Obstructive Coronary Disease Research Articles

POTENTIAL FOR PATHOGENETIC CORRECTION OF PROTEASE-ANTIPROTEASE SYSTEM IMBALANCE IN PATIENTS WITH COMORBIDITY OF STABLE ANGINA PECTORIS OF THE II-III FUNCTIONAL CLASS AND STAGE II-III CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The aim of this study is to assess the clinical effectiveness of the therapy including exogenous L-arginine and statins under the comorbidity of stable angina pectoris of the II-III functional class and chronic obstructive pulmonary disease of the II-III stage.
 Materials and methods. The study included 50 patients with coronary heart disease and chronic obstructive pulmonary disease (mean age 57 years; male/female ratio 78/22%). In order to assess the clinical effectiveness of the therapy for combined cardiopulmonary pathology, the patients were randomized into 2 subgroups: subgroup 1 included 25 patients who took metabolitotropic medication under high-intensity statin therapy (the basic therapy included L-arginine and rosuvastatin as a hypolipidemic agent in a dose of 20 mg/day); subgroup 2 included 25 patients who received only basic therapy under moderately intensive statin therapy (daily doses of atorvastatin 20 mg, rosuvastatin 10 mg)). The groups were comparable in terms of gender distribution and demographic characteristics. Comparative analysis of smoking experience, initial smoking age and smoking history did not differ significantly between the groups. After 12±1 weeks, a control examination was carried out.
 Results. The analysis of the ratio of the MMP-9 activity level before and after the therapy showed that the level of MMP-9 expression decreased by 43.28% (p<0.05) in the 1st subgroup and by 13.18% in the 2nd subgroup until the end of the therapy. TIMP activity after 12 weeks of the treatment was +33.11% (p<0.05) and +11.27% for the 1st and 2nd subgroups respectively. The difference between subgroups 1 and 2 in the level of the CRP marker before and after the therapy was -45.65% (p<0.05) and -9.09%, respectively. 76% of people from the 1st subgroup reached the target level of healthy people before the completion of the therapy that is significantly higher than the similar indicator in the 2nd subgroup (32%) at χ2=8.05, p<0.01.
 Conclusions: The application of L-arginine alongside high-intensity statin therapy for patients presenting with stable angina pectoris of the II-III functional class and stage II-III chronic obstructive pulmonary disease (COPD) resulted in more notable positive changes in the modulation of protease-antiprotease status disorders. This was evidenced by a reduction in the heightened expression of MMP-9 and an increase in the level of TIMP during the course of treatment.

Simplified Approach to Predicting Obstructive Coronary Disease With Integration of Coronary Calcium: Development and External Validation.

The Diamond-Forrester model was used extensively to predict obstructive coronary artery disease (CAD) but overestimates probability in current populations. Coronary artery calcium (CAC) is a useful marker of CAD, which is not routinely integrated with other features. We derived simple likelihood tables, integrating CAC with age, sex, and cardiac chest pain to predict obstructive CAD. The training population included patients from 3 multinational sites (n=2055), with 2 sites for external testing (n=3321). We determined associations between age, sex, cardiac chest pain, and CAC with the presence of obstructive CAD, defined as any stenosis ≥50% on coronary computed tomography angiography. Prediction performance was assessed using area under the receiver-operating characteristic curves (AUCs) and compared with the CAD Consortium models with and without CAC, which require detailed calculations, and the updated Diamond-Forrester model. In external testing, the proposed likelihood tables had higher AUC (0.875 [95% CI, 0.862-0.889]) than the CAD Consortium clinical+CAC score (AUC, 0.868 [95% CI, 0.855-0.881]; P=0.030) and the updated Diamond-Forrester model (AUC, 0.679 [95% CI, 0.658-0.699]; P<0.001). The calibration for the likelihood tables was better than the CAD Consortium model (Brier score, 0.116 versus 0.121; P=0.005). We have developed and externally validated simple likelihood tables to integrate CAC with age, sex, and cardiac chest pain, demonstrating improved prediction performance compared with other risk models. Our tool affords physicians with the opportunity to rapidly and easily integrate a small number of important features to estimate a patient's likelihood of obstructive CAD as an aid to clinical management.

