Normal Coronaries Research Articles

Relationship of serum testosterone with coronary artery disease in young adult males of Bangladesh

The incidence rate and mortality of coronary artery disease is obviously higher in men than in women, which may be related to the influence of serum testosterone. This cross-sectional study was conducted at Department of Laboratory Medicine in collaboration with Department of Cardiology, BSMMU and National Institute of Cardiovascular Diseases (NICVD), Dhaka from March 2020 to February 2021 to investigate the association of serum testosterone with coronary artery disease in young adult males in Bangladesh. Total 110 subjects from inpatient Department of Cardiology were enrolled, 60 were CAD patients and 50 were Normal Coronaries according to coronary angiography report. In this study, 60 patients with coronary artery disease were compared with 50 normal coronary subjects. Mean age in CAD group and normal coronaries was 37.72±2.73 and 37.48±2.54 years respectively. Hypertension, diabetes mellitus and dyslipidemia were significantly higher in CAD group. Total testosterone levels of CAD were significantly lower than those of normal coronaries (2.11±0.81ng/ml vs 2.94±0.78ng/ml). Among 60 CAD patients, 10 patients had single vessel disease, 17 patients had double vessel disease and 33 patients had triple vessel disease. There was significant association between the level of total testosterone and the number of affected vessels within CAD group (p=0.1). This study also showed that total testosterone level was negatively correlated with Gensini score. Serum total testosterone was significantly lower in patients with CAD compared to normal coronaries. Patients with lower total testosterone levels had higher Gensini score. Low level of total testosterone may be related to the develop- ment of coronary artery disease. BSMMU J 2021; 14(3): 67-73

Carotid intima-media thickness predicted the presence but not the severity or complexity of coronary artery disease in a South Asian population

BackgroundCarotid intima-media thickness (CIMT) is considered a marker of atherosclerosis, but the data is lacking from the South Asian population. We aimed to study the relation of CIMT with the presence and severity of coronary artery disease (CAD) in this population. MethodsThis was a prospective, single-center study of consecutive patients undergoing elective coronary angiography. Participants with >50% luminal stenosis in any major coronary artery were included in the CAD group and those with normal coronaries in the non-CAD group. Multivariate linear regression analysis was done to determine independent predictors of CAD. Pearson's correlation coefficients assessed correlations between CIMT and Syntax and Gensini score. ResultsThe mean CIMT was significantly much higher in the CAD group when compared to the non-CAD group (0.83±0.16 vs 0.61±0.14mm, p<0.001). On multivariable linear regression analysis only diabetes (β=0.208 and p=0.024), waist–hip ratio (β=0.178 and p=0.043), current smoker (β=0.293 and p=<0.001) and CIMT (β=0.217 and p=0.031) were independent predictors of CAD. The mean Gensini score in the CAD group was 48.59±34.25 and the mean Syntax score was 19.45±10.24. No significant relation was found between CIMT and Gensini score (r=0.009 and p=0.89), and Syntax score (r=−0.087 and p=0.171). ConclusionMean CIMT is an independent predictor of CAD along with diabetes, waist–hip ratio, and smoking. However, CIMT was not related to the severity and complexity of the CAD as assessed by the Gensini score and Syntax score, respectively.

Angiographic Profiles in Persistent Non-Valvular Atrial Fibrillation Patients

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Cardiology dept. PGIMER, Chandigarh Background The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD. Purpose We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD. Methods The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (&amp;gt;27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery). Results A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (46%) had obstructive CAD, 17/70 (24%) had non obstructive (&amp;lt;50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9 (p value = 0.005). TIMI frame count &amp;gt;31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71). Conclusions CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities. Abstract Figure 1: Flow diagram showing the patie

Evaluation of subclinical LV systolic dysfunction by global longitudinal strain using 2D-speckle tracking echocardiography in patients having angina with normal epicardial coronary arteries

