Nonobstructive Coronary Artery Disease Research Articles

Ejection Fraction-Related Differences of Baseline Characteristics and Outcomes in Troponin-Positive Patients without Obstructive Coronary Artery Disease

Background: The development and course of myocardial infarction with non-obstructive coronary artery (MINOCA) disease is still not fully understood. In this study, we aimed to examine the baseline characteristics of in-hospital outcomes and long-term outcomes of a cohort of troponin-positive patients without obstructive coronary artery disease based on different left ventricular ejection fractions (LVEFs). Methods and results: We included a cohort of 254 patients (mean age: 64 (50.8–75.3) years, 120 females) with suspected myocardial infarction and no obstructive coronary artery disease (MINOCA) in our institutional database between 2010 and 2021. Among these patients, 170 had LVEF ≥ 50% (84 females, 49.4%), 31 patients had LVEF 40–49% (15 females, 48.4%), and 53 patients had LVEF < 40% (20 females, 37.7%). The mean age in the LVEF ≥ 50% group was 61.5 (48–73) years, in the LVEF 40–49% group was 67 (57–78) years, and in the LVEF < 40% group was 68 (56–75.5) years (p = 0.05). The mean troponin value was highest in the LVEF < 40% group, at 3.8 (1.7–4.6) µg/L, and lowest in the LVEF ≥ 50% group, at 1.1 (0.5–2.1) µg/L (p = 0.05). Creatine Phosphokinase (CK) levels were highest in the LVEF ≥ 50% group (156 (89.5–256)) and lowest in the LVEF 40–49% group (127 (73–256)) (p < 0.05), while the mean BNP value was lowest in the LVEF ≥ 50% group (98 (48–278) pg/mL) and highest in the <40% group (793 (238.3–2247.5) pg/mL) (p = 0.001). Adverse in-hospital cardiovascular events were highest in the LVEF < 40% group compared to the LVEF 40–49% group and the LVEF ≥ 50% group (56% vs. 55% vs. 27%; p < 0.001). Over a follow-up period of 6.2 ± 3.1 years, the all-cause mortality was higher in the LVEF < 40% group compared to the LVEF 40–49% group and the LVEF ≥ 50% group. Among the different factors, LVEF < 40% and LVEF 40–49% were associated with an increased risk of in-hospital cardiovascular events in the multivariable Cox regression analysis. Conclusions: LVEF has different impacts on in-hospital cardiovascular events in this cohort. Furthermore, LVEF influences long-term all-cause mortality.

Comparison of myocardial infarction with non-obstructive coronary arteries (MINOCA) versus type 2 MI with NSTEMI presentation; an Italian observation study

Abstract Funding Acknowledgements None. Background In the last decades, NSTEMI, is the predominant phenotype of myocardial infarction (MI) and many NSTEMI patients(pts) have a non-obstructive CAD. NSTEMI, represents an umbrella for many different conditions with distinct underlying pathogenesis and exhibits significant gender discrepancies and survival differences. Further, in absence of non-obstructive CAD, pts could be wrongly comforted about their prognosis. Purpose In this study, we compared the characteristics and the prognosis of pts with MINOCA and type 2 MI with non-obstructive CAD. The primary outcome was a composite of all-cause mortality, non-fatal MI, hospitalization for heart failure (HF) and transitory ischemic attack or non-fatal stroke. Methods Were screened 18223 pts with MI, who underwent coronary angiography between 2005 and 2022. Among them, 7815 pts had NSTEMI presentation, of which 693 pts (9%) had a non-obstructive CAD. After reviewing the angiographic data and clinical presentation, 155 pts were excluded because they belonged to one of the categories known as "MINOCA mimichers" (Fig 1). Five hundred and thirty eight pts with MI, NSTEMI presentation and with non-obstructive CAD were included in the final cohort: 301 (56%) had MINOCA and 237 pts (44%) had type 2 MI (Fig 1). Results The mean age of the population was 68 years, and females were predominant in both groups. MINOCA pts were younger, more frequently had adverse events during pregnancy and endocrine disorders. Pts with type 2 MI were more likely to have typical CV risk factors and comorbidities such as CKD and HF. Pts with type 2 MI had a worse diastolic function, a more dilated left atrium and left ventricle(LV), and non-coronary distribution of regional LV wall-motion abnormalities. At initial clinical presentation, the MINOCA group had typical chest pain upon awakening or at night, responsive to nitrates, while type 2 MI were more often to present with dyspnea, palpitations, and with higher blood pressure. Coronary vasospasm and embolization were the most common identified aetiologies in MINOCA pts while tachyarrhythmias were the most common trigger of type 2 MI, followed by hypertensive crisis. The final model of the predictors of MINOCA at multivariate logistic regression analysis listed in Fig 2, yielded an AUC of 0.865, p<0.01 at ROC analysis(Fig 2a). These variables were used for the generation of nomogram for MINOCA prediction(Fig 2b). During the median follow-up of 61 months (IQR 34.2-100.35), pts with MINOCA had a significantly better survival rate; 135 of 538 pts (25.1%) reached the primary combined endpoint(Fig 3a). The primary end-point was mainly driven by the all-cause mortality, followed by HF hospitalization, non-fatal stroke, non-fatal MI recurrence. Results of Cox multivariable analysis are presented in Fig 3b. Conclusions MINOCA cohort was associated with unconventional risk factors and had a better prognosis compared to T2 MI, which is closer to the classical AMI-CAD.