Peculiarities of Metabolism and Cardiac Electrical Activity in Patients with Chronic Obstructive Pulmonary Disease and Coronary Heart Disease in the Presence of Metabolically-Associated Liver Steatosis

While the development of specific steatohepatitis-associated cardiomyopathy (SHACMP) in the context of fatty liver disease has been documented, it remains unclear whether any cardiac changes occur during the initial stage of fatty liver disease, known as metabolic-associated liver steatosis (LS). Objective — to evaluate the characteristics of metabolism and electrical activity of the heart in patients with chronic obstructive pulmonary disease and chronic forms of coronary heart disease and concomitant liver steatosis. Materials and methods. 35 patients with chronic obstructive pulmonary disease, respiratory insufficiency stages I and II, coronary heart disease, atherosclerotic cardiosclerosis, and heart failure functional classes I and II, were examined. Their diagnosis and treatment were conducted in accordance with established protocols and international recommendations. Depending on the occurrence of LS, patients, matched for age, gender and lung function parameters, were divided into two groups: those suffering from it (n = 26) or not suffering from it (n = 9). Additionally, leptin level was determined, body mass index (BMI), leptin to BMI ratio, De Ritis ratio, hepatic steatosis index, glomerular filtration rate (according to MDRD) were calculated, and automatic ECG test was run. The results were processed statistically; the significance assumed at р &lt; 0.05. Results and discussion. It was established that LS was diagnosed in patients with a higher BMI and was accompanied by clear metabolic changes — higher values of leptin, leptin-to-BMI ratio, fasting blood glucose and total cholesterol levels. The criteria of LS are not only an increase in echogenicity and size of the liver, but also higher values of ALT, De Ritis ratio and hepatic steatosis index. According to the correlation analysis, the deterioration of the liver condition was accompanied by changes in the heart — tachycardia and a decrease in the angle of the QRS complex, which can be considered as signs of the development of SHACMP, characteri­zed by a prolongation of the PQ interval (р = 0.07) and a significant deviation of the angle of the QRS complex. Inflammation and endogenous intoxication are the leading mechanisms of progression of both LS and SHACMP. Conclusions. Patients with chronic obstructive pulmonary disease and chronic forms of coronary heart disease, alongside with liver steatosis, exhibit signs of steatohepatitis-associated cardiomyopathy caused by metabolic changes, inflammation and endogenous intoxication.

Smartphone for heart sound measurement in hospital: which factors affect heart sound quality?

Abstract Background Smartphone has recently been utilized to measure heart sounds in general population, but not in hospitalized patients. Purpose To explore the factors affecting the quality of heart sounds collected from the patients using smartphone in hospital. Methods An App was developed for Android smartphone to use the built-in microphone for measuring heart sounds on cardiac apex for 20 – 30 seconds in patients. Heart sounds were visually assessed for the presence of the first and second heart sounds and categorized into good, uncertain or bad quality. The factors affecting the percentage of good-quality heart sound recordings were analyzed, including the patients’ baseline characteristics, medical history and blood test. Results Among the 296 patients enrolled, 267 (90%) patients had a good-quality heart sound recording. Good-quality heart sounds were less recorded in emergency room (76%), cardiac care unit (82%), intensive care unit (87%) and neurosurgical intensive care unit (88%). Sex, body mass index, body position (supine vs. sitting), heart rate, medical history of atrial fibrillation, coronary artery disease, heart failure or chronic obstructive pulmonary disease, did not significantly affect heart sound quality (all P &amp;gt; 0.05). An advanced age was related to a lower percentage of good-quality heart sounds (&amp;lt; 60 vs. ≥ 60 years: 94% vs. 87%, P = 0.048). Heart sound quality significantly decreased with red blood cell count, hemoglobin level and hematocrit (all P &amp;lt; 0.001). Conclusions Smartphone can be used in hospital settings for measuring heart sounds in good quality, but factors such as department of hospitalization, age and blood indicators need to be considered.Central illustration

Abstract 11425: Association Between Obstructive Coronary Disease and Diabetic Retinopathy: A Cross-Sectional Study of Coronary Angiotomography and Digital Retinal Images

