Moderate Coronary Artery Lesions Research Articles

The relationship between coronary stenosis morphology and fractional flow reserve: a computational fluid dynamics modelling study.

AimsInternational guidelines mandate the use of fractional flow reserve (FFR) and/or non-hyperaemic pressure ratios to assess the physiological significance of moderate coronary artery lesions to guide revascularization decisions. However, they remain underused such that visual estimation of lesion severity continues to be the predominant decision-making tool. It would be pragmatic to have an improved understanding of the relationship between lesion morphology and haemodynamics. The aim of this study was to compute virtual FFR (vFFR) in idealized coronary artery geometries with a variety of stenosis and vessel characteristics.Methods and resultsCoronary artery geometries were modelled, based upon physiologically realistic branched arteries. Common stenosis characteristics were studied, including % narrowing, length, eccentricity, shape, number, position relative to branch, and distal (myocardial) resistance. Computational fluid dynamics modelling was used to calculate vFFRs using the VIRTUheart™ system. Percentage lesion severity had the greatest effect upon FFR. Any ≥80% diameter stenosis in two views (i.e. concentric) was physiologically significant (FFR ≤ 0.80), irrespective of length, shape, or vessel diameter. Almost all eccentric stenoses and all 50% concentric stenoses were physiologically non-significant, whilst 70% uniform concentric stenoses about 10 mm long straddled the ischaemic threshold (FFR 0.80). A low microvascular resistance (MVR) reduced FFR on average by 0.05, and a high MVR increased it by 0.03.ConclusionUsing computational modelling, we have produced an analysis of vFFR that relates stenosis characteristics to haemodynamic significance. The strongest predictor of a positive vFFR was a concentric, ≥80% diameter stenosis. The importance of MVR was quantified. Other lesion characteristics have a limited impact.

Acupuncture as Adjuvant Therapy for Treating Stable Angina Pectoris with Moderate Coronary Artery Lesions and the Mechanism of Heart-Brain Interactions: A Randomized Controlled Trial Protocol.

Background. Stable angina pectoris with moderate coronary artery lesions is a syndrome caused by coronary artery stenosis, which endangers the quality of life. Previous acupuncture studies have shown effectiveness as a complementary therapy for ischaemic heart disease. However, more clinical evidence is needed for verification, and the mechanism should be investigated, especially involving the functional interactions between the heart and brain. Therefore, we designed a clinical trial to provide more evidence for acupuncture efficacy and its mechanism in ischaemic heart disease. Methods/Design. A total of 80 participants will be randomized to the electroacupuncture group and sham-electroacupuncture group at a ratio of 1 : 1. This trial will be conducted over 8 weeks, including a 2-week screening, 2-week treatment, and 4-week follow-up. All participants will continue to receive similar basic disease treatment procedures before the trial (including lifestyle changes and treatment for standard supportive medications, hypertension, and hyperlipidaemia, such as aspirin, metoprolol succinate, atorvastatin, and sodium fosinopril). Additionally, 12 sessions of acupuncture will be administered during the treatment period. The main outcome is Seattle Angina Questionnaire scores. The other observation indices are the heart rate variability and self-rating anxiety scale and self-rating depression scale scores. To explore mechanisms based on the hypothesis of a correlation between heart and brain function, fMRI scans will be used to detect functional brain changes in 15 patients from each group at baseline and at the end of treatment. Finally, the efficacy of acupuncture will be evaluated, and the HRV and imaging data will be correlated with clinical data to investigate the possible relationships between the brain and heart activity. Discussion. This trial will provide evidence for acupuncture as adjuvant therapy for the treatment of stable angina pectoris with moderate coronary artery lesions. The results will shed light on potential mechanisms of heart-brain interactions underlying acupuncture as an adjuvant therapy for treating ischaemic heart disease. Trials registration: Clinical Trial, https://clinicaltrials.gov/ct2/show/ChiCTR1900024937. Registered 4 August 2019, http://www.chictr.org.cn/.