Usability of myocardial work parameters in demonstrating myocardial involvement in INOCA patients.

Myocardial work (MW) is a novel echocardiographic modality, which has been shown to have diagnostic and prognostic values in patients with cardiovascular diseases, patients with obstructive coronary artery disease, in particular. However, only a handful of studies have examined the MW analysis in ischemia with nonobstructive coronary artery (INOCA) disease. This study, therefore, aimed to detect the early left ventricular involvement in INOCA patients diagnosed by an invasive coronary angiography performing the MW analysis. This study included a total of 119 patients with nonobstructive coronary artery disease diagnosed by invasive coronary angiography, who were checked for prior ischemia tests performing myocardial perfusion scintigraphy. Out of these 119 patients, 49 patients developed ischemia (i.e., ischemic group) diagnosed using cardiac single-photon emission computed tomography, whereas 70 patients did not (i.e., nonischemic group). The subjects were divided into three groups based on the global MW tertiles. The groups were compared in terms of the conventional, longitudinal strain, and MW findings by conducting echocardiographic examinations. The study subjects were divided into three groups based on the global constrictive work (GCW) value. The three groups were not statistically different in terms of the mean age of the patients (53.0 ± 12 vs. 52.4 ± 13.3 vs. 52.1 ± 12.3; p = 0.96). Furthermore, the three groups were not statistically different regarding the gender, height, weight, and laboratory parameters of the patients except albumin. There was no statistically difference among the tertiles of GCW groups in the measurements of cardiac chambers, LA diameter, interventricular septum, E wave, and A wave. Also, there was no statistical difference in tissue Doppler recordings. The parameters associated with MW were examined, three groups were not statistically different in terms of the global waste work (GWW) (116 ± 92, 122 ± 73, 135 ± 62, p = 0.52, respectively). In contrast, the three groups were different regarding the Global work index (GWI) (1716 ± 300, 1999 ± 130, 2253 ± 195, p < 0.001, respectively), GCW(1888 ± 206, 2298 ± 75, 2614 ± 155, p < 0.001, respectively), and Global work efficiency parameters (92.8 ± 3.6, 94.4 ± 3.2, 95.1 ± 1.8 p = 0.004, respectively). It was concluded that the MW parameters GCW and GWI may have been used for predicting INOCA in patients.

Mental stress-induced myocardial ischemia detected by global longitudinal strain and quantitative myocardial contrast echocardiography in women with nonobstructive coronary artery disease