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Self Background Global longitudinal strain (GLS), assessed by 2D speckle tracking echocardiography would be a trustworthy noninvasive tool to detect subclinical LV systolic dysfunction in patients having angina with normal epicardial coronary arteries. Objective The primary objective of the study to detect subclinical LV systolic dysfunction by GLS using 2D-STE in patient having angina with normal coronary arteries and also by conventional echocardiogram at baseline. Materials and Methods This was a comparative case control study that was conducted during the period of March 2018 to August 2018. The study included 60 patients who have been suffering from angina like syndrome despite normal coronary arteries along with 60 normal healthy individuals . All subjects were assessed by transthoracic echocardiography (TTE ) and GLS using 2D speckle-tracking analysis to assess resting LV systolic function . The results of all three planes in GLS (the apical four-chamber , two-chamber , and three-chamber views) were combined in a single bull’s eye summary (agreeing with the standard 17-segment model), which presented the analysis of each segment along with a global peak systolic strain value for the LV. Results This study identified normal reference value of the mean GLS in healthy control group was −19.7 ± 1.84%. GLS assessed by 2D STE was significantly impaired in patients having angina like syndrome with normal epicardial coronary arteries (-18.78 ± 1.87 vs -19.7 ± 1.84%; p &amp;lt; 0.007) than healthy control group despite preserved LVEF. In case group, 8 out of 60 patients (13.3 %) had more negative global longitudinal strain than control subject. Conclusions Patients having angina with normal epicardial coronary arteries are likely to have microvascular disease. GLS assessed by 2D STE has the potential to improve the value of conventional echocardiography in the detection of the coronary microvascular disease. Despite normal LVEF, significant impairment of LV global longitudinal systolic function can differentiate microvascular group of patients from others who have angina with normal coronaries.

CLINICAL AND ANGIOGRAPHIC PROFILE OF CORONARY ARTERY DISEASE IN YOUNG WOMEN - A TERTIARY CARE CENTRE STUDY FROM NORTH EASTERN INDIA

Background: Coronary artery disease (CAD) is the biggest killerof women globally.CAD among young women as a group is less easily recognized worldwide. Young women are underrepresented in most of theCAD studies. This study assessed Clinical and angiographic profile of CAD in young women of North-East India to have a better understanding of the nature and courseof the disease. Material and Methods:This was a prospective, observational, single centre analytical study. Totalparticipants were divided into 2 groups – young women less than 55 years and old women more than or equal to 55 years.Modes ofpresentation,riskfactors,clinicalandangiographicprofileofCADwere compared. Risk factors studied were smoking, hypertension, diabetes mellitus,dyslipidaemia, obesity and family history of prematureCAD.CADseveritywas assessedby SyntaxscoreandGensiniscore. Results: A total of 143women were studied. Out of these 57 women were &lt;55 years and 86 women were ≥ 55years of age. Hypertensionwasthe mostcommonriskfactor foundin both groups of women followed by diabetes and dyslipidaemia. Most common presentation among youngerwomen were chronic stable anginafollowed by ST elevation myocardial infarction (STEMI). In younger women most of them had normal Left Ventricular Ejection Fraction, 54.4 % vs 41.9% of patients(p=0.04).Younger women had normal coronaries in19.3% vs. 9.3% in older women (p=0.072).Younger women had significantly lower number of multivessel diseases than older women, 29.8% vs 44.18% (p = 0.045). Left Anterior Descending coronary artery (LAD) was the most common coronary artery involved in both groups (43.9% vs 52.3%). Low Syntax score (≤22) and lowGensini score (≤20) were found in younger women 75.4% vs older women 67.4% (p=0.201)and 56.1% vs. 40.7% (p=0.05), respectively. The increase in Syntax and Gensini score with increase in number of risk factors were found to be statistically significant in both the groups. Conclusion: In younger women, most of the patients presented withchronic stable angina and STEMI with a preceding history of angina. Hypertension and diabetes were most common risk factors both being modifiable needsutmost attention for prevention. Coronary angiography revealedless severe CAD in younger women than older women as assessed by coronary severity score.

Unmasking of Exercise-Induced Diastolic Dysfunction in Symptomatic Post Coronary Angiogram Patients with Normal Coronaries