Introduction: Diabetic retinopathy (DR) and obstructive coronary artery disease (OCAD) are the main microvascular and macrovascular complications of diabetes mellitus (DM), respectively. The assessment of DR by means of spectral domain optical coherence tomography (SD-OCT) and angiography (OCTA) conferred a remarkable progress. Objective: investigate if SD-OCT and OCTA can detect DR that is associated with OCAD, determined by coronary angiotomography (CCTA) Hypothesis: DR, assessed by OCTA and OCT-SD, is associated with OCAD, assessed by CCTA Methods: In this single-center, cross-sectional, single-blind study, patients with DM who had undergone CCTA in the previous 3 years (independent indication) were eligible. They were divided according to the presence of OCAD in two groups and underwent SD-OCT and OCTA. The association between OCAD and DR was evaluated through uni and multivariate analysis and another analysis was performed to identify variables independently associated with the presence of DR. Results: We included 171 patients, 87 OCAD and 84 without OCAD. Age (66 vs 64 y,p=0.28), DM duration (12 vs 13 y, p=0.5) and HbA1c (7.5% vs 6,9%,p=0.08) did not differ. Patients with OCAD were more frequently men (74% vs 38%, P&lt;0.01), had a higher prevalence of insulin use (52% vs 38%, p&lt;0.01) and 64% had already undergone some type of revascularization. SD-OCT and OCTA revealed a higher prevalence of DR (48% vs 22%,p=0.01). The main findings were: microaneurysms (25% vs 13%,p=0.04), intraretinal cysts (22% vs 8%, p=0.01) and areas of reduced capillary density in the superficial retinal plexus (46% vs 20%,p&lt;0.01).We also found lower mean vascular density (MVD) (15.7 vs 16.5, p=0.049) and lower circularity of the foveal avascular zone(FAZ) (0.64±0.1 vs 0.69±0.1, p= 0.04).There were significant and negative correlations between Duke coronary score and MVD (r=-0.189; p=0.03) and circularity of the FAZ (r=-0,206; p= 0.02). In an adjusted model, presence of OCAD increased the chance of DR (OR 4.05 [1.4 -11.6], p&lt;0.01). OCAD, DM duration and insulin use were independently associated to DR. Conclusions: OCAD was associated with a greater chance of presenting DR. OCAD, longer DM duration and insulin use were independently associated to the presence of DR.

Abstract 16882: Comparison of Regadenoson and Adenosine in First Pass Quantitative Perfusion Cardiovascular Magnetic Resonance in Subjects With Suspected Coronary Microvascular Disease

Introduction: Regadenoson and adenosine are commonly used vasodilators in myocardial perfusion imaging for detection of coronary artery disease. There are no comparative studies of the vasodilator properties of two agents in subjects with suspected coronary microvascular disease (CMD). We aimed to compare the potency of two vasodilators by quantifying myocardial perfusion in subjects with suspected CMD. Methods: Subjects with angina and more than two risk factors for CMD (females, or males with diabetes, metabolic syndrome, HTN, hyperlipidemia, and smoking) who had no obstructive coronary disease by invasive coronary angiography or CT angiography were enrolled for first-pass perfusion images using dual sequence. Stress perfusion images were acquired on 1.5T or 3.0T GE Healthcare during adenosine infusion or regadenoson. Rest perfusion images were acquired either 10 minutes following the cessation of adenosine or reversal with aminophylline. Myocardial blood flow (MBF) in ml/min/g and myocardial perfusion reserve (MPR) were quantified using Fermi deconvolution. Results: A total of thirty-two subjects were recruited with a mean age of 62±11 years, 53% men, history of hypertension in 91%, diabetes in 72%, hyperlipidemia in 75%, and tobacco use in 16%. Twenty (63%) of subjects underwent adenosine, while twelve (38%) of subjects underwent regadenoson. Regadenoson produced similar stress MBF compared to adenosine (2.30 ± 0.54 vs. 2.35 ± 0.61 ml/min/g, p = 0.66). Rest MBF was higher in the regadenoson group compared to adenosine group (1.35±0.35 vs. 1.12±0.26 ml/min/g, p=0.07). MPR was non-significantly lower in regadenoson compared to adenosine 1.72±0.70 vs.1.89±0.53 ml/g/min, p=0.13). Conclusions: Based on fully quantitative perfusion using CMR, regadenoson and adenosine have similar vasodilator efficacy in subjects with risk factors for CMD. However, resting blood flows are slightly higher when regadenoson is used which may impact quantification of MPR.