Comparison between Myocardial Ischemia Evaluation by Fractional Flow Reserve and Myocardial Perfusion Scintigraphy

Abstract Background: Moderate coronary artery lesions can be, or not, responsible for myocardial ischemia. The functional analysis of these lesions can be performed by invasive and noninvasive methods. Objective: To compare the functional analysis of moderate coronary lesions by fractional flow reserve and myocardial perfusion scintigraphy. Methods: 47 patients with stable coronary artery disease and at least one moderate coronary artery obstruction were prospectively studied. They were submitted to fractional flow reserve and myocardial perfusion scintigraphy with a median interval of 24.5 days between January 2013 and December 2015. There was no change in clinical status or revascularization procedure between the exams. The population variables were described as medians and interquartile range. Fractional flow reserve was performed in one left main coronary artery; 37 left descending coronary arteries; 12 circumflex arteries and 4 right coronary arteries. Fractional flow reserve < 0.8 was considered positive. The comparative analysis between the results of the tests was performed by two-tailed Fisher’s test and a p-value ≤ 0.05 was considered significant. Results: Fractional flow reserve < 0.8 was found in the left main coronary artery (100%); 13 in the left descending coronary artery (35.14%); 6 in circumflex artery (50%) and 2 in the right coronary artery (50%). Among the patients with positive fractional flow reserve, 83% had myocardial ischemia demonstrated by the myocardial perfusion scintigraphy (p = 0.058). When analyzing specifically the left descending coronary artery, 83% of the patients with negative fractional flow reserve showed no ischemia at the myocardial perfusion scintigraphy, but 69% of the patients with positive fractional flow reserve showed no ischemia at the myocardial perfusion scintigraphy (p = 0.413). Conclusion: Disagreements can occur between the results of the functional analysis of moderate coronary lesions by invasive and noninvasive tests.

Prediction of risk of cardiovascular events in patients with mild to moderate coronary artery lesions using naïve Bayesian networks.

BackgroundThis prospective study integrated multiple clinical indexes and inflammatory markers associated with coronary atherosclerotic vulnerable plaque to establish a risk prediction model that can evaluate a patient with certain risk factors for the likelihood of the occurrence of a coronary heart disease event within one year.MethodsThis study enrolled in 2686 patients with mild to moderate coronary artery lesions. Eighty-five indexes were recorded, included baseline clinical data, laboratory studies, and procedural characteristics. During the 1-year follow-up, 233 events occurred, five patients died, four patients suffered a nonfatal myocardial infarction, four patients underwent revascularization, and 220 patients were readmitted for angina pectoris. The Risk Estimation Model and the Simplified Model were conducted using Bayesian networks and compared with the Single Factor Models.ResultsThe area under the curve was 0.88 for the Bayesian Model and 0.85 for the Simplified Model, while the Single Factor Model had a maximum area under the curve of 0.65.ConclusionThe new models can be used to assess the short-term risk of individual coronary heart disease events and may assist in guiding preventive care.

Prognostic performance of interleukin-10 in patients with chest pain and mild to moderate coronary artery lesions-an 8-year follow-up study.

BackgroundInterleukin (IL)-10, IL-6 and their ratio (IL-6/IL-10) play an important role in the risk of developing coronary artery disease, and may correlate with its outcomes. Few clinical trials have investigated the prognostic impact of these factors on long-term cardiovascular events in patients presented with chest pain.MethodsA prospective study was performed on 566 patients admitted with chest pain and identified mild to moderate coronary artery lesions. IL-10, IL-6 and IL-6/IL-10 were measured.ResultsA total of 511 patients completed the follow-up. The median follow-up time was 74 months. Kaplan-Meier analysis demonstrated a clear increase of the incidence of major adverse cardiac events during the follow-up period in patients with below-median levels of IL-10 (P = 0.006) and above-median levels of IL-6/IL-10 (P = 0.012). Multivariate Cox proportional hazards analysis indicated the IL-10 levels to be strong independent predictors after adjustment for underlying confounders.ConclusionsElevated IL-10 levels are associated with a more favorable long-term prognosis in patients with chest pain and mild to moderate coronary artery lesions. IL-10 could be used for early risk assessment of long-term prognosis.

