Objective Evidence Of Myocardial Ischemia Research Articles

Objective Ischemia, Subjective Angina, and Psychological Distress in Angina With No Obstructive Coronary Disease.

Angina with no obstructive coronary disease (ANOCA) and ischemia with no obstructive coronary disease, prevalent yet underrecognized conditions, mostly affect women. Previous studies rarely distinguished between them. We aimed to compare the prevalence of objective ischemia through various examinations in women with ANOCA and assess the impact of objective and subjective ischemia on their mental health. A total of 84 eligible women with ANOCA and 42 controls underwent mental stress, pharmacological stress, exercise stress, and Holter testing. Objective evidence of myocardial ischemia was assessed by positron emission tomography-computed tomography and ECG, and subjective symptoms were graded using the Canadian Cardiovascular Society scale (CCS). Psychological assessments were conducted using 6 scales. Among 84 women with ANOCA, 37 (44%) received a diagnosis of ischemia with no obstructive coronary disease following mental stress testing, 20 (28.6%) through pharmacological stress testing, 14 (21.2%) via exercise stress testing, and 24 (32.9%) from Holter. Mental stress-induced myocardial ischemia was more prevalent (P<0.05). Among 54 patients with ANOCA who completed all tests, 30% showed no ischemia, and only 1 (1.9%) showed ischemia in all tests. In addition, patients with ANOCA had higher psychological scores than controls (P<0.01). No significant differences was observed in psychological scores between ANOCA with positive and negative ischemia test results (P>0.05). However, ANOCA with milder angina (CCS I) exhibited higher scores across the Hospital Anxiety and Depression Scale, State-Trait Anxiety Inventory, Perceived Stress Scale, and Posttraumatic Stress Disorder Checklist-Civilian Version and a higher prevalence of Type D personality traits (P<0.05). In patients with ANOCA, the positive rate of myocardial ischemia exhibits variability among several noninvasive tests. A worsened psychological state is more closely linked to milder angina symptoms than to ischemia performance, highlighting the importance of focusing on symptom management in their psychological care. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03982901.

Diagnosis and Prognosis of Type 2 Myocardial Infarction Using Objective Evidence of Acute Myocardial Ischemia: A Validation Study

BackgroundDifferentiating type 2 myocardial infarction from myocardial injury can be difficult. In addition, the presence of objective evidence of myocardial ischemia may facilitate identification of high-risk type 2 myocardial infarction patients. MethodsThis was an observational cohort study of adult emergency department patients undergoing high-sensitivity cardiac troponin T (hs-cTnT) measurement. Patients with ≥1 hs-cTnT >99th percentile were adjudicated following the Fourth Universal Definition of Myocardial Infarction. Patients were categorized as “subjective type 2 myocardial infarction” when ischemic symptoms were the lone criteria supporting type 2 myocardial infarction, or “objective type 2 myocardial infarction” when there was ≥1 objective clinical feature (electrocardiography, imaging, angiography) of acute myocardial ischemia. The primary outcome was mortality. ResultsA total of 857 patients were included, among which 55 (6.4%) were classified as subjective type 2 myocardial infarction, 36 (4.2%) as objective type 2 myocardial infarction, and 702 (82%) as myocardial injury. Those with objective type 2 myocardial infarction had a higher risk of mortality during the index presentation (17% vs 1.7%, P < .0001; hazard ratio 11.1; 95% confidence interval, 3.7-33.4) and at 2-year follow-up (47% vs 31%, P = .04; hazard ratio 1.92; 95% confidence interval, 1.17-3.14) than those with myocardial injury. Objective type 2 myocardial infarction had a higher mortality than subjective type 2 myocardial infarction at index presentation (17% vs 2.0%, P = .01) and at 1 (25% vs 9.1%, P = .04) and 3 months (31% vs 13%, P = .04) follow-up. There were no mortality differences between subjective type 2 myocardial infarction and myocardial injury. ConclusionIn patients diagnosed with type 2 myocardial infarction, those with objective evidence of myocardial ischemia have significantly worse outcomes compared with those with myocardial injury and subjective type 2 myocardial infarction. A more rigorous type 2 myocardial infarction definition that emphasizes these criteria may facilitate diagnosis and risk-stratification.