Abstract 13882: Myocardial Hypoperfusion in Severe Aortic Stenosis is Reversed by Aortic Valve Replacement

Background: Myocardial hypoperfusion in severe aortic stenosis (AS) without obstructive coronary disease may be secondary to hemodynamic influences (and therefore readily reversible by aortic valve replacement[AVR]) or structural alterations in the left ventricle (LV) such as increased mass and reduction in capillary density. Aim: To evaluate the early effect of AVR on myocardial blood flow (MBF) in patients with severe symptomatic AS without flow-limiting coronary artery disease. Methods: Prospective case-control study of severe symptomatic AS without obstructive coronary disease referred for surgical or transcatheter AVR and propensity matched to a control cohort with unobstructed coronary arteries. Patients underwent adenosine stress cardiovascular magnetic resonance at baseline and 8-weeks (median) post-operatively. Histology from 9 myocardial septal biopsies taken at AVR were compared against necropsy controls (n=5). Results: 52 patients were included; 26 with severe AS (median [IQR] age 71[66-75], 73% male) and 26 age, sex and co-morbidity matched controls. In AS, peak velocity(Vmax) was 4.3m/s[4.1-4.5] and AVA 0.8cm 2 [0.6-0.9]. AS patients had greater LV mass and late gadolinium enhancement. AS patients had lower stress MBF than controls (1.63ml/g/min[1.38-2.08] vs 2.13[1.76-2.52], p=0.003) which increased to 1.97ml/g/min after AVR (p=0.7 post-AVR vs. Controls). This was driven by a 40% increase in subendocardial MBF (1.26ml/g/min[1.18-1.78] to 1.77[1.62-2.32]). Capillary density was reduced almost threefold in AS (495/mm 2 [407-686] vs 1376[1208-1579], p&lt;0.001). Conclusions: Severe AS results in subendocardial hypoperfusion which is rapidly improved after AVR. There is a threefold reduction in capillary density, however factors related to elevated afterload (which is reduced by AVR) are the most influential.

Abstract 17328: A Case of Reversible Severe Systolic Cardiomyopathy; Thinking Outside the Box

Introduction: Non-ischemic systolic cardiomyopathy is associated with significant morbidity and mortality. Prompt evaluation and timely removal of the potential insult may lead to reverse remodeling and recovery of the left ventricular (LV) systolic function. Case: A 39-year-old female with BMI 40 presented with dyspnea and bilateral lower extremity edema. Vital signs significant for mild tachycardia and hypertension. ECG showed sinus tachycardia. Physical exam revealed bibasilar crackles and 3+ pitting edema of the lower extremities. Laboratory significant for NTpro BNP 563 pg/dL and TSH &lt;0.005 IU/mL with a free T4 of 2.73 ng/dL. Chest x-ray showed pulmonary vascular congestion. Echocardiogram showed severely reduced LV systolic function with ejection fraction (EF) of 27%, global LV hypokinesis and diastolic LV diameter of 6.85 cm. No significant atrial or ventricular arrhythmias noted on Telemetry. A CT angiography of the coronary arteries showed no evidence of calcification or obstructive coronary disease. Additional labs revealed severely elevated TSH receptor antibody and thyroid stimulating immunoglobulin. Diffuse thyroid enlargement noted on ultrasound. Patient was diagnosed with Grave’s disease (GD) with Burch-Wartofsky score of 30 indicating an impending thyroid storm. She was treated with Metoprolol and Methimazole. She underwent intravenous diuresis and was started on guideline-directed medical therapy for systolic cardiomyopathy. In follow-up after 6 months, her TSH had normalized. On repeat imaging, her LVEF improved to &gt; 50% with diastolic LV diameter of 5.6 cm. Discussion: This patient was diagnosed with non-ischemic dilated systolic cardiomyopathy due to severe hyperthyroidism from GD. Thyrotoxicosis-induced systolic cardiomyopathy occurs in about 1% of patients with GD and is associated with increased morbidity and mortality. Excess thyroid hormones in thyrotoxicosis can affect multiple regulatory and structural genes of cardiac myocytes resulting in abnormal intracellular calcium regulation and impaired LV systolic and diastolic function. Our experience is consistent with literature demonstrating the importance of timely diagnosis and treatment of this reversible cause of systolic cardiomyopathy.

