Normal Coronary Arteries Research Articles

Abstract 4137448: Systemic Heparin Administration Does Not Inhibit microRNA Amplification in Patients with Myocardial Infarction

Purpose: MicroRNAs (miRs) have been proposed as biomarkers of myocardial infarction (MI), but prior evidence has demonstrated that heparin, commonly administered to patients presenting with MI, inhibits amplification during quantitative PCR (qPCR). The purpose of this study was to determine whether qPCR amplification of miRs is reduced in plasma of patients receiving heparin and if heparinase reverses this effect. Methods: Blood samples were collected and plasma recovered from patients with normal coronary arteries who had undergone CT coronary angiography ( N=5 ) or who had received intravenous heparin at the time of invasive coronary angiography( N=8 ). Blood was also collected at the time of invasive coronary angiography from patients presenting with ST elevation MI ( N=9 ). RT-qPCR was performed to quantify levels of 84 cardiac miRs, and Cel-miR-39-3p was utilized as a spike-in control. MiR qPCR was also performed following the addition of heparinase to plasma from 2 patients without MI treated with heparin and 2 patients presenting with MI who had received heparin. Results: Mean age of patients was 57 years, and 55% of patients were male. As compared with control patients, the cycle number for cel-miR-39-3p was significantly increased for patients receiving heparin (Figure 1a). No difference was seen in levels of cel-39-3p in heparin-treated patients with respect to the presence or absence of MI. Cel-miR-39-3p cycle times decreased when heparinase was added to samples from heparin-treated patients (Figure 1b). In contrast, heparin did not increase cycle times in any of the cardiac miRs tested, and cycle times decreased even further for miRs 499a-5p and 208b-3p in patients with MI (Figure 2). Conclusions: Systemic heparin treatment inhibits qPCR amplification of cel-mir-39-3p but does not inhibit endogenous miR amplification under these conditions. MiRs 499a-5p and 208b-3p are potentially important candidates for MI detection and quantification.

Abstract 4135025: Inflammation-related 5-hydroxymethylation signatures as markers for clinical presentations of coronary artery disease

Background: Coronary angiography, an invasive method, remains the gold standard technique for coronary artery disease (CAD) diagnosis in clinical practice. However, due to its invasive nature, it cannot be used for mass population screening. There is an urgent need in the clinical to identify new liquid biopsy molecular markers for screening patients with CAD. Methods: We utilized 5hmC-Seal to generate genome-wide 5hmC profiles in plasma cell-free DNA (cfDNA) from 724 CAD patients. To investigate the correlation between 5hmC modifications and CAD, we separated patients into training and validation cohorts and developed a 5hmC-based logistic regression model from the training cohort to predict CAD patients in the validation cohort. Furthermore, we incorporated an external cohort comprising 167 samples to validate the reliability of our model. Results: We found that the differentially hydroxymethylated genes (DhMGs) in people with the normal coronary artery (NCA), nonfatal stable CAD (sCAD), non-ST-elevation myocardial infarction (NSTEMI), as well as ST-elevation myocardial infarction (STEMI) enriched in neutrophil-mediated inflammatory response pathways, and inflammation-related DhMGs can reflect the progression of atherosclerotic plaque. Furthermore, we used machine learning algorithms to develop a predictive model for predicting the occurrence of myocardial infarction (MI) based on 19 inflammatory markers, and the predictive model could effectively predict MI (NSTEMI and STEMI) (AUC = 0.913). Simultaneously, our model has demonstrated strong performance in external validation. Conclusions: We have identified a novel biomarker, the inflammation-associated 5hmC markers, which can reflect the clinical manifestations of CAD and can effectively predict the occurrence of MI.

Abstract 4131815: The Prevalence of Normal Coronary Arteries as Determined by a Coronary Artery Calcium Score of Zero Amongst Subjects with Diabetes Mellitus