BackgroundThe utility of radionuclide myocardial perfusion imaging including positron emission tomography (PET) for diagnosing mental stress-induced myocardial ischemia (MSIMI) is clinically restricted. This study aims to assess the diagnostic performance of novel echocardiographic techniques, including automated strain and quantitative myocardial contrast echocardiography (MCE) with dedicated software and deep neural network (DNN) model, for MSIMI detection. The secondary objective was to explore the correlation between changes in myocardial blood flow (MBF) and MSIMI. Methods72 female patients aged 18 to 75 with angina and nonobstructive coronary artery disease (ANOCA), and 23 healthy controls were prospectively recruited. Both echocardiography with contrast agent and PET imaging were performed during structured mental stress testing. MSIMI was defined as a summed difference score ≥3 on PET. Echocardiographic parameters including left ventricular global longitudinal strain (LVGLS), β and A×β were obtained, and their trends during mental stress testing were observed. ΔGLS, β reserve and A×β reserve were respectively calculated. Results32 ANOCA patients (44%) and 1 control (4%) were diagnosed with MSIMI (P<0.01). For ANOCA patients with MSIMI, LVGLS, β and A×β declined to varied extent during mental stress testing compared to those without MSIMI and the controls (P<0.05). Bland-Altman plots demonstrated good consistency between β reserve and A×β reserve output by the DNN model and iMCE software. Receiver operating characteristic (ROC) curve analyses showed that ΔGLS, β reserve and A×β reserve demonstrated favorable ability to predict MSIMI, especially the combination of A×β reserve using iMCE analysis and ΔGLS (area under the curve [AUC] 0.94, sensitivity 83%, specificity 97%). ConclusionsNovel technologies in echocardiography exhibit the potential to be a clinical alternative to cardiac PET for effectively detecting MSIMI. Attenuated MBF response during structured mental stress testing was correlated with MSIMI, providing a reasonable explanation for the chest discomfort persisting in ANOCA women.

The role of cardiac PET in diagnosis and prognosis of patients with ischemia with no obstructive coronary arteries (INOCA)

Chest pain, a common symptom in cardiovascular care, often leads to the investigation of obstructive coronary artery disease (CAD). However, many patients experience chest pain without obstructive CAD, termed INOCA (Ischemia with Non-Obstructive Coronary Arteries) or CMD (Coronary Microvascular Dysfunction). INOCA can be attributed to endothelial dysfunction, vascular smooth muscle dysfunction, or both, affecting about 20–30 % of patients with nonobstructive CAD. The diagnostic approach for INOCA includes both invasive and non-invasive methods, with cardiac PET (Positron Emission Tomography) playing a significant role in risk stratification and management. PET evaluates various parameters like myocardial blood flow under stress and rest, myocardial flow reserve, and myocardial ischemia. Such comprehensive assessment is essential in accurately diagnosing and managing INOCA, considering the complexity of this condition.

Exploring the interplay between coronary microvascular dysfunction and mental health

BackgroundThe intricate relationship between mental health disorders, notably anxiety and depression, and chest pain associated with non-obstructive coronary artery disease has become a focus of investigation. MethodsThis study from the Coronary Microvascular Disease Registry (CMDR) evaluated the association of mental health disorders and coronary microvascular dysfunction (CMD) among patients with angina with no obstructive coronary artery disease (ANOCA)who had undergone comprehensive invasive physiological testing for CMD. Clinical data regarding baseline characteristics, comorbidities, and noninvasive cardiac testing were obtained from chart review. The primary outcome of interest was the potential relationship between mental health diagnoses and the presence of CMD. ResultsOf patients included in the CMDR, 27 % (41/152) had at least one documented mental health disorder diagnosis (International Classification of Diseases, Tenth Revision codes) and CMD. There was no difference in mental health diagnosis prevalence between CMD-positive and CMD-negative patients (21.1 % vs. 28.9 %, p = 0.34). The most common mental health diagnoses were depression (15.8 %) and anxiety (15.8 %). Furthermore, 46.3 % (19/41) of patients with mental health disorders were prescribed psychiatric medications, with the most common being benzodiazepines (26.8 %). ConclusionPatients with chest pain not due to CMD did not have an increased prevalence of mental health disorders compared with patients with ANOCA due to CMD, challenging the notion of a psychosomatic component in the pathogenesis of ANOCA.Clinical Trial Registration: Coronary Microvascular Disease Registry, clinicaltrials.gov, NCT05960474.

Assessment of the Level of Matrix Metalloproteinases, VEGF and MicroRNA-34a in Patients With Non-obstructive and Obstructive Lesions of the Coronary Arteries.