Abstract 14136: Diagnosis and Prognosis of Type 2 Myocardial Infarction Using Objective Evidence of Myocardial Ischemia

Introduction: Differentiating type 2 myocardial infarction (T2MI) from myocardial injury can be difficult. The presence of objective evidence of acute myocardial ischemia may facilitate the identification of high-risk T2MI patients. Methods: Retrospective, observational cohort post-hoc analysis of adult emergency department patients undergoing hs-cTnT measurement. Patients with ≥1 hs-cTnT&gt;99th percentile were adjudicated following the Fourth Universal Definition of MI. Patients were categorized as “subjective T2MI” when ischemic symptoms were the lone criteria supporting T2MI, or “objective T2MI” when there was ≥1 objective clinical feature (electrocardiography, imaging, angiography) of acute myocardial ischemia. The primary outcome was mortality. Results: A total of 857 patients were included, amongst which 55 (6.4%) were classified as subjective T2MI, 36 (4.2%) as objective T2MI, and 702 (82%) as myocardial injury. Among objective T2MIs, the most common criteria were ischemic electrocardiographic changes (n=29). Median (IQR) maximum hs-cTnT were 24 (18, 43) ng/L in myocardial injury, 34 (19, 80) in subjective T2MI, and 74 (35, 237) in objective T2MI. Those with objective T2MI had a higher risk of mortality during the index presentation (17% vs. 1.7%, p&lt;0.0001; HR 11.1 95% CI 3.7-33.4) and at 2-year follow-up (47% vs. 31%, p=0.04; HR 1.92, 95% CI 1.17-3.14) than those with myocardial injury (Figure). Objective T2MI had a higher mortality than subjective T2MI at index presentation (17% vs. 2.0%, p=0.01) and at 1- (25% vs. 9.1%, p=0.04) and 3-months (31% vs. 13%, p=0.04) follow-up. There were no mortality differences between subjective T2MI and myocardial injury. Conclusions: In patients diagnosed with T2MI, those with objective evidence of myocardial ischemia have significantly worse outcomes compared to those with myocardial injury and subjective T2MI. A more rigorous definition of T2MI might be a more effective way to define this important entity.

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult

ObjectivesSilent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history. Materials and methodsHerein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. ResultsA 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms. ConclusionsSilent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.

Coronary microvascular dysfunction: mechanisms and clinical outcome

A large percentage of patients, predominantly female, who undergo coronary angiography for typical chest pain do not have significant coronary stenosis. Many of these patients with microvascular myocardial disease have left ventricular hypertrophy, cardiomyopathies, valve disease, or other clinical conditions. The definition of microvascular angina is based on (i) symptoms of myocardial ischemia, (ii) absence of obstructive coronary artery disease (<50% stenosis on coronary angiography or coronary computed tomography scan), (iii) objective evidence of myocardial ischemia (ischemic electrocardiographic abnormalities during episodes of chest pain and/or myocardial perfusion defects or regional contractility abnormalities), and (iv) pathological indices of microcirculation (index of microcirculatory resistance >25, coronary flow reserve <2.0) and/or microvascular spasm (TIMI flow <2) during intracoronary vasoreactivity tests. The basic mechanisms and the diagnostic tests of microvascular dysfunction are reported in detail.From a clinical standpoint, while the crucial role of microcirculation in determining short- and long-term prognosis is evident, efforts to date to improve clinical outcomes in patients with microvascular obstruction have had limited success, most likely because microvascular dysfunction is a multifactorial process with several interdependent underlying pathophysiological mechanisms. Therefore, further studies are needed to develop effective therapeutic strategies for microvascular myocardial disease.

Prevalence and determinants of silent myocardial ischemia in patients with type 2 diabetes in Cameroon: a cross-sectional study.

Introductiondiabetes mellitus is a major health problem worldwide. It is associated with high cardiovascular morbi-mortality especially coronary artery disease. Myocardial ischemia is often asymptomatic (silent myocardial ischemia) in people with type 2 diabetes mellitus thus making early diagnosis difficult. Silent myocardial ischemia is defined as the objective evidence of myocardial ischemia in the absence of chest discomfort or other angina equivalents. This study aimed to determine the prevalence and determinants of silent myocardial ischemia in a population of people with type 2 diabetes using exercise stress electrocardiography.Methodswe carried out a cross-sectional study between January and April 2019 at the National Obesity Centre of the Yaounde Central Hospital. Patients with type 2 diabetes underwent a complete clinical evaluation, blood test, resting electrocardiogram (ECG), and exercise stress ECG according to the Bruce protocol. A positive stress test was defined as horizontal or down-sloping ST depression ≥ 1mm or upsloping ST depression of 2 mm or more 0.06 to 0.08 seconds after the J point.Resultsa total of 112 patients with diabetes (63 males and 49 females) were screened. The median age was 58 (IQR: 51 - 64) years. The median time from diabetes diagnosis was 8 (IQR: 5 - 12) years. Fifty-seven (50.4%) had hypertension, 78 (69.0%) had dyslipidemia, 66 (58.4%) were obese, 70 (61.9%) had poor glycemic control, and 23 (20.2%) were smokers. Sixty-five (58%) patients had a positive exercise stress ECG test. Factors independently associated with a positive stress test were abdominal obesity (aOR: 4.2, [95% CI: 1.4 - 12.8]) and Female sex (aOR: 2.5, [95% CI: 1.1 - 5.7]).Conclusionthe prevalence of silent myocardial ischemia was high in a population of asymptomatic patients. This was independently associated with abdominal obesity and female sex.