Background Diastolic dysfunction is the cause in nearly half of cases of heart failure, the hemodynamic equivalent of which is elevated cardiac filling pressures. However, owing to its ubiquity, it is often diagnosed as an incidental finding, but an association with symptoms is not established in many of the patients. Most patients with hypertension or left ventricular (LV) hypertrophy have evidence of impaired diastolic function as a finding on Doppler echocardiography, but do not have any symptoms of heart failure at rest. However, these patients do have symptoms related to diastolic dysfunction only during exercise. In this study, we have contemplated to assess invasively, left ventricular filling pressures in patients with unexplained shortness of breath with normal systolic and diastolic function on echocardiography, on exercise and compare the level of rise in patients with established diastolic dysfunction. Methods This is an observational prospective study, done over a span of 3 months, wherein patients with typical symptoms such as chest pain and shortness of breath, after ruling out systemic causes, and were subjected to coronary angiogram. If no coronary lesion identified, patients were subjected to invasive cardiac catheterization during coronary angiogram. Patients were divided into two groups, one without diastolic dysfunction and the other with established diastolic dysfunction. Simultaneous left ventricular end diastolic pressures (LVEDP) were measured at rest and after 3-minute manual handgrip exercise and readings were noted. Results The mean age of the population (n = 30) was 55.8 ± 7.538 and 20 were males. The mean value of LVEDP in patients with no diastolic dysfunction at resting was 4.4 ± 3.169 and after exercise was 8.40 ± 4.169. The mean value of LVEDP in patients with established diastolic dysfunction at resting was 5.30 ± 3.948 and after exercise was 8.75 ± 4.506. Paired t-test among two groups revealed a significant p-value of 0.001 after exercise among both groups, suggesting a significant increase in LVEDP in patients with exercise. Unpaired t-test comparing both groups revealed that the elevation of LVEDP in no diastolic dysfunction group was comparable with patients with diastolic dysfunction (p = 0.432). Conclusion The increase in LVEDP with exercise is a well-established fact in patients with diastolic dysfunction. Our study adds to the fact that patients with unexplained shortness of breath can have raised LVEDP after exercise, thereby unmasking the underlying diastolic dysfunction. Our study stresses the importance of inclusion of exercise as a provocative test for the assessment of diastolic function, either invasively or non-invasively, in patients presenting with exertional dyspnea.

Association of single nucleotide polymorphism rs113420705 of CASP3 in children with Kawasaki disease from North India.

Kawasaki disease is a pediatric, systemic, vasculitic disorder. Its exact etiology is still unknown. Genetic polymorphisms are being investigated as susceptibility factor for this disorder. These are likely to vary among different populations. To investigate the association of single nucleotide polymorphism (SNP) rs113420705 of CASP3 in Kawasaki disease (KD) from North India. Observational, case-control study. Polymerase chain reaction and bidirectional Sanger sequencing was used for determining genotypes of SNP rs113420705 in 45 cases of KD and 50 healthy age- and sex-matched controls. Allele and genotype frequencies were assessed and compared between the groups. Among 45 cases, 32 had TT (71.1%), 13 had CT (28.9%) and none had CC genotype of SNP rs113420705. No significant differences in allele, genotype, or carrier frequencies of rs113420705 were found between the two groups. A comparison was also made between subgroups of KD with coronary abnormality (7 children; 15.5%) and KD with normal coronaries (38 children; 84.4%). The C allele was significantly overexpressed in KD with coronary abnormality group (P = 0.005). However, no difference was noted in the genotype frequencies. CT genotype of rs113420705 of CASP3 showed a trend to significance with the occurrence of KD in children in North India. However, we could not establish any association between minor allele C and susceptibility to KD. C allele appeared to be over expressed in children with KD with coronary abnormalities. Larger studies will help us to reach conclusive evidence applicable to all ethnicities.

Silent rheumatic severe mitral stenosis with left ventricular noncompaction cardiomyopathy and ramifying normal coronaries: A double whammy in an octogenarian

We report a unique association of rheumatic heart disease with left ventricular (LV) noncompaction cardiomyopathy in an octogenarian. He had severe mitral stenosis with severe LV systolic dysfunction secondary to noncompaction. Although the association of rheumatic heart disease with LV, noncompaction cardiomyopathy has been described sparsely in the literature, our case is a unique illustration of the presence of LV noncompaction cardiomyopathy contributing toward severe LV systolic dysfunction in rheumatic mitral stenosis in an octogenarian with no coronary artery disease.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

BackgroundThe relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. MethodsThe study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. ResultsA total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005). ConclusionsMajority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

Plaque assessment by coronary CT angiography may predict cardiac events in high risk and very high risk diabetic patients: A long-term follow-up study