Background: The CDC reports that in 2021, 11.6% of the American population had diabetes mellitus (DM). Past literature has shown diabetes to be a significant risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). Research Question/Goal: Using data obtained through Computed Tomography Angiography (CTA), we aim to distinguish the risk factors associated with a coronary artery calcium (CAC) score of zero in subjects with DM and to identify the prevalence of non-calcified plaque in individuals with this score. Methods: We performed a retrospective study of patients with DM, who underwent CAC and CTA screenings from October 2004 to January 2024 at our center in Torrance, California to examine CTA outcomes in those with CAC Score of zero and greater than zero. Results: Among the cohort of 2,763 subjects with DM, the average age was 63.8±12.2 years, 62% male. Within this cohort, 465 (17%) subjects had a CAC Score of zero compared to 2,298 subjects with a CAC Score greater than zero with a median score of 428 (Interquartile range (IQR) 91-1267). DM subjects with CAC Score of zero were significantly younger (53.0±13.9 versus 66.0±10.6: p<0.001), were more likely to be female and had significantly lower rates of hypertension (57% versus 76%: p<0.001), and hyperlipidemia (63% versus 76%: p<0.001). In DM subjects with CAC Score of zero, 133 (29%) had a total plaque severity score of 1 or greater (median 1, IQR 1-2) while 332 (71%) had normal coronaries on CTA. Conclusions: A significant percentage of subjects with DM were determined to have a CAC score of zero. Subjects with normal coronary arteries were more likely to be younger, female, and/or absent of other chronic diseases such as hypertension and hyperlipidemia. Although age and sex are nonmodifiable risk factors of ASCVD, limiting the comorbid conditions associated with DM may be beneficial in preventing ASCVD in individuals with diabetes.

Abstract 4136581: Shared Genetic Burden of Ischemic and Non-Ischemic Dilated Cardiomyopathy

Introduction: Ischemic dilated cardiomyopathy (IDCM) is defined as DCM caused by severe stenosis of one or more coronary arteries. Patients with non-ischemic dilated cardiomyopathy (NIDCM) have normal coronary arteries and may possess rare disease-causing variants in cardiac proteins such as TTN . However, IDCM and NIDCM share echocardiographic and pathologic features, possibly suggesting a shared etiology. Hypothesis: There is a similar prevalence of pathogenic (P)/likely pathogenic (LP) variants in patients with IDCM compared to patients with NIDCM. Aims: We compared the prevalence of P/LP genetic variants in DCM-associated genes in a cohort of patients with NIDCM or IDCM who received a heart transplant. Methods: We conducted a retrospective cohort study of patients who received a heart transplant between May 2017 and October 2023 at Cedars Sinai Medical Center in Los Angeles, CA. All subjects had LVEF ≤ 50% and LVEDD ≥ 95 th percentile for sex and height. Whole exome sequencing was performed on explanted heart tissue. We assessed for rare variants (minor allele frequency <0.1%) in genes with a definite, strong, or moderate rating in the ClinGen DCM Gene Curation Expert Panel. Variant pathogenicity was interpreted using the American College of Genetics and Genomics criteria for DCM. Ischemic cardiomyopathy was defined by the Felker criteria (Felker et al., JACC 2002). Results: We included 60 subjects: 16 with IDCM and 44 with NIDCM. There was no difference in LVEF or LVEDD between groups (TABLE). 2/16 (12.5%) patients with IDCM carried a P/LP variant, both of which were in TTN . 11/44 (25.0%) patients with NIDCM carried a P/LP variant: 6 in TTN and 1 each in FLNC, ILK, LMNA, MYH7 , and RBM20 . The prevalence of TTN variants in each group was similar (12.5% in IDCM vs. 13.6% in NIDCM) and higher than the expected frequency in the general population (0.2%). There was no significant difference in the prevalence of P/LP variants between the groups (chi-squared p-value 0.493, Bayes factor 0.45). Conclusion: Patients with IDCM exhibited a similar prevalence of P/LP variants to NIDCM patients, which suggests a shared genetic burden. If further studies confirm our findings, genetic testing for individuals with IDCM may be warranted.

Abstract 4138374: Coronary Endothelial Dysfunction Plays Important Roles on Development of Acute Coronary Syndrome and Fatal Cardiovascular Events During Long-Term Follow-up Over 10 Years

Introduction: Although coronary endothelial dysfunction is thought to affect coronary atherothrombogenic processes, there has been little practical evidence for the relationship between clinical evolution of fatal or non-fatal acute coronary syndrome and coronary endothelial dysfunction. Hypothesis: We assessed hypothesis that coronary endothelial dysfunction has clinical impacts on development of acute coronary syndrome and fatal cardiovascular events. Methods: Coronary endothelial dysfunction was practically graded by the flow-mediated endothelium-dependent reactive changes in coronary artery diameter (CFMD) to infusion of adenosine triphosphate (ATP ; 50μg) into the normal left coronary artery using quantitative coronary arteriography in 150 patients with stable coronary artery disease. The enrolled patients were categorized into tertile groups according to the values of CFMD, and we prospectively followed-up major adverse clinical cardiac events including acute coronary syndrome and cardiovascular death. Results: For a mean follow-up period of 132 months (range; 120 to 144) with complete follow-up, the patients in the lower third with severe coronary endothelial dysfunction (Group-L) more frequently developed acute coronary syndrome than those in the middle third with mild coronary endothelial dysfunction (Group-M) plus those in the higher third without coronary endothelial dysfunction (Group-H) [Group-L versus Group-M plus Group-H: 15(30%) versus 5(10%) plus 0(0%), p<0.001, by Kaplan-Meier analysis]. Majority of the patients who resulted in cardiovascular death belonged to Group-L, [6(12%) versus 1(2%) plus 0(0%), p=0.014, by Kaplan-Meier analysis]. Cox hazard proportional model analyses including clinical and angiographical variables indicated that severe coronary endothelial dysfunction was the strong predictor for future acute coronary syndrome (hazard ratio=7.53, 95%confidential interval; 1.78-12.25, p<0.001) and future cardiovascular death (hazard ratio=13.50, 95%confidential interval; 1.55-25.25, p=0.005). Conclusions: This is the novel and longest follow-up investigation that demonstrates coronary endothelial dysfunction plays important roles on development of acute coronary syndrome and fatal cardiovascular events and therefore the strategies based on practical status of coronary endothelial dysfunction are required to prevent major adverse ischemic cardiac events.