Impact of wall shear stress affected by anatomical difference between acute and chronic coronary syndrome in patients with LAD proximal disease

Abstract Recent hemodynamic studies have demonstrated that progression of coronary atherosclerosis occurs at low wall share-stress site, whereas plaque rupture frequently occurs at high share stress site. It is well recognized that wall shear stress is relatively low along the outer walls of the bifurcation. We investigated consecutive 140 patients (77 with acute coronary syndrome (ACS) and 63 with chronic coronary syndrome (CCS) performed PCI for LAD proximal lesions (AHA seg.6) from January 2016 to December 2019. In CCS group, entry criteria included stenosis of at least 90% in the LAD proximal lesion or at least 70% in the LAD proximal lesion and objective evidence of myocardial ischemia (inducible ischemia with either exercise or pharmacologic vasodilator stress or with pressure wire). Exclusion criteria were patients with maintenance dialysis, chronic total occlusion lesions, in-stent restenosis, and clinically diagnosed unstable angina without troponin I elevation. We measured the distance from LMT distal carina to the culprit site (Distance) and plaque location (Location) with intravascular ultrasound and angle between LMT and LAD with cardiovascular angiography analysis system (CAAS) (Angle). The two groups were generally well balanced with regard to baseline clinical characteristics. The mean (±SD) age of the patients was 69.0±11.8 years, and 75% were men. Medication at baseline was also similar between two groups except higher prevalence of statin prescription in CCS group. The Distance was shorter and Angle was steeper in CCS group than in ACS group. The number of patients with Angle less than 150 degrees and with Location in the lateral wall side was much more in CCS group. In this study, plaques in CCS were frequently observed at low shear stress site, whereas those in ACS at high shear stress site. Plaque progression in CCS may be associated with low wall shear stress, and high shear stress may play key role in plaque rupture in ACS. This anatomical difference can partly explain the different mechanisms of onset between of ACS and CCS. Funding Acknowledgement Type of funding sources: None. Anatomical differenceCharacteristics and results

Abstract 15071: Effect of Percutaneous Coronary Intervention on Death and Myocardial Infarction in Patients Withstable Coronary Artery Disease and Inducible Ischemia

Introduction: There has been a continuous debate about the survival benefit of percutaneous coronary intervention (PCI) for the management of patients with stable coronary artery disease (CAD) and moderate to severe ischemia. To address this, we performed a meta-analysis of RCTs comparing PCI plus MT vs. MT alone in stable CAD patients to evaluate endpoints of all-cause mortality, cardiovascular (CV) mortality, and MI in a larger cohort of patients with objective evidence of myocardial ischemia. Methods: An electronic database search was conducted for RCTs that compared PCI on top of MT versus MT alone. A random effects model was used to calculate relative risk (RR) and 95% confidence intervals (CIs). Results: A total of 7 RCTs with 10,043 patients with a mean age of 62.54 ± 1.56 years and a median follow up of 3.9 years were identified. Among patients with (CAD) and moderate to severe ischemia by stress testing, PCI didn’t show any benefit for the primary outcome of all-cause mortality compared to MT(RR = 0.85; 95% CI 0.646-1.12; p= 0.639). There was also no benefit in cardiovascular (CV) death (RR = 0.88 ; 95% CI 0.71-1.09; p =0.18) or myocardial infarction (MI) (RR = 0.271 ; 95% CI 0.782-1.087; P =0.327) in the PCI group as compared to MT. Conclusions: Among patients with (CAD) and evidence of moderate to severe ischemia by stress testing, PCI on top of MT appears to add no mortality benefit as compared to with MT alone.