Background and aimsThe aim of the present study is to evaluate whether advanced coronary atherosclerosis analysis by CCTA may improve prognostic stratification among diabetic patients at high cardiovascular risk (CV risk). Methods and resultsThe study population consisted of 265 consecutive diabetic patients at high CV risk who underwent CCTA for suspected CAD between January 2011 and December 2016. For every patients both traditional and advanced, qualitative and quantitative coronary plaque analysis were performed. The occurrence of cardiac death, ACS, and non-urgent revascularization were recorded at follow-up.Among the 265 patients enrolled, 21 were lost to follow-up, whereas 244 (92%) had a complete follow-up (mean 45 ± 22 months) and were classified at high (n = 67) or very high cardiovascular risk (n = 177), according to ESC Guidelines. A total of 63 events were recorded (3 Cardiac Death, 3 NSTEMI, 8 unstable angina, 36 late non-urgent revascularization and 13 non-cardiac death) in 57 different patients. Elevated fibro-fatty plaque volume was the only predictor of events over age, gender and traditional risk factor when ACS and MACE were considered as end-points [HR (95% CI) 6.01 (1.65–21.87), p = 0.006 and 3.46 (2.00–5.97); p < 0.001]. ConclusionThe present study confirms the prognostic role of advance coronary atherosclerosis evaluation beyond risk factors and stenosis severity, even in diabetics. Despite the very high cardiovascular risk of study population, a not negligible portion (23%) of patients exhibited totally normal coronaries.

First Report of Acute Myocarditis Post-Pfizer-BioNTech COVID-19 Vaccination in the Kingdom of Bahrain

We present a case of a 24-year-old male patient who presented to our institution five days after receiving his first dose of Pfizer-BioNTech vaccine to rule out acute coronary syndrome due to chest pain along with troponin increase and ECG changes. Acute coronavirus disease 2019 (COVID-19) infection was excluded based on a negative real-time reverse transcription-polymerase chain reaction (RT-PCR) test of specimens acquired using nasopharyngeal swabs for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and all other viral serologies were found to be negative. Coronary angiogram showed normal coronaries, and the presence of late gadolinium enhancement, which is indicative of myocarditis, was identified using cardiac magnetic resonance imaging (MRI). Our case report raises concern that the COVID-19 vaccine may cause myocarditis as a rare side effect.

Normal coronaries - Is it really normal?

Normal coronaries - Is it really normal?

Abstract 9563: Preventive Therapy Changes Following Coronary Computed Tomography Angiography versus Invasive Coronary Angiography in Patients With Nonobstructive Coronary Artery Disease

Introduction: Coronary computed tomography angiography (CCTA) in SCOT-HEART led to increased preventive therapy for coronary artery disease (CAD). We hypothesized that atherosclerosis on CCTA would lead to greater preventive therapy changes compared to invasive coronary angiography (ICA). Methods: We studied 429 consecutive patients with available electronic health records and nonobstructive CAD (1-69% epicardial stenosis) by CCTA for assessment of chest pain or exertional dyspnea (n=143), ICA (n=142), or no CAD on CCTA (n=144). Changes in preventive therapies were assessed at 6 weeks and 6 months. Statin intensification was defined as change to greater LDL-lowering capacity. Intensification of antiplatelet agents, ACEI/ARB, or beta-blockers was defined as increased dose. Pairwise comparisons were made with Bonferroni adjustment. Results: There was no difference in age or gender in nonobstructive CAD patients ( Table ). ICA patients had more baseline therapies. Six week statin initiation was more common (p=0.006) in CCTA nonobstructive group, but not statin intensification (p=0.24) ( Table ). Six month LDL lowering was observed in CCTA (114±40 to 94±39 mg/dL, p&lt;0.001), but not ICA (95±41 to 87±36 mg/dL, p=0.10) nonobstructive patients. Younger age (OR 0.96; 95% CI 0.93-0.99, p=0.006), but not modality (CCTA compared to ICA OR 1.12; 95% CI 0.60-2.07, p=0.73) was associated with statin initiation or intensification at 6 weeks in nonobstructive patients. Greater change in therapies was found in nonobstructive patients by both modalities vs normal coronaries ( Table ). Conclusions: Nonobstructive CAD on CCTA is associated with greater statin initiation, but not intensification, at 6 weeks and lowering of LDL compared to ICA. Antiplatelet, beta-blocker, or ACEI/ARB prescriptions were not different in nonobstructive CAD by CCTA vs ICA. More preventive therapy changes occurred in nonobstructive CAD by either modality vs normal coronaries.