Abstract 4138690: A Case of Hypertrophic Cardimyopathy: Digenic Variants of Uncertain Significance Mutations in MHY7 and RYR2 Genes

Introduction: Hypertrophic Cardiomyopathy (HCM) is primarily a disease caused by mutations in single genes, but around 5% of HCM patients, exhibit 2 (digenic) or more (oligogenic) causal mutations in the same gene or in different genes. We present a case of familial HCM with variants of uncertain significance (VUS) mutations in the MYH7 and RYR2 genes, highlighting the complexity of genetic inheritance and its implications on disease severity. Case presentation: A 40-year-old male presented with a history of hypertension, HCM, and two prior myocardial infarctions. He had syncope, non-sustained ventricular tachycardia, and a family history of sudden cardiac death (SCD) in his maternal grandfather. A dual-chamber ICD was placed for primary prevention of SCD because of his high-risk profile. Echocardiography demonstrated normal LV size and function with moderate asymmetric septal hypertrophy. Cardiac MRI indicated diffuse asymmetric hypertrophy and a 10.9% LV myocardial scar burden. Left heart catheterization revealed normal coronary arteries with LVOT gradient up to 60 mmHg, consistent with HCM. Genetic testing revealed VUS in the MYH7 (c.1305G>A, p.Met435Ile) and RYR2 (c.10528C>A, p.Arg3510Ser) genes (Figure 1). Further family genetic testing confirmed these VUS mutations in multiple relatives (Figure 2). Discussion: The identification of VUS mutations in MYH7 and RYR2 genes in multiple family members highlights the complexity of genetic inheritance in HCM. These findings underscore the challenges in clinical interpretation and risk stratification, as the co-occurrence of mutations in different genes may have synergistic effects on disease severity and phenotype expression. Comprehensive genetic evaluation, including family studies, is crucial for understanding the clinical significance of these mutations and guiding personalized management strategies. Further research is needed to elucidate the impact of VUS mutations on the clinical outcomes of HCM patients.

Endothelial dysfunction in prediabetes and diabetes mellitus in patients with normal coronary arteries

BackgroundDiabetes mellitus (DM) is a global health issue associated with increased cardiovascular disease risk. Endothelial dysfunction is a known precursor to atherosclerosis and cardiovascular disease, and its role in the pathogenesis of DM complications is well-documented. There is limited information in the evaluation of endothelial function in prediabetic patients using flow-mediated dilation (FMD), and studies have not excluded patients with known atherosclerosis or coronary artery disease. Thus, in this study, we aimed to evaluate the endothelial functions using FMD from the brachial artery of DM and prediabetes patients who had normal coronary arteries.MethodsThis study included 73 participants: 25 with DM, 25 with prediabetes, and 23 normoglycemic controls, all with normal coronary arteries on angiography. FMD measurements were conducted following established protocols, and statistical analysis was performed using standard methods to compare FMD levels among groups.ResultsThe groups were comparable in clinical and demographic characteristics, except for fasting plasma glucose levels. Significant differences in FMD levels were observed: 10.1% in the DM group, 16.5% in the prediabetes group, and 14.8% in the control group (P = 0.004). Diabetic patients had significantly lower FMD levels than both prediabetic and normoglycemic individuals. No significant difference in FMD was found between prediabetic and control groups.ConclusionsDiabetic patients exhibited significant endothelial dysfunction compared to normoglycemic individuals, while prediabetic patients did not show similar dysfunction. These findings suggest a window of opportunity in the prediabetic stage for early intervention to prevent advanced endothelial dysfunction.Trial registration numberISRCTN Registry ISRCTN15351014. Registry date: 23/09/2024. Retrospectively registered.