To assess the levels of matrix metalloproteinases (MMP), vascular endothelial growth factor (VEGF), and miRNA-34a expression in patients with ischemic heart disease (IHD) and obstructive and nonobstructive coronary artery (CA) disease. This cross-sectional observational study included 64 patients with IHD (diagnosis verified by coronary angiography or multislice computed tomography coronary angiography), of which 33 (51.6%) were men aged 64.9±8.1 years. 20 patients had nonobstructive CA disease (stenosis &lt;50%), and 44 had hemodynamically significant stenoses. The control group consisted of 30 healthy volunteers. MMP-1, -9, -13, and -14, miRNA-34a, and VEGF were measured in all patients. The concentration of MMP-1 was significantly higher in patients with ischemia and nonobstructive CA disease (INOCAD) (p=0.016), and the concentration of MMP-9 was the highest in the group with obstructive CA disease (p&lt;0.001). The concentrations of MMP-13 and MMP-14 did not differ significantly between the groups. The highest VEGF concentrations were observed in the INOCAD group (p&lt;0.001). The expression of miRNA-34a significantly differed between the IHD groups with different types of CA disease and controls (p &lt;0.001). Patients with hemodynamically significant stenosis showed moderate relationships between the concentrations of MMP-14 and VEGF (ρ=0.418; p=0.024), as well as between VEGF and miRNA-34a (ρ=0.425; p=0.022). Patients with INOCAD had a significant negative correlation between the concentrations of MMP-13 and VEGF (ρ= -0.659; p=0.003). Correlation analysis showed in all IHD patients a moderate relationship of the concentrations of MMP-1 and MMP-14 with VEGF (ρ=0.449; p=0.002 and p=0.341; p=0.019, respectively). According to ROC analysis, a MMP-9 concentration above 4.83 ng/ml can be a predictor for the presence of hemodynamically significant CA obstruction in IHD patients; a VEGF concentration higher than 27.23 pg/ml suggests the absence of hemodynamically significant CA stenosis. IHD patients with INOCAD had the greatest increase in MMP-1, whereas patients with obstructive CA disease had the highest level of MMP-9. According to our data, concentrations of MMP-9 and VEGF can be used to predict the degree of CA obstruction. The expression of miRNA-34a was significantly higher in IHD patients with INOCAD and CA obstruction than in the control group, which suggested a miRNA-34a contribution to the development and progression of coronary atherosclerosis. In the future, it may be possible to use this miRNA as a diagnostic marker for IHD.

Traditional Cardiovascular Risk Factors and Coronary Microvascular Disease in Women and Men- A Single Center Study.

Introduction Coronary microvascular disease (CMD) is common in patients with and without obstructive epicardial coronary artery disease (CAD). Risk factors for the development of CMD have not been fully elucidated, and data regarding sex associated differences in traditional cardiovascular risk factors for obstructive CAD in patients with CMD are lacking. Methods In this single center, prospective registry, we enrolled patients with non-obstructive CAD undergoing clinically indicated invasive assessment of coronary microvascular function between November 2019 and March 2023. Associations between coronary microvascular dysfunction, traditional cardiovascular risk factors, and sex were assessed using univariate and multivariate regression models. Results Overall, 245 patients with non-obstructive CAD were included in the analysis (62.9% female; median age 68 (interquartile range [IQR]: 59,75). Microvascular dysfunction was diagnosed in 141 patients (57.5%). The prevalence of microvascular dysfunction was similar in women and men (59.0% vs. 57.0%; p=0.77). No association was found between traditional risk factors for coronary atherosclerosis and CMD regardless of whether CMD was structural or functional. In women, but not in men, older age and the presence of previous ischemic heart disease were associated with lower coronary flow reserve (CFR) (β=-0.29; p&lt;0.01 and β=-0.15; p=0.05, respectively) and lower resistive reserve ratio (RRR) (β=-0.28; p&lt;0.01 and β=-0.17; p=0.04, respectively). Conclusion For the entire population, no association was found between coronary microvascular dysfunction and traditional risk factors for coronary atherosclerosis. In women only, older age and previous ischemic heart disease were associated with coronary microvascular dysfunction. Larger studies are needed to elucidate risk factors for CMD.

Role of Personalized Medicine in Myocardial Infarction With Nonobstructive Coronary Artery Disease (MINOCA): An Updated Review

Cardiovascular diseases, notably myocardial infarction (MI), contribute significantly to global mortality. While traditional MIs are often associated with notable coronary artery blockages, a subgroup experiences MI without such blockages, termed myocardial infarction with nonobstructive coronary arteries (MINOCA). Current diagnostic methods, like invasive coronary angiograms, are inadequate in diagnosing MINOCA due to the absence of visible vessel blockages. Personalized medicine endeavors to introduce novel diagnostic tools for early identification and tailored management of MINOCA. Unlike percutaneous coronary intervention, which lacks efficacy in MINOCA, personalized medical management aligned with the specific underlying pathophysiological cause is essential. Treatments may include statins, agents modulating the renin-angiotensin system, and antiplatelet therapies if linked to plaque disruption. At the same time, calcium channel blockers may be pivotal if coronary artery spasm is the primary cause. Research is ongoing to refine tailored therapies and discover new biomarkers, highlighting the crucial need for individualized approaches in managing MINOCA.