CRT-200.77 Fractional Flow Reserve Measurements Using Intracoronary Sodium Nitroprusside Infusions Is Similar to Intracoronary Adenosine in Moderately Stenotic Coronary Artery Lesions

The aim of this study was to investigate the efficacy and safety of intracoronary (IC) sodium nitroprusside infusion in comparison with IC adenosine for fractional flow reserve (FFR) measurement in moderate coronary artery lesions. During a nine month period, consecutive of 98 patients with

Status on Heart Transplantation in China.

Status on Heart Transplantation in China.

The Long-Term Influence of Tissue Inhibitor of Matrix Metalloproteinase-1 in Patients with Mild to Moderate Coronary Artery Lesions in a Chinese Population: A 7-Year Follow-Up Study

Objectives: Matrix metalloproteinase-9 (MMP-9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and their ratio (MMP-9/TIMP-1) are involved in multiple processes that are associated with coronary heart disease and are especially associated with cardiovascular events. However, few long-term population-based clinical studies have evaluated the role of these factors in cardiovascular events in a Chinese population. Methods: A prospective study was performed on 560 patients with mild to moderate coronary artery lesions. MMP-9, TIMP-1 and their ratio were determined. Results: A total of 522 of patients completed the follow-up. The median follow-up time was 64 months. Kaplan-Meier analysis demonstrated a clear increase of the incidence of major adverse cardiac events (MACEs) during the follow-up period in subjects with above-median levels of TIMP-1 (p = 0.033), whereas there was no association with either MMP-9 (p = 0.199) or MMP-9/TIMP-1 (p = 0.631). Multivariate Cox proportional hazards analysis showed the same results after further adjustment for covariates. Patients with above-median levels of TIMP-1 were more likely to suffer from adverse outcomes than patients with below-median levels of TIMP-1. However, the lack of relationship of MACEs with MMP-9 and MMP-9/TIMP-1 remained. Conclusions: Higher circulating TIMP-1 concentrations were associated with cardiovascular events during long-term follow-up of Chinese patients with mild to moderate coronary artery lesions.

Prevalence of visual–functional mismatch regarding coronary artery stenosis in the CVIT-DEFER registry

The fractional flow reserve (FFR) is considered to be a reliable index for the assessment of clinically relevant coronary artery stenosis. However, mismatch in assessing the severity of coronary stenosis between coronary angiography and the FFR has been pointed out. The cardiovascular intervention therapeutics (CVIT)-DEFER registry is a prospective multicenter registry study that has enrolled 3,228 consecutive patients among 3,804 patients with angiographically moderate coronary artery lesions in whom FFR analysis was clinically indicated. The demographic and angiographic parameters associated with an FFR ≤0.8 were analyzed, and the incidence of discrepancy between the angiographic severity of coronary stenosis and the FFR was assessed. Based on the visual assessment, 1,609 (42.9%) lesions were categorized as showing 50% stenosis, 1,882 lesions (50.2%) as 75% stenosis, and 257 lesions (6.9%) as 90% stenosis. Angiographic-FFR "mismatch," which was defined as visual stenosis ≥75% with FFR >0.80, was found in 43.4% of lesions, while reverse angiographic mismatch (visual stenosis <75% with FFR ≤0.8) was found in 23.2%. The independent predictors for "angiographic-FFR mismatch" were the presence of percutaneous coronary intervention (PCI) history, one-vessel disease, non-left anterior descending artery (LAD) location, non-diffuse lesion, non-ostial lesion, and non-tandem lesion. Conversely, "reverse angiographic mismatch" was independently associated with the multivessel disease, LAD location, and diffuse lesion. The FFR is not only influenced by luminal stenosis but also by coronary artery morphology and the amount of jeopardized myocardium. Angiographic-FFR mismatch is frequent in patients with moderate coronary stenosis, which suggests the clinical importance of using physiological assessment to guide PCI.