Toll Like Receptor 2 Genotypes and Intra-Coronary Stent Restenosis

AbstractBackground: Intra-coronary Stent Restenosis (ISR) is a common complication after Percutaneous Coronary Interven-tion (PCI). There is an association between many genes such as Toll Like Receptor 2 (TLR2), Adrenergic B2 Receptor (ADRB2), platelet glycoprotein IIIa, Nitric Oxide Synthase3 (NOS3), P2Y12 receptor (P2Y12), cyclin-dependent kinase inhibitor (p27kip1) and the process of intra-coronary stent restenosis. Study of the genetic polymorphisms of these genes is very important to detect which is protective against intra-coronary stent restenosis, and which is risky for development of this problem. Our study selected TLR2 gene to detect its different genotypes involved in the problem of ISR.Aim of Study: To find the association between TLR2 genotypes, polymorphisms and Intra-coronary Stent Restenosis (ISR) complication after PCI procedures.Patients and Methods: The study included 200 patients with previous coronary revascularization by stent implantation. All patients were re-admitted to coronary angiography because of objective evidence of myocardial ischemia. The patients were classified into two groups: Group (A) included 100 patients who developed ISR and Group (B) included 100 patients who did not develop ISR. The two groups were compared regarding distribution of TLR2 genotypes and alleles.Results: 78% of patients with (GG) genotype, 14% of patients with (GA) genotype and 7% of patients with (AA) genotype developed ISR. There was no association between TLR2 (GA), (AA) genotypes and risk of ISR when compared by (GG) wild homozygous genotype (p>0.05, OR=1.2). We also did not find any association between TLR2 gene alleles and risk of ISR complication (p>0.05, OR=0.9).Conclusion: There was no association between different TLR2 genotypes, alleles and risk of ISR development.

Targeted therapy with a localised abluminal groove, low-dose sirolimus-eluting, biodegradable polymer coronary stent (TARGET All Comers): a multicentre, open-label, randomised non-inferiority trial

The FIREHAWK is a drug-eluting stent with a fully biodegradable sirolimus-containing polymer coating localised to recessed abluminal grooves on the stent surface. We investigated clinical outcomes with this targeted, low-dose, biodegradable polymer, sirolimus-eluting stent compared with XIENCE durable polymer, everolimus-eluting stents in an all-comers population. The TARGET All Comers study was a prospective, multicentre, open-label randomised non-inferiority trial done at 21 centres in ten European countries. Patients with symptomatic or asymptomatic coronary artery disease and objective evidence of myocardial ischaemia who qualified for percutaneous coronary intervention were randomised 1:1 to undergo implantation of a FIREHAWK or XIENCE. Randomisation was web-based, with random block allocation and stratification by centre and ST elevation myocardial infarction. Outcome assessors were masked to treatment allocation, but treating physicians and patients were not. The primary endpoint was target lesion failure at 12 months, a composite of cardiac death, target vessel myocardial infarction, or ischaemia-driven target lesion revascularisation. The control event rate for XIENCE was assumed to be 7%, the non-inferiority margin was 3.5%, and the primary analysis was in the intention-to-treat population, censoring patients who did not have either an event before 365 days or contact beyond 365 days. Late lumen loss was the primary endpoint of an angiographic substudy designed to investigate the non-inferiority of the FIREHAWK compared with the XIENCE stent. This trial is registered with ClinicalTrials.gov, number NCT02520180. From Dec 17, 2015, to Oct 14, 2016, 1653 patients were randomly assigned to implantation of the FIREHAWK (n=823) or XIENCE (n=830). 65 patients in the FIREHAWK group and 66 in the XIENCE group had insufficient follow-up data and were excluded from the analyses. At 12 months, target lesion failure occurred in 46 (6·1%) of 758 patients in the FIREHAWK group and in 45 (5·9%) of 764 patients in the XIENCE group (difference 0·2%, 90% CI -1·9 to 2·2, pnon-inferiority=0·004, 95% CI -2·2 to 2·6, psuperiority=0·88). There were no differences in ischaemia-driven revascularisation or stent thrombosis rates at 12 months. 176 patients were included in the angiographic substudy, in which in-stent late lumen loss was 0·17 mm (SD 0·48) in the FIREHAWK group and 0·11 mm (0·52) in the XIENCE group (p=0·48), with an absolute difference of 0·05 mm (95% CI -0·09 to 0·18, pnon-inferiority=0·024). In a broad all-comers population of patients requiring stent implantation for myocardial ischaemia, the FIREHAWK was non-inferior to the XIENCE as assessed with the primary endpoint of target lesion failure at 12 months and in-stent late lumen loss at 13 months. The FIREHAWK is a safe and effective alternative stent to treat patients with ischaemic coronary artery disease in clinical practice. Shanghai Microport Medical.

Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury.

First, describe how acute myocardial infarction criteria are used to diagnose type 1 (T1MI) and 2 (T2MI) myocardial infarction. Second, determine whether subjective or objective criteria are used for T2MI. Third, examine outcomes for T2MI based on the presence or absence of objective evidence of myocardial ischemia compared with myocardial injury. Post-hoc analysis of UTROPIA (NCT02060760), a prospective, observational, cohort study involving 1640 consecutive emergency department patients with serial high-sensitivity cardiac troponin I among whom 74 (4.5%) had T1MI, 103 (6.3%) T2MI, and 245 (15%) myocardial injury. Compared with T1MI, patients with T2MI were less likely to have ischemic symptoms (97% vs. 83%), Q waves (24% vs. 1%), new ST-T wave changes (74% vs. 51%), new regional wall motion abnormality (64% vs. 11%), and a culprit lesion on coronary angiography (59% vs. 0%) (all p <0.05). T2MIs were more likely to be diagnosed using subjective criteria (symptoms alone) than T1MI (42% vs. 12%, p <0.0001). Patients with objective T2MI, but not subjective T2MI, had a two-fold increase in early mortality compared with myocardial injury, with 30- and 60-day hazard ratios (95% confidence interval) of 2.3 (0.9, 6.2) and 2.0 (0.9, 4.7) respectively. Among patients with T2MI, many cases are diagnosed using subjective criteria. The presence of objective evidence of myocardial ischemia may identify a higher-risk group of T2MI patients in whom early outcomes are worse than myocardial injury. Emphasis on using objective evidence of myocardial ischemia to diagnose T2MI may result in a more precise and specific disease definition.

Coronary Sinus Reducer Implantation for the Treatment of Chronic Refractory Angina: A Single-Center Experience

ObjectivesThe aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina. BackgroundThe coronary sinus Reducer is a novel device to aid in the management of patients with severe angina symptoms refractory to optimal medical therapy and not amenable to further revascularization. MethodsFifty patients with refractory angina and objective evidence of myocardial ischemia who were judged unsuitable for revascularization were treated with coronary sinus Reducer implantation at a single center between March 2015 and August 2016. Safety endpoints were procedural success and the absence of device-related adverse events. Efficacy endpoints, assessed at 4- and 12-month follow-up, were a reduction in Canadian Cardiovascular Society angina class, improvement in quality of life assessed using the Seattle Angina Questionnaire, improvement in exercise tolerance assessed using the 6-min walk test, and reduction in pharmacological antianginal therapy. ResultsProcedural success was achieved in all patients, with no device-related adverse effects during the procedure or at follow-up. Regarding the efficacy endpoint, 40 patients (80%) had at least 1 reduction in Canadian Cardiovascular Society class, and 20 patients (40%) had at least 2 class reductions, with a mean class reduction to 1.67 ± 0.83 vs. 2.98 ± 0.52 (p < 0.001) at 4-month follow-up. All Seattle Angina Questionnaire items improved significantly (p < 0.001 for all). A significant increment in 6-min walk distance to 388.6 ± 119.7 m vs. 287.0 ± 138.9 m (p = 0.004) was observed. Sixteen patients (32%) and 3 patients (6%) demonstrated reductions of at least 1 or 2 antianginal drugs, respectively. The benefit of Reducer implantation observed at 4-month follow-up was maintained at 1 year. ConclusionsIn this real-world, single-center experience, implantation of the coronary sinus Reducer appeared safe and was associated with reduction in anginal symptoms and improvement in quality of life in patients with refractory angina who were not candidates for further revascularization.

Efficacy of cardiac shock wave therapy in patients with stable angina: The design of randomized, triple blind, sham-procedure controlled study