Abstract 13587: Long-Term Outcomes of CT-Derived Fractional Flow Reserve in the Emergency Department

Introduction: In acute chest pain (ACP) patients, CT-derived fraction flow reserve (FFRCT) is feasible and adjudicates need for immediate coronary revascularization. There are no long-term outcome studies of FFRCT in ACP. Hypothesis: In ACP patients, FFRCT is safe and associated with favorable outcomes when negative. Methods: ACP patients with no known coronary artery disease or definitive acute coronary syndrome undergoing coronary CTA with FFRCT were compared to those having CTA alone for the composite major adverse cardiac event (MACE) endpoint of death, nonfatal myocardial infarction, unplanned percutaneous (PCI) or surgical (CABG) revascularization over 2 years. FFRCT ≤ 0.80 was considered positive for hemodynamically significant stenosis. Results: From September 2015 to July 2018, 2,568 ACP patients (mean age 55 years, 52% female) underwent CTA of which 236 (10%) had FFRCT (156 negative, 80 positive). Of the total, 1629 (63.2%) had normal coronaries, and 43 (1.7%) were uninterpretable. FFRCT patients were older (p&lt;0.001) with more diabetes mellitus (18.2% vs. 12.2%, p = 0.009), hypertension (50.8% vs. 38.2%, p&lt;0.001), hyperlipidemia (43.6% vs. 25.4%, p&lt;0.001), and &gt;25% stenosis on CTA (93% vs. 13.6%, p&lt;0.001). Positive FFRCT was associated with higher MACE (10% vs. 2.1%, p&lt;0.001). With comparable stenosis on CTA, positive FFRCT had higher MACE compared to negative FFRCT or CTA alone (Table 1). Conclusions: In ACP patients, negative FFRCT and CTA alone are comparable for MACE. Positive FFRCT portends higher MACE at 2 years within similar stenosis categories. FFRCT can provide incremental value to ACP evaluation with coronary CTA.

Abstract 13539: CT-Derived Fractional Flow Reserve in Patients With Non-ST Elevation Myocardial Infarction

Introduction: In patients with non-ST Elevation Myocardial Infarction (NSTEMI), coronary CTA has high diagnostic accuracy to diagnose obstructive coronary artery disease (CAD). The value of CT-derived fractional flow reserve (FFRCT) in NSTEMI patients is unclear. Hypothesis: In acute chest pain (ACP) patients diagnosed with an NSTEMI, FFRCT is feasible, safe and adjudicates the need for immediate revascularization. Methods: In ACP patients with NSTEMI and no prior coronary artery disease, those undergoing coronary CTA with FFRCT were compared to those having CTA alone for the composite major adverse cardiac event (MACE) endpoint of death, nonfatal myocardial infarction, unplanned percutaneous (PCI) or surgical (CABG) revascularization over 2 years. NSTEMI was defined as peak troponin I levels ≥ 0.04 ng/mL. FFRCT ≤ 0.80 was considered positive for hemodynamically significant stenosis. Results: From September 2015 to July 2018, 276 ACP patients with NSTEMI (mean age 59 years, 45% female) underwent CTA of which 35 (13%) had FFRCT (14 negative, 21 positive). Of the total, 126 (45.6%) had normal coronaries and 11 (4.0%) were uninterpretable. FFRCT patients were older (p&lt;0.001) with no difference in diabetes (14.3% vs. 14.1%, p=1.0), hypertension (57.1% vs. 49.4%, p=0.391), hyperlipidemia (34.3% vs. 28.2%, p=0.460) and mean troponin I levels (0.49 ± 0.9 ng/mL vs. 1.10 ± 4.58 ng/mL, p = 0.061). All FFRCT patients had &gt;25% stenosis on CTA (100% vs. 42%, p&lt;0.001). Among patients with comparable stenosis on CTA, FFRCT and CTA had equivalent MACE (5.7% vs. 18.5%, p=0.137), with no difference between FFRCT negative and positive patients (Table 1). Conclusions: In this small study, FFRCT did not add incremental value to CTA in patients with NSTEMI across similar stenosis categories with respect to MACE. Larger prospective studies are needed to examine FFRCT in NSTEMI.

Myocardial Aldosterone Receptor and Aquaporin 1 Up-Regulation Is Associated with Cardiomyocyte Remodeling in Human Heart Failure.

