Obstructive Coronary Artery Disease Research Articles

Type 2 diabetes mellitus aggravates coronary atherosclerosis in hypertensive individuals based on coronary CT angiography: a retrospective propensity score-based study

BackgroundThe effect of type 2 diabetes mellitus (T2DM) on coronary atherosclerosis detected on coronary computed tomography angiography (CCTA) in hypertensive patients has attracted increasing attention. This study investigated the relationships of T2DM with coronary artery plaque characteristics and semiquantitative CCTA scores in hypertensive patients.Materials and methodsIn this single-center study, 1,700 hypertensive patients, including 850 T2DM [HT(T2DM+)] and 850 non-T2DM [HT(T2DM−)] individuals, were retrospectively analyzed after propensity matching. Plaque type, extent, coronary stenosis, segment involvement score (SIS), segment stenosis score (SSS), and CT-based Leaman score (CT-LeSc) based on CCTA were assessed and compared between the two groups.ResultsHT(T2DM+) patients had more coronary segments with calcified plaque (2.08 ± 2.20 vs. 1.40 ± 1.91), mixed plaque (2.90 ± 2.87 vs. 2.50 ± 2.66), nonobstructive stenosis (4.23 ± 2.44 vs. 3.62 ± 2.42), and obstructive stenosis (1.22 ± 2.18 vs. 0.78 ± 1.51), a lower proportion of 1-vessel disease (15.3% vs. 25.5%), a higher proportion of 3-vessel disease (59.6% vs. 46.7%), and higher SIS (5.5 ± 3.1 vs. 4.4 ± 3.0), SSS (10.3 ± 8.5 vs. 7.7 ± 7.1), and CT-LeSc (9.4 ± 5.6 vs. 7.9 ± 5.2) than HT(T2DM−) patients (all P-values <0.05). Multivariable analysis revealed that T2DM was an independent risk factor for calcified plaque [odds ratio (OR) = 2.213], obstructive coronary artery disease (CAD) (OR = 1.271), multivessel disease (OR = 1.838), SIS > 4 (OR = 1.910), SSS > 6 (OR = 1.718), and CT-LeSc > 5 (OR = 1.584) in hypertension population (all P-values <0.05).ConclusionT2DM was independently associated with the presence of calcified coronary artery plaque and increased the risk of obstructive CAD, multivessel disease, and CT-LeSc > 5 in hypertensive patients. More attention should be given to the assessment and management for coronary atherosclerosis in hypertensive patients with T2DM, as this population may have a higher risk of cardiovascular events.

CONTRAST STRESS ECHOCARDIOGRAPHY FINDINGS IN MYOCARDIAL BRIDGING COMPARED TO NORMAL CORONARY COURSE, WITH AND WITHOUT CORONARY ARTERY DISEASE

Abstract Background Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD). Methods We evaluated all consecutive patients who underwent contrast stress echocardiography and coronary computed tomography angiography (CCTA) due to suspected symptoms of CAD within 3 months in Parma Hospital. Coronary computed tomography angiography served as the reference standard for detecting MB and obstructive CAD. The patients were divided into 3 groups: (1) MB and no evidence of obstructive CAD (MB group, N = 64), (2) no evidence of obstructive CAD or MB (NoCAD group, N = 135), (3) obstructive CAD without MB (CAD group, N = 68). Results The coronary flow velocity reserve in the LAD (CFVR–LAD) was reduced in the MB and CAD groups, measuring 1.91 ± 0.21 and 1.82 ± 0.28, respectively, whereas it was 2.27 ± 0.34 in the NoCAD group (P < .001). The MB and CAD groups exhibited a higher prevalence of reversible myocardial perfusion defects (rMPDs) compared to the NoCAD group (57.8% vs 64.7% vs 3.7%, P < .001). Reversible wall motion abnormalities were frequently observed in the CAD group and rarely found in the MB and NoCAD groups (47.1% vs 18.8% vs 4.4%, P < .001). In multivariable analyses, the presence of MB was independently associated with reduced CFVR–LAD (odds ratio = 14.55; 95% CI, 6.84–30.93; P < .001) and the presence of rMPD (odds ratio = 37.96; 95% CI, 13.49–106.84; P < .001). Patients with deep MB (>2 mm depth) and very deep MB (≥5 mm depth) exhibited significantly greater CFVR–LAD reduction and rMPD than those with superficial MB. Conclusions Myocardial bridging is capable of inducing rMPD and reducing CFVR–LAD similar to obstructive CAD. The depth of the MB correlates with the abnormalities found in the stress echo evaluation. Contrast stress echo may serve as a valuable noninvasive tool for evaluating patients with MB.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