Abstract 15756: To Close or Not to Close: A Case of Multisystem Immune Checkpoint Inhibitor Toxicity and PFO

Introduction: Recent emergence of immune checkpoint inhibitors (ICIs) in oncologic treatments has led to increasing research on their side effect profile. Myocarditis occurs in roughly 0.04-1.14% of patients treated with ICIs and is associated with up to 50% mortality. We present a case of multisystem ICI toxicity requiring comprehensive evaluation to ultimately reveal a PFO shunt as the cause of persistent hypoxemia. Case: A 67-year-old male with Stage IIIC cutaneous melanoma presented with non-radiating pleuritic chest pain, diplopia, dyspnea and syncope. ECG showed high grade AV block and right bundle branch block. Labs showed elevated troponin, creatinine kinase and inflammatory markers. An echocardiogram showed edematous myocardium, a small pericardial effusion, and akinetic apical/inferior septal segments. Despite diuresis, 5g of methylprednisolone, IV immunoglobulin plus mycophenolate and resolution of AV block, the patient had hypoxemia on 100% FiO2. He underwent a CTA (which ruled out PE and ICI-induced pneumonitis) and fluoroscopic sniff test (revealing bilateral moderate diaphragm paresis). A recent cardiac catheterization on prior admission showed no obstructive coronary disease. Arterial blood gas showed pO2 120 mmHg without hypercapnia on 100% FiO2. We suspected a shunt as the underlying cause and obtained a bubble study disclosing a large (&gt; 25 bubble) PFO with right-to-left shunt. Results: Given the timing of symptoms, it was determined that pembrolizumab administration caused myocarditis and myositis with diaphragmatic paresis. In patients with pulmonary disease or diaphragmatic paresis, elevated intrathoracic and pulmonary artery pressures have been a proposed mechanism of acute worsening of right-to-left shunt resulting in hypoxemia. The patient underwent right heart catheterization and PFO closure using Gore Cardioform septal occluder with resolution of hypoxemia. A repeat echocardiogram obtained 1 month later was normal. Conclusion: All concerning clinical symptoms in the setting of ICI use require a thorough evaluation. In this case, persistent hypoxemia despite treatment for ICI toxicity unmasked a large PFO requiring closure. A multisystem approach should be used to assess suspected ICI myocarditis.

Prognostic value of coronary microvascular dysfunction in patients with aortic stenosis and nonobstructed coronary arteries.

Patients with aortic valve stenosis have been postulated to have coronary microvascular dysfunction (CMD) contributing to the clinical symptoms and adverse outcomes. The coronary angiography (CAG)-derived index of microcirculatory resistance (caIMR) is proposed as a novel, less invasive and pressure-wire-free index to assess CMD. This study aimed to quantify CMD assessed by caIMR and investigate its prognostic impact in patients with aortic valve stenosis. This study included 77 moderate or severe aortic valve stenosis patients with no obstructive coronary disease (defined as having no stenosis more than 50% in diameter) who underwent caIMR measurement. CMD was defined by caIMR at least 25. Major adverse cardiovascular events (MACE) were the clinical outcomes during the median 40 months of follow-up. The incidence of CMD was 47.7%. Seventeen MACE occurred during the follow-up duration. CMD was associated with an increased risk of MACE (log-rank P < 0.001) and an independent predictor of clinical outcomes [hazard ratio 5.467, 95% confidence interval (CI) 1.393-21.458; P = 0.015]. The receiver-operating characteristic (ROC) curve analysis demonstrated that caIMR could provide a significant predictive value for MACE in aortic valve stenosis patients (AUC 0.785, 95% CI 0.609-0.961, P < 0.001). In addition, the risk of MACE was higher in CMD patients with severe aortic valve stenosis (log-rank P < 0.001) and no aortic valve replacement (log-rank P = 0.003) than in other groups. Aortic valve stenosis patients demonstrated markedly impaired caIMR. CMD assessed by caIMR increases the risk of MACE and is an independent predictor of adverse outcomes in aortic valve stenosis patients. This finding suggests that using caIMR in the clinical assessment may help identify high-risk groups and stimulate earlier intervention.

Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA).

