months, and graft patency was assessed with computed tomography coronary angiography. The average graft patency was 86.725% for the grafts with CE. Patients with left anterior descending (LAD) CE had higher perioperative mortality (5%), overall survival (89.79% at 3 months), and graft patency rates (87%) were favorable. The outcome following single vessel CE was better than multivessel CE. Conclusion: In patients with diffuse CAD, CE is a safe technique with comparable mortality and lesser complication rate if performed adequately. Despite perioperative difficulties, early outcomes are favorable for CE to the LAD artery grafted with the left internal thoracic artery. Single vessel CE yielded a better result as compared to multivessel CE.

May Coronary Artery Bypass Grafting Affect Native Coronary Atherosclerosis progression?

Background: Coronary artery bypass grafting (CABG) continues to be the best standard in the management of severe coronary artery disease (CAD), providing good symptom management and life extension. Although CABG was first performed by reversed saphenous veins (SVGs), surgeons have increasingly adopted arterial conduits because of their longer-term patency and resistance to atherosclerosis. CABG's efficacy may potentially be affected by the extension of atherosclerosis in the native coronary arteries. Few researches have investigated the long-term angiographic disease progression of native coronary arteries after surgical revascularization, or the variables that may impact this progression. Proximal native disease progression was presented to be two to six times more common than distal disease progression, with greater rates of progression in coronaries bypassed by SVGs than arterial grafts. The goal of this research was to determine influence of CABG on the extension of native coronaries atherosclerosis.&#x0D; Methods: This prospective study was established on 25 patients who were diagnosed to have ischemic heart disease in cardiothoracic surgery department in Faculty of Medicine Menoufia University.&#x0D; Results: The study showed that according to the risk factors among the studied cases, smoking was (60%), Dyslipidemia was (32%), HTN was (32%) and Diabetes was (32). According to grafts in proximal lesions, there was progression of atherosclerosis up to total occlusion, but in Distal lesions, there was significant regression of atherosclerosis. As result, there was statistically significant difference between proximal with distal lesions. Also, study showed that there was a significant difference between left system (LAD, D, OM) in comparison with right system (PDA) regarding distal lesion. Our results showed that univariate logistic regression analysis for progression in distal lesion regarding Dyslipidemia and Diabetes.&#x0D; Conclusion: Progression of disease is more evident in coronary segment proximal to anastomosis, while regression of disease is more evident in coronary segment distal to anastomosis with statistically significant difference between them, also the risk of disease progression post CABG was found to be multifactorial, as certain risk factors can affect progression of the disease as Diabetes mellitus and dyslipidemia that were of statistically significance.

ANATOMICAL STUDY OF CORONARY ARTERIES AND ITS BRACHING PATTERN IN COSTAL ANDHRA PRADESH POPULATION

Aim: The aim of this anatomical study of coronary arteries and its branching pattern in costal andhra pradesh population is to assess risk factors for occurrence of CADs. Methods: Conventional Dissection method. Results: Coronary artery disease (CAD) is a major cause of death and disability in developed countries, and incidence of CAD is increasing annually in the underdeveloped world. Today, percutaneous coronary intervention plays a major role both in diagnosis and treatment of CAD. This present study was done to assess the normal patterns of coronary arteries with reference to its origin, branching pattern, caliber, predominance, variations and anomalies. 100 adult male and female cadaveric and fresh hearts preserved with 10% formalin were obtained from the Department of Anatomy &amp; Department of forensic, Rangaraya Medical College, Kakinada, Andhra Pradesh. The origins, various branching patterns and diameter of right and left coronary arteries were observed. Both RCA &amp; LCA was originating from the anterior aortic sinus in 100% and LCA from left posterior aortic sinus in 100. In the present study, termination of RCA occurs between acute margin and crux of heart in 8% of specimens, at PIVA posterior Interventricular artery or crux of heart in 12% of specimens, in between crux and obtuse margin of the heart in 76% of specimens, at the obtuse margin of the heart in 4% of specimens. The main trunk of LCA divides into two branches (bifurcation) in 76% of specimens, into three branches (trifurcation) in 20% of specimens, into four branches (quadrifurcation) in 2% of specimen, into five (pentafurcation) branches in 2% of specimen. The minimum diameter of RCA was 2.5 mm. The maximum diameter ofRCAwas 3.9mm. The minimum diameter of LCA was 2.6 mm the maximum LCA diameter was 6.2 mm. In 100 specimens the posterior interventricular artery arose from the right coronary artery indicating right dominance in 90 specimens and in 10 specimens from the left circumflex coronary artery indicating left dominance. Right dominance was present in 90%, left dominance in 10% and co-dominance was nil. Variations in branching pattern of coronary arteries as reported in present study necessitate its importance for proper diagnosis and management of coronary artery disease. Conclusion: Arterial pattern and its variations are important to prevent false interpretation of the arterial angiograms in management of coronary artery diseases.

CT or Invasive Coronary Angiography in Stable Chest Pain

BackgroundIn the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.MethodsWe conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.ResultsAmong 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).ConclusionsAmong patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)

Coronary Physiology: Delivering Precision Medicine?