CARDIOVASCULAR TOXICITY IN METASTATIC PROSTATE CANCER TREATMENT: BALANCING RISKS, TREATING CONSEQUENCES

Abstract Introduction Enzalutamide inhibits the receptor of androgen hormones. It is administered for treating metastasized prostate cancer. Enzalutamide is known to have a cardiotoxic effect. Case Report A 76 year–old man on–treatment for hypertension and overall good health underwent radical prostatectomy and bilateral ileo–obturator lymphadenectomy in 2021 for prostate cancer. In July 2023, infiltrated lymph node and lung/bone metastases were identified. Therefore, oncologist started Enzalutamide administration, i.e. Androgen Deprivation Therapy. Ecocardiography before therapy showed no alterations in cardiac morphology with normal left ventricle ejection fraction (LVEF). Three months after Enzalutamide administration, he experienced worsening dyspnea and peripheral lower extremity edema. He was admitted to the emergency Department of our hospital due to worsening dyspnea at rest, diffuse crackles and increased values in brain natriuretic peptide (BNP, 3203 pg/mL) and troponins. He was transferred to Intensive Care Unit for acute heart failure. Instrumental findings: 2D ECHOCARDIOGRAPHY: LVEF ∼20%, marked global hypocontractility at strain evaluation (GLS –9.3%); LUNG ULTRASOUND: abundant bilateral basal pleural effusion on the right extending to the middle field with atelectasis of the contiguous parenchyma; 24h Holter ECG: frequent supraventricular and ventricular ectopic arrhythmias. He begins non–invasive ventilation (NIV), high–dose diuretics, and Levosimendan. We observed amelioration in symptoms, reduction in pleural effusion, peripheral edema, and BNP levels (from 3203 pg/ml to 468.6 pg/ml). We proceed with weaning from NIV by monitoring respiratory function and performance by means of blood gas analysis. Amelioration in congestion status was evaluated by bioimpedance. After clinical stabilization, coronary angiography was performed which highlighted a bi–vessel obstructive coronary artery disease (long critical stenosis, ∼80%, on the proximal–middle section of the left anterior descending artery, ∼70% at middle section of circumflex and proximal section of first margianl). Therefore, revascularization by PCI plus DES was performed on proximal–middle LAD and on CX–MO1. Patient was discharged soon after in stable condition and underwent outpatient follow–up. Conclusions Enzalutamide might provoke important cardiotoxic effects. It might induce acute cardiac impairment and/or coronary artery diseases. Further analysis and evaluations should be performed.

ROLE OF CORONARY CT IN THE EMERGENCY ROOM IN THE PATIENTS WITH CHEST PAIN

Abstract Objective Assess the use of Coronary CT in patients attending the emergency room (ED) with chest pain and/or doubtful signs/symptoms of acute coronary syndrome (ACS). Background Patients coming to the ED for chest pain are an important challenge. According to the guidelines (ESC 2023) it is necessary a fast selection between those who need hospitalization and urgent coronary angiography (rule–in) and those who can be discharged home (rule–out). However, it is difficult to obtain an early diagnosis and therefore patients often need a prolonged observation. Materials and Methods We subjected to Coronary CT 104 patients (pts) with symptoms and/or alteration of parameters suspected for ACS (ECG, echocardiography, high sensitivity troponin) arrived in the cardiological holding (cardiological observation) of the San Camillo Forlanini Hospital from the emergency room. Clinical–instrumental data, incidence of positive results on Coronary CT and concordance with coronary angiography, waiting time for the examination and length of hospitalization were retrospectively evaluated. Results The average age of the pts was 56 ± 2 years, 65 men (62.5%) 39 women (37.5%). Coronary CT exams were performed on the first day after admission to the ED in 83% of cases. Pts presented with chest pain (61% noncardiac, 13% cardiac), and/or palpitations (10%), and/or dyspnea, presyncope, or syncope (overall 16%). CT was performed in 79% of cases due to the association of symptoms and instrumental findings (ECG 54% of cases, hs troponin 34%, echocardiogram 12%); in 21% only for clinical findings. Coronary CT excluded obstructive coronary artery disease in 95 out of 104 pts (91.3%) and was positive in 6/104 pts (5.8%), with coronary angiographic correspondence in 5 cases. In 3/104 (2.9%) the test resulted doubtful/positive (angiographic confirmation in a single case). Only 8.7% of pts underwent coronary angiography (those with positive or doubtful CT result). In all pts with chest pain only (21%) the Coronary CT was negative. Troponin positivity (34% of pts) was not strictly associated with the presence of coronary artery disease: in 94% of pts with positive hs troponin (average value 500 pg/mL) the CT scan did not show critical lesions. The average stay of pts with negative Coronary CT was 1.5 days. Conclusions Coronary CT can significantly reduce the use of coronary angiography and the length of stay in pts coming in ED with chest pain and/or doubtful signs/symptoms of ACS.