Objective:Despite revascularization and optimal medical treatment (OMT), patients with angina often have a reduced quality of life due to inadequate relief from symptoms. Recent studies have shown that the application of shock waves may reduce angina symptoms and improve quality of life, exercise capacity, and myocardial perfusion due to the stimulation of angiogenesis. However, there is limited evidence due to small, single-arm, single-center studies of low to moderate quality. The purpose of this study is to evaluate the impact of cardiac shock wave therapy (CSWT) on exercise tolerance and angina symptoms in patients with coronary artery disease and objective evidence of myocardial ischemia who cannot undergo traditional revascularization and experience angina despite OMT in comparison to sham procedure.Methods:We designed a randomized, triple-blind, placebo-controlled, multicentre trial (NCT02339454) to assess the efficacy of CSWT in addition to OMT in patients with stable angina and myocardial ischemia documented by exercise treadmill test (ETT). All patients were treated with stable doses of standard medical treatment 4 weeks before screening. An increase in the total exercise duration on ETT by ≥90 s from the baseline at the end of the study was set as the primary endpoint. Secondary endpoints included angina class, Seattle angina questionnaire scores, symptoms, and ECG changes during stress test. Patients underwent nine sessions of CSWT or corresponding sham procedure applied to all segments of the left ventricle, within 9 weeks. Endpoint assessments were performed at 6-month follow-up. The imaging substudies assessed the potential of CSWT to reduce stress-induced myocardial ischemia detected by dobutamine stress echocardiography, cardiac single-photon emission computed tomography, and cardiac magnetic resonance imaging.Results:At two centers, 72 of the 323 screened patients were randomized in two groups (ratio 1:1): active treatment and placebo control. Study patients were predominantly males (70.8%); the mean age of the patients was 68.4±8.3 years. Of these, 44 patients had angina Canadian Cardiovascular Society class III, and 66.7% of the patients had a history of myocardial infarction.Conclusion:Using sham applicators, blinding study participants, investigators, and endpoints assessors to the study data as well as centralized randomization ensures rigorous methodology and low risk of bias in this large randomized controlled CSWT study.

Hepatitis C as a risk factor for coronary artery disease in silent myocardial ischemia

Objective The aim of the present study was to evaluate the relationship between seropositivity of hepatitis C virus (HCV) and the severity of coronary artery disease in silent myocardial ischemic patients. Background Silent myocardial ischemia is defined as an objective evidence of myocardial ischemia occurring in the absence of symptoms. HCV was found to have a positive association with carotid artery plaque. Patients and methods We investigated 50 patients with silent myocardial ischemia. Patients were divided into two groups (group A included 25 HCV-seropositive patients and group B included 25 HCV-seronegative patients). Patients were subjected to history taking, clinical examination, and investigations such as 24-h Holter monitoring, complete blood count, liver and renal function tests, and random blood glucose, lipid profile, viral marker tests. Abdominal ultrasonography, echocardiography, and coronary angiography were carried out for all patients. The SYNTAX score was calculated. Results Fifteen patients of group A had left anterior descending disease versus seven of group B (P = 0.013). Thirteen patients of group A had left circumflex disease versus six of group B (P = 0.013). Fourteen patients of group A had right coronary artery disease versus six of group B (P = 0.0023).The SYNTAX score of group A was 15.76 ± 6.75, whereas the score for group B was 11.36 ± 7.64 (P = 0.0.036). Conclusion There was a positive relationship between HCV and number of diseased coronary vessels, and there was a positive relationship between HCV seropositivity and complexity of coronary lesions in the light of SYNTAX score as well.

Impact of coronary revascularization on the clinical and scintigraphic outlook of patients with myocardial ischemia.

The impact of coronary revascularization on outcomes and ischemic burden among patients with objective proof of ischemia is not yet established. We appraised the impact of revascularization on outcomes and residual ischemia in patients with objective evidence of ischemia at myocardial perfusion scintigraphy (MPS). We queried our database for stable patients with myocardial ischemia at MPS, excluding those with prior myocardial infarction, systolic dysfunction, or cardiomyopathy. The impact of revascularization (defined as revascularization as first follow-up event) on outcomes and changes in myocardial ischemia at repeat MPS was appraised with propensity-matched analyses. From 6195 patients, propensity matching yielded 1262 pairs of patients undergoing revascularization versus not undergoing revascularization. After 35.2 ± 23.9 months, revascularization was associated with lower risks of cardiac death [2 (0.2%) versus 10 (0.8%) in those not revascularized, P = 0.038] and of the composite of cardiac death or myocardial infarction [17 (1.3%) versus 37 (2.9%), P = 0.007]. In addition, revascularization was associated with a higher rate of improvement in ischemia degree after 28.1 ± 20.7 months of follow-up (P < 0.001), with 257 (69.3%) patients with moderate or severe ischemia at baseline MPS improving after revascularization versus 136 (42.0%) in the nonrevascularization group. Conversely, revascularization did not prove impactful on follow-up MPS in patients with only minimal or mild ischemia at baseline MPS (P < 0.001). In a large series of patients with objective evidence of myocardial ischemia at MPS, especially when moderate or severe, revascularization was associated with a better clinical prognosis and a lower ischemic burden at repeat MPS.