Association of postsystolic shortening on stress echocardiography and significant coronary artery stenosis:A single-centre retrospective cohort study.

Postsystolic shortening (PSS) is one of the proposed quantitative measures to predict myocardial ischaemia in the stress echocardiographic (SE) evaluation. It is previously known that hypo-/akinesia (HA) correlates well with coronary stenosis. However, some patients undergoing SE only present with PSS, and their risk of significant coronary stenosis is less clear. This study aimed to evaluate the association between PSS and significant coronary stenosis compared with HA. This was a retrospective cohort study at the hospital of S:t Görans, Stockholm, Sweden. All patients who underwent SE to investigate inducible ischaemia between 1 January2018 and 15 October 2021were eligible for inclusion. Exclusion criteria were normal SE and inconclusive test. Pathological SE were divided into two groups, patients with HAand those with PSS. Outcome was significant coronary artery stenosis visualized by invasive coronary angiography. The final study population consisted of 108 patients (73 PSS, 35 HA). The presence of HA was associated with a higher risk of significant stenosis compared to those with PSS (63% vs. 23%, p < 0.001). This relationship was observed among males (p < 0.001), but not among females (p = 0.133). Nonsignificant stenosis trended to be more common among patients with PSS (21% vs. 6%, p = 0.053) CONCLUSIONS: The finding of PSS without HA was associated with a lower risk of significant coronary stenosis than HA. However, patients with PSS still often had nonsignificant coronary stenosis and PSS in the evaluation for nonobstructive coronary artery disease (CAD) should be further investigated.

Psychosocial distress and health status as risk factors for ten-year major adverse cardiac events and mortality in patients with non-obstructive coronary artery disease

BackgroundWe examined the risk of psychosocial distress, including Type D personality, depressive symptoms, anxiety, positive mood, hostility, and health status fatigue and disease specific and generic quality of life for MACE in patients with non-obstructive coronary artery disease (NOCAD). MethodsIn the Tweesteden mild stenosis (TWIST) study, 546 patients with NOCAD were followed for 10 years to examine the occurrence of cardiac mortality, a major cardiac event, or non-cardiac mortality in the absence of a cardiac event. Cox proportional hazard models were used to examine the impact of psychosocial distress and health status on the occurrence of MACE while adjusting for age, sex, disease severity, and lifestyle covariates. ResultsIn total 19% of the patients (mean age baseline = 61, SD 9 years; 52% women) experienced MACE, with a lower risk for women compared to men. Positive mood (HR 0.97, 95%CI 0.95–1.00), fatigue (HR 1.03, 95%CI 1.00–1.06), and physical limitation (HR 0.99, 95%CI 0.98–1.00) were associated with MACE in adjusted models. No significant interactions between sex and psychosocial factors were present. Depressive symptoms were predictive of MACE, but no longer after adjustment. ConclusionsIn patients with NOCAD fatigue, low positive mood, and a lower physical limitation score were associated with MACE, without marked sex differences. Type D personality, psychosocial factors, and health status were not predictive of adverse outcomes. Reducing psychosocial distress is a valid intervention goal by itself, though it is less likely to affect MACE in patients with NOCAD.

Comparison of Baseline and Post-Nitrate Exercise Testing in Patients with Angina but Non-Obstructed Coronary Arteries with Different Acetylcholine Test Results.