Understanding Perioperative Acute Myocardial Ischemia Following Coronary Artery Bypass Grafting.

Surgical revascularization and coronary artery bypass grafting are often pursued as treatment for obstructive coronary artery disease. Despite trends of increased referrals for complex percutaneous coronary intervention, surgical revascularization often remains the standard of care for patients with multivessel or complex coronary artery disease. Myocardial ischemia during the perioperative and postoperative periods during coronary artery bypass grafting remains a challenge. Nuanced consideration is necessary to decide on interventions that include conservative management and percutaneous or repeat surgical revascularization.

AI-Enhanced Electrocardiography Analysis as a Promising Tool for Predicting Obstructive Coronary Artery Disease in Patients with Stable Angina

Abstract Background The clinical feasibility of artificial intelligence (AI)-based electrocardiography (ECG) analysis for predicting obstructive coronary artery disease (CAD) has not been sufficiently validated in patients with stable angina, especially in large sample sizes. Methods A deep learning framework for quantitative ECG (QCG) analysis was trained and internally tested to derive risk scores (0–100) for obstructive CAD (QCGObstCAD) and extensive CAD (QCGExtCAD) using 50,756 ECG images from 21,866 patients who underwent coronary artery evaluation for chest pain (invasive coronary or computed tomography angiography). External validation was performed in 4,517 patients with stable angina who underwent coronary imaging to identify obstructive CAD. Results QCGObstCAD and QCGExtCAD scores were significantly increased in the presence of obstructive and extensive CAD (all p < 0.001), and with increasing degrees of stenosis and disease burden, respectively (all ptrend < 0.001). In internal and external tests, QCGObstCAD exhibited good predictive ability for obstructive CAD (area under the curve [AUC], 0.781 and 0.731, respectively) and severe obstructive CAD (AUC, 0.780 and 0.786, respectively), and QCGExtCAD exhibited good predictive ability for extensive CAD (AUC, 0.689 and 0.784). In the external test, QCGObstCAD and QCGExtCAD scores demonstrated independent and incremental predictive value for obstructive and extensive CAD, respectively, over that with conventional clinical risk factors. QCG scores demonstrated significant associations with lesion characteristics, such as the fractional flow reserve, coronary calcification score, and total plaque volume. Conclusions AI-based QCG analysis for predicting obstructive CAD in patients with stable angina, including those with severe stenosis and multivessel disease, is feasible.

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

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

Computed tomography myocardial perfusion imaging to detect myocardial ischemia in patients with anxiety and obstructive coronary heart disease post-exposure to mental stressors