Assessing Intermediate Coronary Lesions

Although invasive coronary angiography traditionally has been considered the reference standard for diagnosing coronary artery disease, its limitations are being highlighted with increasing frequency.1 This is particularly evident in patients with intermediate or moderate coronary artery lesions. For this subset of narrowings, a number of adjunctive, invasive techniques have been proposed to improve the diagnostic accuracy of the coronary angiogram. Article see p 2557 In landmark work by Lance Gould and colleagues, coronary flow reserve (CFR) defined as hyperemic coronary flow divided by resting coronary flow, was first proposed as a method for evaluating the functional significance of intermediate stenoses.2 However, CFR by definition interrogates the status of the entire coronary circulation, both the epicardial vessel and the microcirculation. In patients with microvascular dysfunction, for example from diabetes mellitus or a past myocardial infarction, CFR will be abnormal, thus limiting its application for identifying ischemia-producing epicardial disease. CFR is also limited by its lack of a normal value in any given patient or vessel. For example, in 1 patient a value of 3 may be normal, whereas in another patient a value of 5 is normal. A final limitation of CFR is its variability or lack of reproducibility; because resting flow is a component of its definition, changes in resting flow that occur with hemodynamic perturbations can dramatically affect CFR.3,4 For these reasons, CFR has fallen out of favor for invasively evaluating intermediate coronary lesions.5 Others have proposed intracoronary anatomic evaluation with techniques, such as intravascular ultrasound.6 Intravascular ultrasound provides improved morphologic assessment of intermediate coronary disease, but its ability to predict future events7 or to correlate with other measures of myocardial ischemia has been disappointing,8 because it fails to account for 1 of the most important determinants of the ischemic …

Comparison between fractional flow reserve and visual assessment by multiple observers in patients with moderate coronary artery lesions

Objectives: Our aim was to evaluate whether more than one observer or fractional flow reserve has the same re­sults in assessing coronary lesion severity in intermediate lesions. Methods: Our hospital’s database was searched for frac­tional flow reserve procedures and then these patient’s lesions were assessed visually by three experienced in­terventional cardiologist. Results: 8 of 46 patients were (17.4%) female and 38 of 46 were (82,6%) male. Average age was 61±11 years (Male: 60±11 / Female: 70±7 years). One observer could only detect 66.7% of severe lesions and 76.2% of non-severe lesions. When two observers agreed about lesion sever­ity, true detection of severe lesions was (max) 76.7%, and true detection of non-severe lesions was (max) 66.7%, so a decrease in true detection of non-severe lesions was observed. When one of the observers called a lesion “se­vere” and the lesion was assumed as “severe”, detection of a severe lesion was 83.3% (p=0.017); if all of the ob­servers agreed that the lesion was “non-severe” then true detection of a non-severe lesion was 90.5% (p<0.05). Conclusion: One observer can’t detect a lesion sever­ity sufficiently, but when three observers’ information was evaluated, there was nearly 90% concordance with frac­tional flow reserve results.

Angina with normal coronary arteries: a common but often neglected association

The angiographic evidence of normal coronary arteries or moderate coronary artery disease is a relatively common finding in patients with a history of angina, with a higher prevalence in females. This condition is not a single pathological entity, but comprises several different presentations, such as cardiac syndrome X, vasospastic angina, myocardial bridges, as well as coronary alterations with more doubtful clinical implications, such as serial moderate coronary artery lesions or focal coronary dilations. These pathological conditions are different in pathophysiology, management, and prognosis, and for this reason their correct diagnostic definition, beyond the angiographic evidence of normal coronary arteries, appears mandatory. This review aims at providing an update in the conundrum of entities comprising angina with normal coronary arteries, and at explaining different diagnostic and therapeutic approaches.