Afebrile Kawasaki disease: A case report

Objective: Kawasaki disease (KD) is an acute, self-limiting vasculitis and the most common cause of acquired heart disease in children under 5 years old. Despite over 50 years of research, the etiology and long-term prognosis of KD remain unclear.Case presentation: A 2-year-7-month-old boy presented with all the typical KD symptoms, including conjunctival injection, cracked lips, strawberry tongue, and membranous desquamation of the fingers and toes, but without fever. The patient was admitted with a 9-day history of peeling skin on his fingers, and no history of illness or fever in the past two weeks. Laboratory tests revealed elevated platelet count. An echocardiogram showed normal coronary arteries. The patient was diagnosed with KD and treated with low-dose aspirin and dipyridamole. He was discharged on the third day and showed complete symptom resolution and normal coronary arteries at follow-up.Conclusions: This case report describes an instance of afebrile KD, emphasizing the need for clinical vigilance and comprehensive assessment for diagnosis and treatment. Afebrile KD poses a diagnostic challenge as fever is a major diagnostic criterion. However, clinicians should consider afebrile KD when other clinical features and laboratory results suggest KD, and initiate appropriate treatment to prevent severe complications like coronary artery lesions. This case underscores the importance of early diagnosis, timely intervention, and multidisciplinary team collaboration for effective management of KD.

Angina pectoris prevalence and sick leave burden one year after MINOCA

Abstract Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents approximately 5-10% of all myocardial infarctions (MI), with heterogenous etiologies and insufficient knowledge on symptom burden after the acute phase. Purpose To evaluate the prevalence of angina and sick leave in MINOCA, using individuals with MI due to coronary artery disease (MI-CAD) as control. Methods This observational study used prospectively collected data from the Swedish national quality register SWEDEHEART. All individuals with invasively assessed, first time MI between 2005 – 2022, available at one year follow-up were included and categorized as MINOCA (normal coronary arteries or <50% lumen obstruction) or MI-CAD (>50% lumen obstruction). We excluded subjects with previous coronary intervention, previous heart failure, tachy- or bradyarrhythmia at admission and not fully revascularized MI-CAD. Chest pain was assessed by a clinical nurse and angina graded according to the Canadian Cardiovascular Society, excluding non-ischemic chest pain. Occupational status was self-reported. Results We included N=46 428 individuals (mean age 62, 71% male; MINOCA n= 5281/MI-CAD n=41 157). Subjects with MINOCA were predominantly females, more commonly divorced or widowed, non-smoking and had a higher degree of hypertension, hyperlipidemia, and chronic obstructive pulmonary disease, compared to fully revascularized MI-CAD. Angina prevalence was 11.6 % and 8.8% in MINOCA and MI-CAD respectively (p <0.001). After adjustment for background variables clinically relevantly associated to both MI type and anginal status OR was 1.21 [95% CI 1.10 – 1.34] (Figure 1). Sick leave was more common in MINOCA both at index care, and at one year (8.0 vs 5.6 % and 13.4 vs 10.9%, both p <0.001) (Figure 2). Conclusion MINOCA patients suffer significant distress, with higher levels of angina and sick leave compared to fully revascularized MI-CAD counterparts. Further research on causes of ischemic symptoms in this heterogenous condition is warranted.

NICE guidance in the rapid access chest pain clinic: does it work?

Abstract Background Rapid Access Chest Pain Clinics (RACPC) were developed following the publication of the National Service Framework for Coronary Heart Disease in 2000(1). The National Institute for Health and Care Excellence (NICE) produces guidelines for the management of patients with recent onset chest pain of suspected cardiac origin(2). In 2016 the guidance was updated and recommended the use of CT coronary angiography (CTCA) as the initial investigation for patients with chest pain which was typical or atypical of angina. Adherence to the guideline may be dependent upon factors such as local availability of CT scanners and clinician preference. The RACPC in this tertiary centre is nurse-run with no medical involvement. There is good engagement with the CT department and in July 2017 the NICE guidance was adopted in the clinic. Purpose To evaluate the use of CTCA as the first line investigation for patients with typical or atypical chest pain. Methods Data from all patients reviewed in the clinic between 01/07/2017 and 31/12/2023 were prospectively collected, entered into a database, and then retrospectively analysed. The data were organised into 3 groups: patients with typical chest pain; atypical pain and those with non-cardiac sounding chest pain. The number of patients in each group who underwent a CTCA, and the outcome of the scan were evaluated. The CT scans were categorised as showing significant coronary artery disease (CAD), non-obstructive CAD, no CAD, or as inconclusive. The outcome of patients who had a positive CTCA was also recorded. Results 2986 patients were reviewed in the RACPC in the above period. 14.2% of patients presented with typical pain, 47.4% with atypical pain, and 30.6% had non-cardiac pain. The remaining patients presented with other symptoms such as breathlessness. CTCA was used as the first investigation in the majority of patients with typical or atypical pain, unless alternative investigations or management were deemed to be more clinically appropriate. In 59.5% of typical and 78.5% of atypical presentations, the CT scan showed no CAD, or non-significant CAD. There was a low incidence of positive scans in both groups, however patients with typical pain were more likely to have significant CAD (Table). All patients who had a CTCA indicating significant CAD, were referred for invasive angiography. 88.0% of typical presentations, and 64.0% of those with atypical pain, underwent revascularisation. No patient who underwent invasive angiography was found to have normal coronary arteries. Conclusion Atypical pain is the most frequent presentation in the RACPC, however the majority of these patients, and most of those with typical pain, do not have significant CAD. Careful assessment and the use of CTCA as the initial investigation, enable the identification of those patients who need invasive angiography. This is a cost-effective strategy which also reduces risk and radiation exposure for patients.