Coronary physiological assessment is now widely used to assess epicardial coronary lesions in cath lab. Based on clinical evidence, fractional flow reserve (FFR) is the gold standard method to select whether epicardial coronary lesions need revascularization. While additional epicardial indexes, such as instantaneous wave-free ratio (iFR), are also used for revascularization decision-making, several indexes are now also available to explore the coronary microcirculation. Therefore, coronary physiological assessment now allows to explore the entire coronary tree and offer the potential of precision medicine for patients affected by coronary artery disease (CAD). This paper will provide review of the epicardial and microvascular indexes available for the assessment of coronary physiology. More specifically, the already demonstrated contributions of these indexes in the management of CAD and the role they could play in precision medicine will be reviewed with special emphasis on chronic coronary syndrome.

Evaluation of Oxidative Stress Parameters and Antioxidant Status in Coronary Artery Disease Patients.

A surge in oxidative stress and weakened antioxidant defense contributes to the initiation and progression of Coronary Artery Diseases (CAD). The resultant burst in free radicals causes oxidation of lipoproteins mainly oxidized low-density lipoprotein (oxLDL). Further studies need to be conducted to find whether the management of CAD can be evaluated within the context of oxidant/antioxidant balance with the contribution of newer markers. This study was performed to evaluate, compare, and correlate oxidative stress parameters and antioxidant status in CAD patients with controls and evaluate and compare pro-oxidant, a pro-inflammatory enzyme, myeloperoxidase (MPO) and anti-oxidant, anti-inflammatory enzyme, and paraoxonase (PON) between CAD patients and controls. OxLDL, an oxidation product of low-density lipoprotein, malondialdehyde (MDA), an oxidative marker, and reduced glutathione (GSH), an anti-oxidant marker, and lipid profile were assessed and compared in CAD patients and controls. The activity of MPO was correlated with that of PON, and MDA level was correlated with GSH level. A total of 100 clinically proven CAD patients, in the age range of 35-70 years, were selected from the Out Patient Department (OPD) of our Institute. A total of 60 controls in the same age range and without CAD were selected after undergoing health checkups in the hospital. Based on the obtained results, oxLDL, MDA, and MPO were significantly increased in patients than in controls (P<0.05), and PON and GSH were significantly lowered in patients than in controls (P<0.05). Total cholesterol, triglyceride, and LDL were significantly high in CAD patients. A significant negative correlation was observed between MPO and PON levels and between MDA and GSH levels. Increased oxidative stress and decreased antioxidant status were observed in patients with CAD. Formation of oxLDL increased MPO and decreased PON are all additional risk factors for the development of CAD and can be targeted for future therapeutic purposes. Lifestyle modifications and treatment methods can reduce CAD risk through the reduction of oxidative stress and improvement of antioxidant status.

Physicians' perceptions on the impact of COVID-19 in coronary artery disease diagnostic imaging and treatment: A Latin America survey. For the Society of Cardiovascular Imaging of the Inter-American Society of Cardiology.

BackgroundServices during the pandemic were severely restricted, public reluctance to seek medical assistance rose, with a reduction of diagnostic and therapeutic modalities use in coronary artery disease (CAD). However, information about perceived barriers of care among cardiologists is limited. We aim to explore these barriers diagnostic and treatment modalities of CAD in Latin America during the pandemic.MethodsAn anonymous Google form 12 closed-questions survey was conducted between November 2020 to January 2021. Latin American cardiologists members of the Imaging Society (SISIAC) of the Inter-American Society of Cardiology (SIAC) were reached by email and social media.ResultsDifferences were found in relation to patients’ perceived reluctance to undergo testing, particularly in South America and inpatient care (p < 0.05). Respondents’ perceived barriers in the use of CV tests were higher in South America (p < 0.05) and related to public practice (p < 0.01). Barriers to the treatment of myocardial infarction were present in all regions (p < 0.05), and follow-up was influenced by COVID-19 in both public and private practices (p = 0.01).Conclusions Regardless of treatment and diagnostic approach (invasive or non-invasive) followed, according to physicians’ perception, the pandemic significantly impacted the clinical management of CAD in the Latin American population, similar to the global situation.

Measurement uncertainty quantification for myocardial perfusion using cardiac positron emission tomography imaging

Perfusion, the flow of blood, and hence oxygen, is essential to the functioning of the heart. Reduced perfusion (or ischemia), is a reliable indicator of the presence of significant obstructive coronary artery disease (CAD), which is one of the biggest causes of death in Europe. Myocardial perfusion imaging is a non-invasive technique used in the diagnosis, management and prognosis of CAD and is a key component in the triage of patients into treatment and non-treatment groups. Cardiac positron emission tomography (PET) is an imaging technique with high sensitivity and specificity to CAD, however perfusion measurements are difficult to calibrate against a common reference standard, and confidence in them is generally not quantified in terms of measurement uncertainty. There are a number of steps involved in measuring perfusion using cardiac PET—from patient preparation to data analysis—each associated with potential sources of uncertainty. The absence of measurement uncertainty quantification can lead to inaccuracies in measurement results, a lack of comparability between devices or scanning facilities, and is likely to be detrimental to a decision-making process. In this paper, we identify some of the sources of measurement uncertainty in the cardiac PET perfusion measurement pipeline. We assess their relative contribution by performing a sensitivity analysis using experimental data of a flow phantom acquired on a PET scanner. The results of this analysis will inform users of how parameter choices in their imaging pipeline affect the output of their measurements, and serves as a starting point to develop an uncertainty quantification method.