This study aims to measure myocardial blood flow (MBF) using dynamic CT- myocardial perfusion imaging (CT-MPI) combined with mental stressors in patients with obstructive coronary artery disease (OCAD) and in patients with anxiety and no obstructive coronary artery disease (ANOCAD). A total of 30 patients with OCAD with 30 patients with ANOCAD were included in this analysis. Using the 17-segment model, the rest and stress phase MBF of major coronary arteries in participants were recorded respectively. Compared with ANOCAD patients, OCAD patients were more likely to have localized reduction of MBF (p < 0.05). For patients with ANOCAD, both global MBF and MBF of the main coronary arteries in the stress phase were lower than those in the rest phase (all p < 0.05), but there was no significant difference in MBF among the main coronary arteries in the rest or stress phase (p = 0.25, p = 0.15). For patients with OCAD, the MBF of the target area was lower than that of the non-target area in both the rest and stress phase, and the MBF of the target area in the stress phase was lower than that in the rest phase (all p < 0.05). However, there was no significant difference in MBF between the rest or stress phase in the non-target area (p = 0.73). Under mental stress, the decrease in MBF in ANOCAD patients was diffuse, while the decrease in MBF in OCAD patients was localized. Dynamic CT-MPI combined with mental stressors can be used to detect MBF changes in anxiety patients.

Microvascular dysfunction associated with reduced nailfold capillary density in patients with ischemia with no obstructive coronary artery disease

Abstract Funding Acknowledgements None. Introduction The impairment of microvascular function present in coronary microcirculation with chronic angina without obstructive coronary arteries. There are insufficient data in the literature regarding possible generalized microangiopathy in this population. Aim The aim of this study is to demonstrate whether patients with Angina with No Obstructive Coronary Artery Disease (ANOCA) compared to individuals without coronary microvascular dysfunction (CMD) are characterized by a different level of nailfold capillaroscopy abnormalities. Methods We examined 18 participants without CMD - non-CMD group [9 female, 50%, mean age: 54.4±8.1 years) and 26 patients with ANOCA - CMD group (22 female, 84,6%, mean age : 53.2±10.7 years). Functional coronary angiography was performed for the assessment of coronary microcirculation in all patients. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured in the left anterior descending coronary artery using a temperature/pressure sensor-tipped guidewire. In addition, the assessment of skin microcirculation was performed by capillaroscopy, a non-invasive technique to evaluate small vessels of the microcirculation in the nailfold, using stereomicroscope in all patients. Results In CMD group, mean CFR and IMR were 1.34±0.6 and 44.8±28, respectively. Out of the 26 MVD patients with abnormal CFR, 7 of them (27%) had a normal value of IMR, indicating functional microvascular dysfunction. On the other hand, 18 patients (69%) had an abnormal IMR, indicating structural microvascular dysfunction. Capillary density in patients with MVD was significantly decreased compared to the control group (7.6±2.2 vs 10.9±1.8 vessels/mm, p=0.04). The difference in capillary density between the two groups was statistically significant after adjustment for multiple comparisons (p&amp;lt;0.05). No significant difference was found in body mass index, renal function, medical history of dyslipidemia, diabetes mellitus and smoking status between the two groups (p&amp;lt;0.05). Conclusion Nailfold capillary density was reduced in ANOCA patients compared to control group. These data may provide new insights regarding possible generalized microangiopathy in CMD patients. These results suggest that there is an association between microcirculatory impairment at both heart and peripheral vascular bed level.

Direct vs. staged TAVI in the acute management of decompensated severe aortic stenosis