Acute myocarditis presentation and intra-hospital prognosis: results of the multicenter prospective MYOCARDITIRM study

Abstract Background Acute myocarditis (AM) usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favorable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders and is considered the leading cause of sudden cardiac death in young apparently healthy adults. There is no recommendation for AM, only expert consensus, given the lack of important databases for a strong level of confidence. Methods We performed a multicenter prospective observational study of patients admitted for AM acknowledged by cardiac MRI to describe baseline characteristics, management, in-hospital and long-term outcomes of AM patients in France. Secondary objectives were to investigate determinants of prognosis, modalities of treatment and follow-up, and to identify gaps between expert consensus and real-life management. Results We enrolled 805 consecutive patients hospitalized for AM in 49 participating centers between May 2016 and February 2019. Median age was 31 (IQR 23-41) with 19% of female. Chest pain was the most frequent symptom (93%) and 112 (14%) had severity criteria upon admission (LVEF<50% or severe ventricular arrythmia or high-grade AV block or cardiogenic shock). ST elevation was observed in 49% of patients. One 26-years old patient died during initial hospital stay. Overall, 62 patients (8%) experienced intra-hospital complication of their AM, defined as a combined endpoint of death, LVEF<40% (MRI), sustained ventricular or supraventricular arrythmia, acute renal failure, cardiogenic shock, need for ventricular assistance device, need for inotropic drugs, temporary cardiac pacing, pace-maker or cardiac defibrillator implantation. Patients with initial severity criteria were 10 times more likely to present intra-hospital complication (33% vs 3.6%, p<0.001). Conclusion This prospective cohort represents the largest database on AM worldwide. Here we report baseline characteristics and in hospital events. Most patients had typical presentation with favorable outcomes but as much as 8% of patients did exhibit intra-hospital complication. The prospective follow up will provide valuable data to better identify subset of patients with poor prognosis that may be of interest to develop new therapeutic strategies.Acute myocarditis on cardiac MRI

Association between inflammatory burden index and coronary slow flow phenomenon in patients with chest pain and no obstructive coronary arteries

BackgroundThe inflammatory burden index (IBI), a novel inflammation-based indicator, to is associated with the presence and prognosis of various diseases. However, few studies have focused on exploring the relationship between IBI and the coronary slow flow phenomenon (CSFP). In this study, we aimed to investigate the predictive value of IBI for CSFP in patients with chest pain and no obstructive coronary artery disease.MethodsA total of 1126 individuals with chest pain and no obstructive coronary arteries were consecutively included in this study. 71 patients developed CSFP were included in the CSFP group. A 1:2 age- and sex-matched patient with normal blood flow and angiographically proven normal coronary arteries was selected as the control group (n = 142). Plasma C-reactive protein (CRP), neutrophil, and lymphocyte counts were measured to determine the value of IBI.ResultsThe IBI were significantly higher in the CSFP group than in the controls (21.1 ± 6.5 vs. 14.5 ± 6.4, P < 0.001). The IBI increasedelevated with the increase of the numbers of vessels affected by CSFP. Multivariate logistic regression analysis revealed that IBI and body mass index (BMI) were independent predictors of CSFP. Receiver operating characteristic (ROC) curve analysis showed that when IBI was > 15.74, the sensitivity and specificity were 77.5% and 67.6%, respectively, and the area under the ROC curve (AUC) was 0.799 (95% CI: 0.737-0.862, P<0.001).ConclusionThe IBI may be an independent predictor of CSFP in patients with chest pain and normal coronary arteries. The IBI could improve the predictive value of CSFP compared with the indicators alone.