Safety and efficacy of a device to narrow the coronary sinus for the treatment of refractory angina: A single-centre real-world experience

ObjectiveThe coronary sinus Reducer is a recently introduced device to treat patients with severe angina symptoms refractory to optimal medical therapy and not amenable for conventional revascularisation. We aimed to assess the safety and efficacy of the Reducer in a real-world cohort of patients with refractory angina.MethodsThis is a single-centre retrospective registry. Patients with severe angina symptoms, objective evidence of myocardial ischaemia using any adequate non-invasive modality and without options for conventional revascularisation were regarded eligible for Reducer implantation.ResultsTwenty-three patients (74 % male, mean age 70 ± 8 years, 91.3 % previous bypass surgery, 82.6 % previous percutaneous intervention, 47.8 % previous myocardial infarction, 52.2 % diabetes mellitus) underwent Reducer implantation. The safety endpoint (successful implantation of the first device without device-related adverse events) was met in all patients. After a median follow-up of 9 (8–14) months the efficacy (any reduction in Canadian Cardiovascular Society (CCS) class and revascularisation-free survival) was reached in 17 patients (74 %): 8 patients (34.8 %) improved by 1 CCS class, 7 (30.4 %) by 2 CCS classes and 2 (8.7 %) by 3 CCS classes. One patient died 4 months after implantation because of progressive heart failure (not associated with Reducer implantation).ConclusionIn this single-centre real-world experience, Reducer implantation was safe and demonstrated excellent clinical efficacy in the treatment of refractory angina at mid-term follow-up.

Meta-Analysis of Trials on Mortality After Percutaneous Coronary Intervention Compared With Medical Therapy in Patients With Stable Coronary Heart Disease and Objective Evidence of Myocardial Ischemia

Outcomes of percutaneous coronary intervention (PCI) versus medical therapy (MT) in the management of stable ischemic heart disease (SIHD) remain controversial, with some but not all studies showing improved results in patients with ischemia. We sought to elucidate whether PCI improves mortality compared to MT in patients with objective evidence of ischemia (assessed using noninvasive imaging or its invasive equivalent). We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PCI to MT in patients with SIHD. To maintain a high degree of specificity for ischemia, studies were only included if ischemia was defined on the basis of noninvasive stress imaging or abnormal fractional flow reserve. The primary outcome was all-cause mortality. We identified 3 RCTs (Effects of Percutaneous Coronary Interventions in Silent Ischemia After Myocardial Infarction II, Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2, and a substudy of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial) enrolling a total of 1,557 patients followed for an average of 3.0 years. When compared with MT in this population of patients with objective ischemia, PCI was associated with lower mortality (hazard ratio 0.52, 95% confidence interval 0.30 to 0.92, p=0.02). There was no evidence of study heterogeneity or bias among included trials. In this meta-analysis of published RCTs, PCI was shown to have a mortality benefit over MT in patients with SIHD and objective assessment of ischemia using noninvasive imaging or its invasive equivalent. In conclusion, this study provides insight into the management of a higher-risk SIHD population that is the focus of the ongoing International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial.

A false positive case of cardiac troponin I: Which diagnostic approach?