Abstract Funding Acknowledgements None. Background Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe aortic stenosis across a spectrum of surgical risks, potentially diminishing the role of balloon aortic valvuloplasty (BAV) as a transient solution or a bridge to definitive intervention. With advancements in TAVI technology and expertise, patients even in unstable conditions are increasingly receiving direct, definitive TAVI, avoiding the risks associated with staged, multiple procedures. Aims The study set out to assess whether immediate TAVI is safer and more effective than BAV followed by elective aortic valve replacement (AVR) in acute severe aortic stenosis. Methods Conducted as a retrospective analysis at a single center, this study encompassed a cohort of consecutive patients who received either urgent or emergency BAV, as bridge to AVR, or TAVI to manage decompensated severe aortic stenosis from May 2012 to May 2023. The primary outcomes were mortality rates at both 30 days and one year following the procedures. Results In this cohort, 258 cases of urgent or emergent percutaneous aortic valvuloplasty were evaluated. BAV was performed in 47 patients, whereas 211 received direct TAVI. A significantly higher proportion of the BAV group (36%) was treated due to cardiogenic shock as the primary indication, compared with just 11% in the TAVI group (p&amp;lt; 0.001). Demographic parameters and comorbid condition profiles were equivalently balanced across both groups. The median age was 81 years (interquartile range: 74-85, p= 0.40), and males constituted 56% of the patient population (p= 0.72). Most patients (65%) presented with left ventricular systolic dysfunction, and nearly half (49%) were diagnosed with obstructive coronary artery disease. The reduction in peak aortic valve gradient was significantly more pronounced in the TAVI group (-56±25 mmHg) compared to the BAV group (-27±19 mmHg, p&amp;lt; 0.001). TAVI recipients also had a higher incidence of VARC-2 minor and major bleeding events (26% versus. 6% for BAV, p&amp;lt;0.001), and a greater occurrence of advanced atrioventricular block necessitating temporary pacing (19% vs. 9% for BAV, p= 0.02). Thirty-day survival rates favored the TAVI group (93%) over BAV (86%). This trend persisted at the one-year mark, with survival rates of 84% for TAVI and 70% for BAV. Furthermore, the one-year hazard ratio for mortality among patients undergoing BAV was 2.01 (95% confidence interval: 1.34–3.01, p&amp;lt; 0.001). Conclusion The data from this retrospective analysis indicate that for patients with decompensated severe aortic stenosis, immediate TAVI may confer a mortality benefit over BAV followed by elective procedures. Despite a higher rate of procedural complications, the direct TAVI approach was associated with better survival rates at both 30 days and one year. These outcomes suggest a potential reevaluation of treatment strategies in acute settings may be warranted.

Determining risk factors for vascular and bleeding complications after TAVR using CT angiography

Abstract Funding Acknowledgements None. Introduction The use of pre-procedural computed tomography angiography (CTA) of the iliofemoral sector in the planning of transaortic valve replacement (TAVR) has demonstrated a reduction in the risk of vascular complications in patients undergoing TAVR. In this study, we aimed to characterise the clinical and radiological factors associated with bleeding and vascular complications after TAVR. Methods Patients undergoing transfemoral TAVR in a tertiary centre between 2017 and 2019 were included in this analysis. All patients underwent iliofemoral CTA before the procedure and classical CTA-derived data as well as iliofemoral calcium volume were collected. Clinical data and outcomes regarding bleeding events, as well as vascular complications according to Valve Academic Research Consortium 2 (VARC-2) criteria, were also collected. 207 patients were included in this analysis, of whom 53% were women. The median age was 82 years (IQR 76-86) and the median STS mortality risk score was 3.9% (IQR 2.59-5.99). In this population, vascular complications according to the VARC-2 criteria occurred in 33% of patients (19% with major complications). Patients with lower body mass index (BMI) were more likely to suffer vascular complications. Vascular access with fluoroscopy was associated with a higher prevalence of complications compared to ultrasound-guided vascular access (62% vs. 38%, p=0.037). When considering radiological criteria, smaller minimum luminal diameter and area of the common femoral and external iliac arteries were associated with a greater risk of vascular complications, as were increased sheath to external iliac artery ratios and luminal attenuation values (p&amp;lt;0.05 for all). Bleeding complications occurred in 20 patients, with a greater prevalence of bleeding events in female patients (77% vs. 23%, p=0.001). Patients with a lower BMI, a history of obstructive pulmonary disease or coronary artery disease, aortic insufficiency and fluoroscopic valvular access were more likely to have bleeding complications. Regarding radiological criteria, decreased maximal luminal diameter of the common femoral artery and smaller minimal luminal diameters and areas of the external iliac artery were associated with bleeding complications. Increased sheath-to-femoral artery ratios and luminal attenuation values were associated with an increased risk of vascular complications (p&amp;lt;0.05 for all). Conclusion Our study underscores the importance of pre-procedural CTA in TAVR planning and identifies separate risk factors for vascular and bleeding complications.

Novel Anatomical Variation of Left Coronary Artery Origin at the Sinotubular Junction Level With Coeval Hypoplastic Left Circumflex, Superdominant Right Coronary Artery, and Obstructive Coronary Artery Disease: A Case Report

Novel Anatomical Variation of Left Coronary Artery Origin at the Sinotubular Junction Level With Coeval Hypoplastic Left Circumflex, Superdominant Right Coronary Artery, and Obstructive Coronary Artery Disease: A Case Report

Acute Infarct of Myocardium without Coronary Arterial Obstructive Disease in a Patient with Colon Cancer: A Case Report

Acute Infarct of Myocardium without Coronary Arterial Obstructive Disease in a Patient with Colon Cancer: A Case Report

Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome.