Evaluation of IL 12 gene expression and serum levels of OxPL / apoB in patients with coronary artery disease

Background: Atherosclerotic lesions are formed as a result of low-density lipoprotein (LDL) accumulation, which is produced by oxidizing enzymes and oxidized phospholipids (OxPL). Phospholipid oxide causes inflammation-inducing activation genes and hyper-inflammation in addition to the initiation of inflammation and expression of Th1 cytokines. Interleukin 12 (IL-12) is one of the most significant stimulants of inflammation and immune responses, among the Th1cytokines. Therefore, it may play a significant role in contributing to atherosclerosis. The quantitative expression of IL-12 mRNA, along with serum OxPL levels, has been analyzed in patients with coronary artery disease (CAD). Methods: Coronary angiography patients, aged 45 to 65 years and referred with chest pain, were examined. The patients were classified into normal coronary arteries (N = 38) and severe three-vessel involvement coronary arteries (N = 41). Molecular testing was performed using real-time PCR. Also, an ELISA test was used to check the OxPl level. Results: Expression of IL12 in Individuals with coronary artery disease was increased but was not statistically significant.

Coronary heart disease evaluation using PCAT radiomics model based on coronary CT angiography and pericoronary adipose tissue.

To explore the clinical application value of radiomics model based on pericoronary adipose tissue (PCAT) in predicting coronary heart disease. A retrospective analysis was performed for inpatients who had undergone coronary computed tomography angiography from January to December 2023, and 164 cases of coronary artery lesions were screened as the lesion group and 190 cases of normal coronary artery samples were selected as the control group. The clinical data and imaging data of all patients were collected, the radiomics features were extracted by relevant software, and the "region of interest" of pericoronary fat was delineated, and the selection operator and multivariate logistic regression were used to screen the radiomic features of pericoronary fat. A coronary heart disease evaluation model was constructed by the best radiomics features. Area under the curve values of the PCAT radiomics scoring model for predicting the receiver operating characteristic curve of coronary heart disease were 0.863 and 0.851 in training and test sets, respectively. After calibration curve analysis, PCAT radiomics scoring model has a high consistency between the predictive evaluation results and the actual results of coronary heart disease events. In addition, in the training set, the PCAT radiomics scoring model has a net benefit on all threshold probabilities. In the test set, the model has a negative net return with only a small number of threshold probabilities. After combining the clinical characteristics model, the evaluation accuracy of the model for coronary heart disease can reach 0.896. PCAT radiomics model based on coronary computed tomography angiography can effectively predict and evaluate coronary heart disease, which is of great value for the clinical diagnosis of coronary artery disease.

8355 Pheochromocytoma In The Elderly: A Mini Case Series

Abstract Disclosure: S. Nabi: None. A. Golash: None. P. Panwar: None. G. Powner: None. C. Schiteanu: None. C. George: None. M. Vallabhaneni: None. B.G. Issa: None. A. Clark: None. D. Bailey: None. J. Waldron: None. F.W. Hanna: None. Diagnosis and management of pheochromocytoma in the older population is challenging due to the co-morbidities and general age-related frailty. We present a mini case series of four patients aged 72 to 86 years who presented to our tertiary referral center at the University Hospitals of North Midlands UK, between 2019 and 2022.The case series documents the challenges of managing pheochromocytoma in this population, emphasizing how close monitoring, regular follow ups and collaboration between different members of the multidisciplinary team helped to achieve the desirable outcomes in these cases. Case 1: Adrenal incidentaloma in 84-year-old female. Background of hypertension and diabetes mellitus. History of occasional palpitations. Investigations showed raised plasma and urinary metanephrines. MIBG scan confirmed pheochromocytoma and after adequate alpha and beta blockade underwent successful laparoscopic surgery. No intra or post operative complications and showed good recovery. Discharged on the 5th day post operative. Case 2: 82-year female under cardiology with non-ST elevation myocardial infarction. Background of hypertension, chronic kidney disease and gastroesophageal reflux disease. Initial presentation with shortness of breath, sweating and swelling lower limbs. Normal coronary arteries on angiography, so investigated for possible excess catecholamine production. Had significantly raised 24-hour urinary normetadrenaline. Paraaortic paraganglioma confirmed on MIBG SPECT scan. Initially opted for medical treatment however quality of life worsened over the next year and eventually underwent robot assisted excision. Procedure was uneventful with good post-operative recovery. Was able to go home 2 days after the procedure. Case 3: 72-year-old female referred with right adrenal incidentaloma. Background of hypertension, diabetes mellitus, hypothyroidism, asthma, arthritis and Ca breast treated 10 years ago. Results showed raised plasma metanephrines, subsequently, MIBG scan revealed a 3 cm right adrenal nodule with increased uptake. Full alpha and beta blockade achieved before she underwent surgical treatment with no complications. Discharged on the 3rd day post op. Case 4: An 80-year-old male was referred with left adrenal incidentaloma. History of diabetes, chronic kidney disease, ischemic heart disease and heart failure, recent myocardial infarction and atrial fibrillation. Biochemical and radiological investigations confirmed pheochromocytoma. He was started on alpha blockade that proved difficult to achieve due to underlying co-morbidities. The patient needed close monitoring by the endocrine team and was finally established on adequate alpha and beta blockade. Due to significant risks associated with the procedure, the patient decided not to proceed with the surgery and opted for medical management. Remains under active follow up. Presentation: 6/2/2024