Background: Abnormal aldosterone signaling is a recognized source of cardiovascular damage. Its influence on cardiomyocyte structure, function, and hormonal receptors when associated with heart failure is still unreported. Methods: Twenty-six consecutive patients with heart failure (LVEF < 40%) and normal coronaries and valves underwent left ventricular endomyocardial biopsy (EMB) for evaluation of myocardial substrate. Biopsy samples were processed for histology, electron microscopy, immunohistochemistry, and Western blot analysis of myocardial aldosterone receptor and aquaporin-1 correlated with plasma aldosterone (AD) and renin activity (PRA). Eight patients with virus-negative inflammatory cardiomyopathy (ICM) had a control EMB after 6 months of immunosuppressive therapy and recovery of cardiac function with re-evaluation of cardiomyocyte structure and receptor expression. Results: EMB in addition to the diagnosis of myocarditis (15 cases), dilated cardiomyopathy CM (6), alcohol CM (2), and diabetic CM (3) showed vacuolar degeneration and cloudy swelling of cardiomyocytes corresponding at electron microscopy to ions and water accumulation into cytosol, membrane-bound vesicles, nucleus, and other organelles, and was associated with an increased AD, PRA, and myocardial expression of aldosterone receptor (2.6 fold) and aquaporin 1 (2.7 fold). In the 8 patients recovered from ICM, cardiomyocyte diameter reduced with disappearance of intracellular vacuoles and normalization of cytosol, nucleus, and cell organelles’ electron-density, along with down-regulation of aldosterone receptor and aquaporin-1. Conclusion: Human heart failure is associated with overexpression of myocardial aldosterone receptor and aquaporin-1. These molecular changes are paralleled by intracellular water overloading and cardiomyocyte swelling and dysfunction. Cardiac recovery is accompanied by down-regulation of hormonal receptors and normalization of cell structure and composition.

Predictors of coronary slow flow phenomenon in patients with angina and normal epicardial coronaries

Abstract Background Coronary slow flow phenomenon (CSFP), also called as syndrome Y is characterized by the delayed passage of contrast distally when injected into the epicardial coronaries. It accounts for upto 7% of patients undergoing coronary angiogram (CAG) for angina. Conventionally, it is determined by the coronary filling time. We aimed to determine whether coronary emptying time is a significant predictor of the coronary slow flow. Purpose To determine the coronary artery filling time and emptying time at prespecified vascular landmarks in patients with chest pain and normal epicardial coronaries. To determine the association of coronary arterial filling time and emptying time in patients with coronary slow flow phenomenon. To determine the association of various conventional coronary artery disease risk factors and various clinical parameters in patients with coronary slow flow phenomenon. Methods Patients with angina, having normal epicardial coronaries on CAG were selected consecutively between January 2019 and December 2020. Each angiogram was assessed for the coronary filling and emptying times at prespecified standard vascular landmarks on the basis of TIMI frame counts (TFC). Results A total of 37 patients with normal epicardial coronaries were analyzed, out of which 27 patients had slow flow in LAD and 17 patients had slow flow in RCA (10 had normal flow in LAD and 12 had normal flow in RCA). Eight had non dominant RCA, which were too small for analyzing TFC were excluded from the study. We observed positive correlation of coronary filling times and emptying times, both in LAD (R-Sq 0.24) and RCA (R-Sq 0.05) in slow flow patients unlike those with normal flow. We found the filling times and emptying times are significantly prolonged in slow flow patients [with mean CTFC values of 77.94 &amp; 92.85 in LAD and 36.91 &amp; 120.82 in RCA, respectively (P&amp;lt;0.05)]. The capillary and venous transit time is prolonged both in LAD and RCA slow flow groups, which was of statistical significance in the RCA slow flow group (P&amp;lt;0.05), but not in LAD slow flow group (P=0.43). We observed slow flow significantly more in male population (P=0.02) and associated with high LDL/HDL ratios and high triglycerides. Conclusion 1. In addition to coronary artery filling times, Coronary artery emptying time is an independent and significant predictor of coronary slow flow phenomenon. 2. Capillary and venous transit time is significantly prolonged in patients with slow flow in RCA whereas in patients with LAD slow flow there is non significant prolongation of capillary and venous transit time. 3. There is a positive correlation of coronary emptying time with coronary filling time in Coronary Slow Flow. This correlation is not seen in patients with normal coronary flow. 4. Coronary slow flow is observed significantly more in male population. 5. Coronary slow flow is significantly associated with high LDL/HDL ratios and triglyceride levels. Funding Acknowledgement Type of funding sources: None. Study designAngiographic landmarks for LAD and RCA – Pictorial representation