The finding of elevated cardiac troponin levels (i.e. values above the99thpercentilevalueofthereferencepopulation)notrelatedtoischemicmyocardial injury in patients admitted to the emergency department(ED) with suspected acute myocardial infarction (AMI), represents arelevant clinical problem, increasingly observed in the last few years,following the implementation of cardiac troponin (cTnI, cTnT) measure-ment with high-sensitivity immunoassays [1]. Indeed, the majority ofpatients (up to 70%) admitted to the ED with more than one elevatedtroponin level may actually have myocardial injury unrelated to acutecoronary syndrome (ACS), especially when they have an age of morethan 70 years, heart failure, and/or other comorbidities [2,3]. In suchpatients, the incidence of “falsepositive”cases,i.e.the findingof troponinelevations in the absence of clinically documented myocardial injury, isactually unknown. Clinical observation however suggests that the per-centage of “false positive” troponin elevations is extremely low.Inapaperrecentlypublishedinthejournal[4],aclinicalcaseofapa-tient presenting to the ED with suspicion of AMI and non-diagnosticECG that shows a false positive cTnI result due to the presence in theblood sample of an analytical interference caused by heterophilic anti-bodies,hasbeenpublished.Theauthorssuggesttheadoptionofanalgo-rithm that allows the prompt detection of the supposed false-positiveresult. The described protocol considers the systematic measurementof CK-MB reflex testing in all troponin-positive samples as a reliabletool for the identification of biological and analytical interference. Thisreflextestingisbasedontheuseofawellknownbutoutdatedbiomark-erwhichlackssensitivityandspecificityforthedetectionofmyocardialinjury when compared with cardiac troponin. In addition the Authorsseemtoignorecurrentinternationalguidelines[5],whichbasethediag-nosis of myocardial infarction, along with the documentation of objec-tive evidence of myocardial ischemia, on the correct interpretation ofserialcardiactroponintesting.Infacttheanalysisofthereleasekineticsof troponin may permit the distinction between myocardial damagecaused by myocardial ischemia from myocardial injury caused byother factors and, possibly, from “false positive” troponin elevations[5,6]. According to these criteria, the detection of a rise and/or fall pat-tern of troponin with at least one value above the 99th percentileupper reference limit, is needed to make the diagnosis. It is well know,instead, that theinterference ofaheterophilicantibodytypically causesa constant (chronic) increase in troponin values, which cannot beconfused with the typical kinetic of the biomarker in AMI patients.Therefore, the interference by heterophilic antibodies should be differ-entiated from the huge number of clinical conditions which can causea chronic increase in troponin levels [5].Reflex testing is usually per-formed when the result of a first screening test is positive, in order toimprovethespecificity,althoughatthecostoflowersensitivity.Thisdi-agnostic strategy, therefore, should be adopted in clinical laboratorypractice to improve specificity employing a second text more specific(but more expensive and time consuming) than the screening text.Inthe case of the proposed reflex testing [4], the cardiac specificity of thesecond test (i.e. CK-MB) is significantly lower than the specificity ofthe screening test (i.e. cardiac troponin) and significantly less sensitivefor cardiac damage. As a consequence, the potential clinical advantageof using a very sensitive and cardio-specific screening test, such as thecardiactroponins, appearsto be, intheproposed “reflextesting” strate-gy, completely lost. A huge number of clinical studies have definitivelydemonstrated that cardiac troponins (particularly when assayed withhigh-sensitivity methods) represent a more cardiac-specific and sensi-tive biomarker than CK-MB in cardiovascular risk stratification, both inthe general population as well as in patients with cardiac disease [1,7]confirmingthatthemeasurementof CK-MBisnowobsolete.Moreover,considering that the incidence of heterophilic antibodies in the generalpopulationvariesgreatlyindifferentstudies(from0.17to40%)[8,9]thereflextestingproposed,ifappliedsystematicallyinallpatientsadmittedto the ED with increased troponin values, may allow the detection of

High-Risk Plaque Detected on Coronary CT Angiography Predicts Acute Coronary Syndromes Independent of Significant Stenosis in Acute Chest Pain: Results From the ROMICAT-II Trial

BackgroundIt is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain. ObjectivesThe primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI). MethodsWe included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment. ResultsOverall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients [46.0%] and significant CAD with ≥50% stenosis in 45 patients [9.5%]). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio [OR]: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis. ConclusionsIn patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239)

Transcatheter treatment for refractory angina with the coronary sinus Reducer

To evaluate the clinical efficacy of the coronary sinus (CS) Reducer in attenuating angina severity in patients suffering from severe refractory angina. Patients with refractory angina, objective evidence of myocardial ischaemia and no option for revascularisation were treated with CS Reducer implantation at two medical centres. Six-month follow-up evaluation consisted of clinical assessment of angina severity. Objective assessment of ischaemia at six-month follow-up was performed in one of the two centres. Successful CS Reducer implantation was achieved in 21 of 23 eligible patients, at both centres. No device-related adverse effects were observed during the procedure or the follow-up period. Canadian Cardiovascular Society (CCS) score diminished from a mean of 3.3 at baseline to 2.0 at six months (n=20, p<0.01), exercise duration was prolonged from 3:16 to 5:16 min (min:sec; n=8, p=0.05). Thallium SPECT summed stress score and summed difference score were both reduced (n=9, 21.5±10 vs.13.2±9, p=0.01, and 11.1±6 vs. 4.7±4, p=0.007, respectively). Wall motion score index at peak dobutamine infusion was also significantly improved (n=8, 1.9±0.4 vs. 1.4±0.4, p=0.046). CS Reducer implantation was safe and resulted in significant improvement of angina class. The results of the ongoing randomised sham-control trial will address the concern regarding the possible placebo effect, and hopefully further support our encouraging observations.