Background: Intracoronary acetylcholine testing may induce epicardial coronary artery spasm (CAS) or coronary microvascular spasm (CMVS) in patients with angina syndromes but non-obstructive coronary artery disease, but their causal role in individual patients is not always clear. In this prospective, observational single-center study, we aimed to assess whether (1) the induction of myocardial ischemia/angina by electrocardiogram (ECG) exercise stress test (EST) differs between patients showing different results in response to acetylcholine testing (i.e., CAS, CMVS, or no spasm); (2) the preventive administration of short-acting nitrates has any different effects on the EST of those patients who showed a positive basal EST. We expected that if exercise-induced angina and/or ischemic ECG changes are related to CAS, they should improve after nitrates administration, whereas they should not significantly improve if they are caused by CMVS. Methods: We enrolled 81 patients with angina syndromes and non-obstructive coronary artery disease, who were divided into three groups according to acetylcholine testing: 40 patients with CAS (CAS-group), 14 with CMVS (CMVS-groups), and 27 with a negative test (NEG-group). All patients underwent a basal EST (B-EST). Patients with a positive B-EST repeated the test 24-48 h later, 5 min after the administration of short-acting nitrates (N-EST). Results: There were no significant differences among the groups in terms of the B-EST results. B-EST was positive in eight (20%) patients in the CAS-group, seven (50%) in the CMVS-group, and six (22%) in the NEG-group (p = 0.076). N-EST, performed in eight, six, and five of these patients, also showed similar results in the three groups. Furthermore, the N-EST results also did not significantly differ compared to B-EST in any group, remaining positive in seven (87.5%), four (66.7%), and four (80%) patients in the CAS-group, CMVS-group, and NEG-group, respectively (p = 0.78). Conclusions: Our data show that patients with angina and non-obstructive coronary artery disease show largely comparable results of the ECG exercise stress test and similar poor effects of short-acting nitrates on abnormal ECG exercise stress test results. On the whole, our findings suggest caution in attributing to the results of Ach testing a definite causal role for the clinical syndrome in individual patients.

Receptor for advanced glycation end products polymorphisms in coronary artery ectasia

BackgroundAlthough the implication of receptor of advanced glycation endproducts (RAGE) has been reported in coronary artery disease, its roles in coronary artery ectasia (CAE) have remained undetermined. Furthermore, the effect of RAGE polymorfisms were not well-defined in scope of soluble RAGE (sRAGE) levels. Thus, we aimed to investigate the influence of the functional polymorphisms of RAGE -374T > A (rs1800624) and G82S (rs2070600) in CAE development. MethodsThis prospective observational study was conducted in 2 groups selected of 2452 patients who underwent elective coronary angiography (CAG) for evaluation after positive noninvasive heart tests. Group-I included 98 patients with non-obstructive coronary artery disease and CAE, and Group-II (control) included 100 patients with normal coronary arteries. SNPs were genotyped by real-time PCR using Taqman® genotyping assay. Serum sRAGE and soluble lectin-like oxidized receptor-1 (sOLR1) were assayed by ELISA and serum lipids were measured enzymatically. ResultsThe frequencies of the RAGE -374A allele and -374AA genotype were significantly higher in CAE patients compared to controls (p < 0.001). sRAGE levels were not different between study groups, while sOLR1 levels were elevated in CAE (p = 0.004). In controls without systemic disease, -374A allele was associated with low sRAGE levels (p < 0.05), but this association was not significant in controls with HT. Similarly, sRAGE levels of CAE patients with both HT and T2DM were higher than those no systemic disease (p = 0.02). The -374A allele was also associated with younger patient age and higher platelet count in the CAE group in both total and subgroup analyses. In the correlation analyses, the -374A allele was also negatively correlated with age and positively correlated with Plt in all of these CAE groups. In the total CAE group, sRAGE levels also showed a positive correlation with age and a negative correlation with HDL-cholesterol levels. On the other hand, a negative correlation was observed between sRAGE and Plt in the total, hypertensive and no systemic disease control subgroups. Multivariate logistic regression analysis confirmed that the -374A allele (p < 0.001), hyperlipidemia (p < 0.05), and high sOLR1 level (p < 0.05) are risk factors for CAE. ROC curve analysis shows that RAGE -374A allele has AUC of 0.713 (sensitivity: 83.7 %, specificity: 59.0 %), which is higher than HLD (sensitivity: 59.2 %, specificity: 69.0 %), HT (sensitivity: 62.4 %, specificity: 61.1 %) and high sOLR1 level (≥0.67 ng/ml)) (sensitivity: 59.8 %, specificity: 58.5 %). ConclusionBeside the demonstration of the relationship between -374A allele and increased risk of CAE for the first time, our results indicate that antihypertensive and antidiabetic treatment in CAE patients causes an increase in sRAGE levels. The lack of an association between the expected -374A allele and low sRAGE levels in total CAE group was attributed to the high proportion of hypertensive patients and hence to antihypertensive treatment. Moreover, the RAGE -374A allele is associated with younger age at CAE and higher Plt, suggesting that -374A may also be associated with platelet activation, which plays a role in the pathogenesis of CAE. However, our data need to be confirmed in a large study for definitive conclusions.