Antithrombotic strategy in patients with atrial fibrillation and acute coronary syndrome

Abstract Background Atrial fibrillation (AF) is frequent in patients admitted with acute coronary syndromes (ACS). The development of this arrhythmia occurs in 2–21% of patients with non ST-elevation ACS and 21% of ST-elevation ACS. According with the most recent European guidelines, a short period up to 1 week of triple antithrombotic therapy (TAT) is recommended, followed by dual antithrombotic therapy (DAT) using a NOAC and a single antiplatelet agent, preferably clopidogrel. Objective To compare the antithrombotic strategy (DAT vs TAT) used and its prognostic value in patients with AF and ACS. Methods Retrospective analysis of patients' data admitted with ACS in a multicentric registry between 10/2010–09/2019. TAT was defined as the prescription of dual antiplatelet therapy and one anticoagulant and DAT as one antiplatelet and one anticoagulant. Survival and rehospitalization were evaluated through Kaplan-Meier curve. Results 1067 patients were included, mean age 67±14 years, 72.3% male. Patients who developed de novo AF during hospitalization due to ACS were older (75±12 vs 66±14 years, p&amp;lt;0.001) and with higher prevalence of cardiovascular risk factors and cardiovascular disease. AF was more often in patients with ST elevation ACS (53.4%). During hospitalization, AF patients were more often medicated with aspirin, glycoprotein inhibitor, heparin, fondaparinux and vitamin K antagonists. No difference was found regarding P2Y12 inhibitors. AF patients presented more often obstructive coronary disease (normal coronaries 5.4 vs 8.5%, p&amp;lt;0.001) so they were more often submitted to PCI (79.5 vs 70.9%, p&amp;lt;0.001). AF patients presented with higher rates of adverse in-hospital events as re-infarction, heart failure, shock, ventricular arrhythmias, cardiac arrest, stroke, major bleeding and death (p&amp;lt;0.001). At discharge, AF patients were less prescribed with aspirin or ticagrelor, but the rate of clopidogrel prescription was higher, such as vitamin K antagonists or any of the new anticoagulants. In the AF group, 21.5% patients were discharged with TAT and 30.3% with DAT. Concerning patients discharged with TAT, 1-year follow-up revealed no significant differences in mortality (p=0.578), re-admission for cardiovascular causes (p=0.301) and total re-admission rates (p=0.291). Patients discharged with DAT had similar mortality (p=0.623) and re-admission for cardiovascular causes rates (p=0.138), but significant differences were identified regarding total re-admissions (p=0.024). Conclusions In patients with ACS and de novo AF, a low percentage of patients was discharged with oral anticoagulation (51.8%). In those whose anticoagulation was initiated, DAT was the preferred strategy. 1-year outcomes were not different between the antithrombotic strategy, except for all cause re-admission. Funding Acknowledgement Type of funding sources: None.

Correlation between Peri-Coronary Epicardial Adipose Tissue Volume, Cardiac Calcification and the Severity of Coronary Artery Disease by Multi Slice Computed Tomography