Multimarker Approach for the Prediction of Cardiovascular Events in Patients With Mild to Moderate Coronary Artery Lesions

Few studies have assessed the incremental usefulness of multimarkers as predictors of cardiovascular events in patients with mild to moderate coronary artery lesions.We examined 9 plasma inflammatory cytokines (cathepsin S, CXCL16, sopluble CD40 ligand, interleukin-10, placental growth factor, GDF15, matrix metalloproteinase 9, monocyte chemoattractant protein-1, and high-sensitivity C-reactive protein) in 964 patients showing mild to moderate lesions and assessed their association with risk of cardiovascular events during 3 years of follow-up (median 17 months).In a backward Cox regression procedure, Cystatin S (hazard ratio [HR]: 1.788, 95% CI: 1.233 to 2.593, P = 0.02), soluble CD40 ligand (HR: 1.255, 95% CI: 1.054 to 1.494, P = 0.011), placental growth factor (HR: 1.194, 95% CI: 0.976 to 1.461, P = 0.035), and GDF15 (HR: 0.725, 95% CI: 0.550 to 0.956, P = 0.023) were significantly related to cardiovascular events. Compared with multimarker score (according to regression coefficients of significant biomarkers) in the lowest two quintiles, patients in the highest quintile had a higher risk of cardiovascular events after adjustment for traditional risk factors (HR: 2.77, 95% CI: 1.30 to 5.87, P = 0.008). Adding the multimarker score to traditional risk factors contributed significantly to the prediction of cardiovascular events (AUC increased from 0.67 to 0.72).A multimarker approach added to the predictive information obtained from traditional risk factors in patients with mild to moderate coronary artery lesions.

The pressure wire as a diagnostic tool in patients with congenital cardiac disease

The pressure wire has emerged as a useful tool to assess the clinical severity of moderate coronary artery lesions. We report a novel use of the pressure wire in adult patients with complex congenital cardiac disease in whom it was used in assessing pressures beyond the stenosis in the distal pulmonary artery, aorto-pulmonary collaterals, and across prosthetic tricuspid valves, where conventional catheters were unable to reach. We used this in three of our patients for assessment of pulmonary artery pressures and in two patients for assessment of pressures across a prosthetic St Jude® valve. Out of the three patients referred for assessment, only two had significantly raised distal pulmonary pressures enabling them to receive appropriate therapy. Out of the two patients with a prosthetic tricuspid valve, only one required surgery based on this assessment. We describe a novel use of the pressure wire in the functional assessment of adults with congenital cardiac disease in whom conventional catheter techniques may not be able to provide adequate data. It can be a guide to provide appropriate therapy and avoid unnecessary interventions in this patient group.

Reverse J-curve relation between diastolic blood pressure and severity of coronary artery lesion in hypertensive patients with angina pectoris.

The existence of the J-curve in hypertension treatment remains controversial. The major question is whether the increase in mortality from coronary disease is induced by the lowering of blood pressure (BP) or by the severity of underlying coronary artery disease. We recruited patients with a history of hypertension (systolic BP (SBP) >160 mmHg and/or diastolic BP (DBP) >90 mmHg) and a diagnosis of angina pectoris with angiographically confirmed coronary artery lesion. The relationship among the treated levels of SBP and DBP, the severity of coronary artery lesion, and the clinical consequences were investigated. Among the 234 enrolled patients, 115 experienced further events, 19 of which were serious. There were no significant differences in the average BP of patients with and those without events, but the coronary severity indices (CSI) were significantly greater in patients with events. As a function of DBP from < or = 74 to 105 < or = mmHg, there was a positive association with the incidence of serious events, and a reversed J-curve in CSI with a nadir at 95-104 mmHg. A similar relationship was observed in SBP, but a potentially unfavorable outcome was suggested in the lowest SBP range of < or = 124 mmHg. In conclusion, there was no J-curve for DBP in hypertensive patients with angina pectoris; rather, the lower the DBP, the better was the prognosis. Interestingly, the severity of coronary lesion is in a reversed J-curve relation with DBP, suggesting that high BP plays a critical role in serious events in hypertensive patients with moderate coronary artery lesions.