Clinical significance of echocardiographic signs of right heart dysfunction in patients with chronic heart failure with preserved left ventricular ejection fraction

Aim: To analyze the features of clinical signs, quality of life and psycho-emotional state in patients with heart failure with preserved left ventricular ejection fraction (HFpEF) and non-obstructive atherosclerosis of the coronary arteries, depending on the presence of echocardiographic criteria for dysfunction of the right heart.Material and Methods. Patients underwent an extended protocol of echocardiography with an assessment of the structure and function of the right heart; ultrasound examination of the lungs with the determination of the number of B-lines; a six-minute walk test, a test for the presence of a symptom of bendopnea with the determination of blood oxygen saturation (SpO2) before and during the test. In addition, quality of life was assessed using the Minnesota questionnaire and the SF-36 questionnaire (The Short Form-36); the psycho-emotional state of patients was analyzed according to the HADS (Hospital Anxiety and Depression Scale), the level of adherence to treatment was analyzed according to the Morisky – Green questionnaire. Patients were divided into two groups depending on signs of right heart dysfunction: Tei index more than 0.54, tricuspid annulus systolic excursion (TAPSE) less than 17 mm, tricuspid annulus systolic velocity (RV S’) less than 9,5 cm/sec.Results. Echocardiographic signs of right heart dysfunction in patients with HFpEF was associated with lower quality of life indicators according to the SF-36 questionnaire, in particular, general health status (p = 0.008) and role limitations due to emotional problems (p = 0.03). During the bendopnea test (p = 0.04), the majority of patients with signs of dysfunction of the right heart (66.7%) had a decrease in SpO2, while in the comparison group the proportion of such patients was 36.7% (p = 0.04). The psycho-emotional state according to the HADS scale and adherence to treatment did not differ in both groups (p &gt; 0.05). The frequency of detection of B-lines according to lung ultrasound was also comparable.

Myocardial flow reserve recovery in patients with Takotsubo syndrome: insights from positron emission tomography

BackgroundCoronary microvascular dysfunction (CMD) has been implicated in the pathogenesis of Takotsubo syndrome (TTS). Positron emission tomography (PET) plays a key role in the assessment of CMD through myocardial flow reserve (MFR). However, there is limited information on the temporal progression of MFR and its relationship to coronary artery disease (CAD) in TTS patients. MethodsThis study evaluated patients with TTS who underwent cardiac catheterization and PET within one year of hospitalization. Patients were categorized into acute (≤10 days), subacute (11-30 days), and chronic (≥31 days) stages based on post-onset time of PET assessment. MFR values and prevalence of abnormal MFR (<2.0) were compared between stages. Temporal MFR changes in patients with obstructive CAD (≥70% stenosis by coronary angiography), non-obstructive CAD, and normal coronaries were compared. ResultsOf the 88 patients studied (mean age 70; 96% female), 52 (59%) were in the acute, 17 (19%) in the subacute, and 19 (22%) in the chronic stage. Median MFR in the acute stage was 2.0 (1.5-2.3), with 58% of patients showing abnormal MFR. A significant time-dependent improvement in MFR was observed (p=0.002), accompanied by a decreased prevalence of abnormal MFR (p=0.016). While patients with normal coronaries showed significant MFR improvement over time (p=0.045), patients with obstructive or non-obstructive CAD demonstrated no improvement across three stages (p=0.346 and 0.174, respectively). ConclusionsPET-derived MFR was impaired in TTS patients during the acute phase, with improvement suggesting potential recovery from CMD over time. The concurrent presence of obstructive CAD might impede this recovery process.

Determining the Frequency of Non-Obstructive Coronary Artery Disease in Elective Angiography Cases

Cardiovascular disease particularly ischemic heart disease has emerged as a leading cause of death. Atherosclerosis in epicardium results in CAD without the restriction of coronary circulation but the other processes that may disrupt the myocardial supply and demand in patients exhibiting angina symptoms or indications may be suspected of having non-obstructive CAD. Objective: To find out the prevalence of non-obstructive CAD in patients enrolled for elective angiography. Methods: A cross-sectional descriptive analysis was done in the Cardiology department in King Edward Medical University and Mayo Hospital, Lahore. The duration of study was for six months from 01-08-2022 to 01-02-2023. After approval from hospital ethical committee, 150 patients were enrolled in the study with informed written consent. Demographics including Name, age, BMI, confounding factors like (diabetes, hypertension, smoking and family history) and address were noted. All selected patients underwent coronary angiography via right femoral artery approach by a consultant cardiologist. Non-obstructive coronary artery disease was assessed as per operational definition. All the information was noted on pre-designed proforma (attached). Results: A total of 150 patients were selected for the study. It showed that out of 150 patients, 2.7% (n=4) fall in age group of 18-40 years and 97.3 % (n=146) were in age group of 41-60 years, average age was 51.94±5.26 years and the BMI was 27.96±6.44 kg/m2. There were 62.7 % (n=94) male and 37.3 % (n=56) females. Frequency of diabetes mellitus was 34.7 % (n=52), hypertension was 24.7 % (n=37), smokers 16.7 % (n=25), family history was 12.7 % (n=19) and frequency of non-obstructive CAD was 27.3 % (n=41). Conclusions: It is to be concluded that a considerable percentage of patients enrolled for elective coronary angiography had non-obstructive CAD.