ABSTRACT The authors in that article addressed a very important and relevant issue. Background Epicardial adipose tissue (EAT) is a complex endocrine organ that plays an important role in the development of unfavorable metabolic and cardiovascular risk profile. EAT may express a variety of inflammatory mediators which may contribute to the pathogenesis of coronary artery disease (CAD). Aortic and mitral valve calcification may reflect generalized atherosclerosis in the elderly and may be a marker of high prevalence and severity of CAD. There is a direct correlation (extent, severity and the future CV events) between the coronary artery calcium and the CAD. Aim and Objectives To correlate peri-coronary epicardial adipose tissue and coronary artery calcification and valvular (aortic and mitral) calcification with the severity of the coronary artery disease. Patients and Methods The study recruited 200 patients with suspected coronary artery disease. The amount of EAT surrounding the left main and the three main coronary arteries was quantified in axial cuts with the most distinct layer of EAT. The amount of calcium in the aortic and mitral valve and the coronaries were quantified with multi-detector computed tomography MDCT using dedicated software for measuring calcium score that is based on Agatson score. Coronary artery disease severity was assessed in terms of number of vessels affected and the severity of coronary stenosis by multi-planner reformation technique. Results Based on the finding of the MDCT and according to the presence of calcification in the aortic or the mitral valves, and the significance of the coronary artery disease, patients were classified into two groups, group (I): 115 patients with normal coronaries or with non significant lesions in their coronaries, and group (II): 85 patients with significant coronary artery disease. The Mean ± SD (in millimeters) of EAT for the entire study cohort in various coronary artery locations were as follows: LM EAT 9.82 ± 2.67, proximal LAD EAT 10.06 ± 2.80, mid LAD EAT 9.15 ± 2.41, distal LAD EAT 6.46 ± 1.87, proximal LCX EAT 8.10 ± 1.90, distal LCX EAT 6.83 ± 1.79, proximal RCA EAT 10.23 ± 2.42, mid RCA EAT 9.26 ± 2.72, distal RCA EAT 7.25 ± 2.58. Statistically highly significant difference was observed between the two groups with regards to LM EAT, proximal, mid and distal LAD EAT, proximal and distal LCX EAT, proximal, mid and distal RCA EAT (8.38 ± 2.18 Vs 11.77 ± 1.94 P: 0.000, 8.49 ± 2.21 Vs 12.18 ± 2.00, 7.93 ± 1.77 Vs 10.81 ± 2.16, 5.45 ± 1.26 Vs 7.82 ± 1.68 P: 0.000, 7.08 ± 1.34 Vs 9.46 ± 1.67, 6.05 ± 1.50 Vs 7.89 ± 1.61 P: 0.000, 9.01 ± 1.94 Vs 11.88 ± 1.99, 8.07 ± 2.32 Vs 10.86 ± 2.39, 6.31 ± 2.26 Vs 8.51 ± 2.45 P: 0.000; respectively). Statistically highly significant difference was observed between the two groups with regards calcium score and the severity of CAD in the three major vessels (LAD, LCX and RCA) and the total calcium score in all vessels (35 (16 – 85.5) Vs 179.5 (59.5 – 243) P: 0.000, 20.5 (7 – 50.5) Vs 56 (33 – 95) P: 0.000, 31 (9 – 54) Vs 97 (54 – 199) P: 0.000, 12 (0 – 84) Vs 286 (106 – 511) P:0.000; respectively) while calcium score in the LM was not statistically significant with the severity of CAD (4 (3 – 26) Vs 12 (9 – 16) P: 0.360). As regards aortic valve calcification there was statistically highly significant difference between the two groups; P value 0.000, while mitral valve calcification was found to be not statistically significant between the two groups P: 0.272. Conclusion The present study demonstrated a significant correlation between the peri-coronary epicardial adipose tissue, coronary calcification and aortic valve calcification and the severity of the coronary artery disease.

The Role of Coronary Computed Tomography Angiography in Evaluation of High Troponin Patients with Narrow-Complex Supraventricular Tachycardia.

Aim:The aim of this study was to investigate the relation of high-sensitive cardiac troponin T (hs-cTnT) elevation with characteristics of supraventricular tachycardia (SVT) episode (duration and maximum heart rate) and coronary computed tomography angiography (CCTA) findings in patients with SVT who presented to the emergency room with palpitation.Methods:This retrospective, single-center, noninvasive study included all patients aged between 18 years and 65 years who presented to the emergency department due to narrow-complex SVT and underwent CCTA to rule out coronary artery disease (CAD) due to elevation of hs-cTnT and reverted back to sinus rhythm after intravenous adenosine. The first, second, and the maximum hs-cTnT levels were obtained from the database. The patients were classified into normal coronaries, nonobstructive CAD, and obstructive CAD according to findings of the CCTA. The findings of the groups were compared.Results:Eighty-five patients were enrolled in the study. Of them, 21 (26%) patients were female. Sixty-three patients (74%) had normal coronary arteries as per CCTA results, whereas 22 patients (22%) had nonobstructive CAD and two patients (2%) had obstructive CAD. The groups did not differ statistically in respect to hs-cTnT measurements, duration of the arrhythmia, and maximum heart rate at SVT episode. There was no significant statistical correlation between hs-cTnT and the study parameters except the maximum heart rate.Conclusion:Cardiac troponins may increase in patients with paroxysmal SVT irrespective of the presence of coronary lesions, and the CCTA may not be an appropriate investigation in the differential diagnosis of paroxysmal SVT with elevated hs-cTnT.