6390 Takotsubo Cardiomyopathy (Case Report)

Abstract Disclosure: H.A. Ballout: None. I. Malas: None. Z. Sakor: None. M. Ismail: None. C. Najjar: None. Takotsubo is a reversible stress-induced cardiomyopathyusually associated with emotional or physical stress.Thyroid stormhas been identified as a rare cause of takotsubo. We report a rarecase of 64-year-old female presented with high BP. Blood testsshowed elevated troponin level and high FT4 FT4 Cardiacultrasound revealed normal size of the LV &amp;anteroseptal wallakynisia,low ejection fraction,&amp;diastolic LVD.Cardiac cathshowed normal coronary arteries, ventriculography showed apicalballooning and bulging in the left ventricle, suggesting Takotsubocardiomyopathy as a final diagnosis. patient was treated for thethyroid storm&amp;takotsubo cardiomyopathy.month later she showedsignificant improvement in the cardiac function &amp;thyroid hormone levels. As this case represented a rare stress-induced cardiomyopathy, the early diagnosis &amp;suitable therapy areessential to prevent ongoing myocardial damage and providebetter chance for recovery. Presentation: 6/2/2024

Cardiogenic shock in phaeochromocytoma multisystem crisis- a case report

Abstract Background Phaeochromocytoma multisystem crisis (PMC) is characterised by labile blood pressures (extremes of hypo- and/or hypertension) and multiorgan failure as a result of catecholamine excess. Initial stabilisation requires pharmacological and/or mechanical circulatory support, followed by institution of antihypertensives to correct the underlying pathophysiology. Case summary A previously well 40-year-old male developed sudden onset of breathlessness. On presentation, he was in shock with multiorgan failure. He required intubation, mechanical ventilation, dual inotropic support and renal replacement therapy. Bedside echocardiogram showed a severely impaired left ventricular ejection fraction (LVEF) of 25%. Coronary angiography revealed normal coronary arteries. In view of raised inflammatory markers and transaminitis, a CT abdomen/pelvis was performed. An incidental left adrenal mass was found. Further work-ups revealed raised plasma metanephrine and normetanephrine, 24-hour urine epinephrine and norepinephrine. A cardiac magnetic resonance (CMR) showed myocardial inflammation and reverse Takotsubo pattern of regional wall motion abnormality (RWMA). The diagnosis of cardiogenic shock and stress cardiomyopathy secondary to phaeochromocytoma multisystem crisis was made. He was subsequently initiated on α- and β-blockers and goal-directed medical therapy for heart failure. A 68Ga-DOTATATE scan showed avid tracer uptake of the left phaeochromocytoma. An interval CMR 3 weeks from presentation showed near normalisation of the LVEF and RWMA. He underwent a successful laparoscopic left adrenalectomy and was antihypertensive-free since. Conclusion The clinical suspicion for PMC as the cause of cardiogenic shock requires astute clinical judgement, while the management requires understanding of the underlying pathophysiology that call for multidisciplinary inputs.

Coronary Artery Aneurysm or Ectasia as a Form of Coronary Artery Remodeling: Etiology, Pathogenesis, Diagnostics, Complications, and Treatment.