Chemokine Fractalkine and Non-Obstructive Coronary Artery Disease-Is There a Link?

Non-obstructive coronary artery disease (NO-CAD) constitutes a heterogeneous group of conditions collectively characterized by less than 50% narrowing in at least one major coronary artery with a fractional flow reserve (FFR) of ≤0.80 observed in coronary angiography. The pathogenesis and progression of NO-CAD are still not fully understood, however, inflammatory processes, particularly atherosclerosis and microvascular dysfunction are known to play a major role in it. Chemokine fractalkine (FKN/CX3CL1) is inherently linked to these processes. FKN/CX3CL1 functions predominantly as a chemoattractant for immune cells, facilitating their transmigration through the vessel wall and inhibiting their apoptosis. Its concentrations correlate positively with major cardiovascular risk factors. Moreover, promising preliminary results have shown that FKN/CX3CL1 receptor inhibitor (KAND567) administered in the population of patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), inhibits the adverse reaction of the immune system that causes hyperinflammation. Whereas the link between FKN/CX3CL1 and NO-CAD appears evident, further studies are necessary to unveil this complex relationship. In this review, we critically overview the current data on FKN/CX3CL1 in the context of NO-CAD and present the novel clinical implications of the unique structure and function of FKN/CX3CL1 as a compound which distinctively contributes to the pathomechanism of this condition.

Heterogeneity of Coronary Vascular Function and Myocardial Oxygenation in Women with Angina and Non-obstructive Coronary Artery Disease.

Women with angina and non-obstructive coronary artery disease (ANOCA) have a heightened risk for cardiovascular events, and the pathophysiology for ischemic symptoms may be related to alterations in microvascular structure and function. We examined the use of breathing-enhanced oxygenation-sensitive cardiac magnetic resonance imaging (OS-CMR) using vasoactive breathing maneuvers to assess myocardial oxygenation in women with ANOCA. We recruited women (aged 40-65 years) from two sites in Canada who presented to healthcare with persistent retrosternal chest pain and found to have ANOCA, or without a history of cardiovascular disease. All participants were scanned using a clinical 3T MRI scanner, OS-CMR images were acquired over a breath hold following paced hyperventilation to measure global and regional measurements of heterogeneity.Fifty-four women with ANOCA (age: 55 +/- 6.2 years) and 48 healthy controls (age: (51.2+/- 4.8 years) were recruited. There was no significant difference in volume, function, mass, or global myocardial oxygenation between the two groups (mean % Δ in SI: 4.9 (+/- 7.3) vs. 4.5 (+/- 10.1), p = 0.82). Women with ANOCA had higher regional variations in myocardial oxygenation in circumferential (median % Δ in SI: 5.1 (2.0-7.6) vs. 2.2 (1.4-3.5), p = 0.0004) and longitudinal directions (median % Δ in SI: 11.4 (5.4-16.7) vs. 6.0 (3.0-7.0), p = 0.001), which remained present in a multivariate model. Heterogeneous myocardial oxygenation may explain ischemic symptoms without any associated epicardial obstructive coronary artery disease. Regional variations in myocardial oxygenation on OS-CMR could serve as an important diagnostic marker for microvascular dysfunction in women with ANOCA.

An unusual presentation of pheochromocytoma: myocardial infarction with nonobstructive coronary artery disease and QT prolongation.

An unusual presentation of pheochromocytoma: myocardial infarction with nonobstructive coronary artery disease and QT prolongation.

Positron emission tomography assessment of coronary microvascular angina in patients with angina and nonobstructive coronary artery disease

Positron emission tomography assessment of coronary microvascular angina in patients with angina and nonobstructive coronary artery disease