This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences. The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.

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

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

Coronary calcifications as assessed on routine non-gated chest CT; a gatekeeper to tailor downstream additional imaging in patients with stable chest pain

Background and aimsCurrently applied methods for risk-assessment in coronary artery disease (CAD) often overestimate patients’ risk for obstructive CAD. To enhance risk estimation, assessment of coronary artery calcium (CAC) can be applied. In 10 % of patients presenting with stable chest pain a previous non-gated computed tomography (CT) has been performed, suitable for CAC-assessment. This study is the first to investigate the clinical utility of CAC-assessment on non-gated CT for risk-assessment of obstructive CAD in symptomatic patients. MethodsFor this analysis, all patients referred for coronary computed tomography angiography (CCTA), in whom a previous non-gated chest CT was performed were included. The extent of CAC was assessed on chest CT and ordinally scored. CAD was assessed on CCTA and obstructive CAD defined as stenosis of ≥70 %. Patients were stratified according to CAC-severity and percentages of patients with obstructive CAD were compared between the CAC groups. ResultsIn total, 170 patients of 32–88 years were included and 35 % were male. The percentage of obstructive CAD between the CAC groups differed significantly (p < 0.01). A calcium score of 0 ruled out obstructive CAD irrespective of sex, pre-test probability, type of complaints and number of risk factors with a 100 % certainty. Furthermore, a mild CAC score ruled out obstructive CAD in patients with low – intermediate PTP or non-anginal complaints with 100 % certainty. ConclusionWhen available, CAC on non-gated chest CT can accurately rule out obstructive CAD and can therefore function as a radiation-free and cost-free gatekeeper for additional imaging in patients presenting with stable chest pain.

Exploring the interplay between coronary microvascular dysfunction and mental health

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

C-37 | No difference in anginal symptoms and coronary microvascular disease in Angina vs Ischemia with no obstructive coronary artery disease (ANOCA/INOCA)

C-37 | No difference in anginal symptoms and coronary microvascular disease in Angina vs Ischemia with no obstructive coronary artery disease (ANOCA/INOCA)

Determining the Cause of Coronary Vasomotor Disorders in Patients With Ischemia and Nonobstructive Coronary Arteries: Design and Rationale of the DISCOVER INOCA Prospective, Multicenter Registry

BackgroundApproximately 30% to 50% of patients who are referred for diagnostic coronary angiography are found to have no obstructive coronary artery disease (CAD). Ischemia and nonobstructive coronary arteries (INOCA) is increasingly recognized and encompasses coronary microvascular dysfunction, vasospastic angina, symptomatic myocardial bridging, and other vasomotor disorders. However, the prevalence of these disorders and whether underlying atherosclerotic plaque burden and morphology affect the long-term outcomes of each physiologic phenotype is unknown. MethodsThe DISCOVER INOCA registry is ongoing at 8 centers in the United States and plans to enroll 500 patients with ischemic heart disease referred for angiography undergoing coronary function testing (CFT). All participants will complete patient-reported outcome measures and undergo protocol-guided angiography, acetylcholine provocation, coronary thermodilution, and intravascular imaging. Follow-up assessments occur at 30 days, 6 months, 1 year, and annually for 5 years. The primary short-term end point is the prevalence of INOCA phenotypes based on physiology and the degree of atherosclerosis based on intravascular ultrasound or optical coherence tomography (intravascular imaging). The primary long-term end point is the incidence of major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, hospitalization for cardiovascular causes, or coronary revascularization at a follow-up of 5 years. At the time of this publication, 100 participants have been enrolled. ConclusionsDISCOVER INOCA is the first prospective study of INOCA patients to integrate anatomic and physiologic measures of disease and correlate them with long-term outcomes. DISCOVER INOCA will report on the prevalence of INOCA phenotypes, the safety of comprehensive invasive CFT, and the impact of testing on diagnoses and medical therapy. Symptoms and cardiovascular adverse events at long-term follow-up will be determined in patients with no obstructive CAD undergoing angiography.