Coronary artery aneurysm or ectasia (CAAE) is a term that includes both coronary artery ectasia (CAE) and coronary artery aneurysm (CAA), despite distinct phenotypes and definitions. This anomaly can be found in 0.15-5.3% of coronary angiography. CAE is a diffuse dilatation of the coronary artery at least 1.5 times wider than the diameter of the normal coronary artery in a patient with a length of over 20 mm or greater than one-third of the vessel. CAE can be further subdivided into diffuse and focal dilations by the number and the length of the dilated vessels. Histologically, it presents with extensive destruction of musculoelastic elements, marked degradation of collagen and elastic fibers, and disruption of the elastic lamina. Conversely, CAA is a focal lesion manifesting as focal dilatation, which can be fusiform (if the longitudinal diameter is greater than the transverse) or saccular (if the longitudinal diameter is smaller than the transverse). Giant CAA is defined as a 4-fold enlargement of the vessel diameter and is observed in only 0.02% of patients after coronary. An aneurysmal lesion can be either single or multiple. It can be either a congenital or acquired phenomenon. The pathophysiological mechanisms responsible for the formation of CAAE are not well understood. Atherosclerosis is the most common etiology of CAAE in adults, while Kawasaki disease is the most common in children. Other etiological factors include systemic connective tissue diseases, infectious diseases, vasculitis, congenital anomalies, genetic factors, and idiopathic CAA. Invasive assessment of CAAE is based on coronary angiography. Coronary computed tomography (CT) is a noninvasive method that enables accurate evaluation of aneurysm size and location. The most common complications are coronary spasm, local thrombosis, distal embolization, coronary artery rupture, and compression of adjacent structures by giant coronary aneurysms. The approach to each patient with CAAE should depend on the severity of symptoms, anatomical structure, size, and location of the aneurysm. Treatment methods should be carefully considered to avoid possible complications of CAAE. Simultaneously, we should not unnecessarily expose the patient to the risk of intervention or surgical treatment. Patients can be offered conservative or invasive treatment. However, there are still numerous controversies and ambiguities regarding the etiology, prognosis, and treatment of patients with coronary artery aneurysms. This study summarizes the current knowledge about this disease's etiology, pathogenesis, and management.

The Effect of CD31 on Coronary Collateral Development.

Coronary collaterals are the feeding bridges between the main epicardial arteries, and research has shown that this collateral development plays a crucial role in myocardial performance, especially in patients with coronary artery disease. However, the evolution of these collaterals has not been fully explained. In this study, we aimed to reveal the effect of CD31 on coronary collateral development. As a result of coronary angiography performed in our clinic, 89 patients with coronary artery disease and 90 patients with normal coronary arteries were included in the study. Collateral development degrees were recorded from the angiographic images of the subjects. CD31 values were compared between the group with coronary artery disease and the control group. In addition, the coronary artery disease group was divided into subgroups according to the collateral development in terms of good collateral development and poor collateral development, and the factors that may affect the collateral development were tried to be determined. CD31 levels were significantly higher in the group with coronary artery disease compared to the control group (p <0.001). In addition, CD31 levels in the subgroup with good collateral were significantly higher than in the group with weak collateral (p <0.001). In the correlation analysis, a significant positive correlation was found between serum CD31 level and SYNTAX score, age, glucose, and rentrop grade. Multivariate logistic regression analysis showed CD31 to be an independent predictor of good coronary collateral development. CD31, a marker of angiogenesis, may be involved in coronary collateral development.

Resting segmental speckle tracking strain and strain rate in stable coronary artery disease and revascularized myocardial infarction

Patients with acute coronary artery disease (CAD) exhibit reduced global and regional strain and strain rate (S/SR). However, knowledge about segmental S/SR in stable CAD patients is still limited. This study aimed to investigate whether resting segmental S/SR measurements differ in patients with chronic chest pain who have normal coronary arteries or stenotic coronary arteries, and to compare these measurements to those in patients with revascularized myocardial infarction (MI). We prospectively enrolled 510 patients with chronic chest pain referred for coronary computed tomography angiography (CCTA) and 102 patients revascularized after MI. All participants underwent transthoracic echocardiography featuring S/SR analysis. In addition to the patients with MI, patients with suspected CAD based on CCTA findings subsequently underwent invasive coronary angiography (CAG). We assessed global longitudinal strain (GLS) and averaged segmental peak longitudinal strain during systole (PLS), peak systolic strain rate (SRs), peak early diastolic strain rate (SRe), and post systolic shortening (PSS). We also determined functionally reduced segment percentages using differing S/SR cut-off values. There were significant disparities in all average segmental S/SR metrics between the No-CAD and MI groups. SRe was the only S/SR metric that differed significantly between the No-CAD and PCI groups. Differences in SRe, PLS and GLS measurements were observed between the No-CAD and CABG groups. The proportion of diminished segmental S/SR mirrored these findings. For the percentage of pathological segments with varying cut-off values, segmental SRe below 1.5 s− 1 displayed the most marked difference among the four groups (p < 0.001). Revascularized MI patients or those referred to CABG present with diminished segmental S/SR values. However, among patients with chronic chest pain, only segmental SRe discerns subtle disparities between the No-CAD and the PCI group. The diagnostic accuracy of SRe warrants further exploration in subsequent studies.