Identifying ischemic heart disease (IHD) in women based on symptoms is challenging. Women are more likely to endorse non-cardiac symptoms. More than 50% of women with suspected ischemia have no obstructive coronary disease (and thus, INOCA) and impaired outcomes during follow-up. We aimed to identify symptoms having predictive capacity for INOCA in women with clinical evidence of coronary ischemia. We included 916 women from the original WISE cohort (NCT00000554) who had coronary angiography performed for suspected ischemia and completed a 65-item WISE symptom questionnaire. Sixty-two percent (n = 567) had suspected INOCA. Logistic regression models using a best subsets approach were examined to identify the best predictive model for INOCA based on Score χ2 and AICc. A 10-variable, best-fit model accurately predicted INOCA (AUC 0.72, 95% CI 0.68, 0.75). The model indicated that age ≤ 55 years, left side chest pain, chest discomfort, neck pain, and palpitations had independent, positive relationship (OR > 1) to INOCA (p < 0.001 to 0.008). An inverse relationship (OR < 1) was observed for impending doom, and pain in the jaw, left or bilateral arm, and right hand, interpreted as INOCA associated with the absence of these symptoms (p ≤ 0.001 to 0.023). Our best-fit model accurately predicted INOCA based on age and symptom presentation ~72% of the time. While the heterogeneity of symptom presentation limits the utility of this unvalidated 10-variable model, it has promise for consideration of symptom inclusion in future INOCA prediction risk modeling for women with evidence of symptomatic ischemia.

The prognostic effect of lymphocyte, monocyte, and platelet counts, mean platelet volume, neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet-to-lymphocyte ratio on different stages of pressure ulcers

Background/Aim: Pressure ulcers (PU) pose a significant problem for patients in intensive care. Various factors contribute to the development of pressure sores. The primary focus of treatment is to implement measures that prevent factors such as nutrition and positioning, which can lead to PUs. Therefore, it is crucial to identify parameters that can serve as warning signals for the formation and progression of PU. This study investigates the potential use of hematological parameters as warning signals. Methods: Demographic data, co-morbidities, PU stages, and laboratory parameters of 158 patients hospitalized in the intensive care unit who developed pressure ulcers during their hospital stay were recorded and analyzed. Results: Among the 158 cases included in the study, PUs were more prevalent in patients of advanced age, those with pneumonia, chronic obstructive pulmonary disease (COPD), coronary diseases, and neurodegenerative diseases. Mean platelet volume (MPV) was significantly higher in PU stages 2 and 3 compared to stage 1. However, age, lymphocyte count, monocyte count, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) did not exhibit significant differences among the stages of PU (P&lt;0.05). Conclusion: Advanced age, pneumonia, COPD, coronary diseases, and neurodegenerative diseases are identified as risk factors for PU. Although MPV was initially considered a potential, stimulating parameter, the evidence was insufficient. Further research is required to explore this issue. The impact of parameters other than MPV did not show any excitatory signal in this study.

Influence of Age on the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Obstructive Coronary Disease in Symptomatic Patients

Concerns have been raised about the added diagnostic value of coronary artery calcium score (CACS) of 0 for reducing the likelihood of obstructive coronary artery disease (CAD) in younger patients. Our study aimed to assess the influence of age on the value of CAC=0 in symptomatic patients who underwent coronary computed tomography angiography (CCTA). We conducted a 2-center retrospective study assessing symptomatic patients with suspected CAD who underwent CACS and CCTA. Pretest probability was calculated according to the Juarez-Orozco method and obstructive CAD was defined as ≥50% luminal stenosis. The diagnostic likelihood ratios and negative predictive values were used to assess the diagnostic value of a CACS of 0 to rule out obstructive CAD. A total of 2,043 patients (mean age 60 ± 11years, 60% women, 48.5% CACS of 0) were analyzed. The pretest probability of obstructive CAD increased with age, whereas the proportion of patients with a CACS of 0 decreased with age. The added diagnostic value of a CACS of 0 was lower in younger patients (negative likelihood ratios ranging from 0.36 for <50years to 0.10 for ≥70years). However, the prevalence of obstructive CAD in patients with a CACS of 0 was low in all age groups. In a cohort of symptomatic patients who underwent CCTA for suspected CAD, the added diagnostic value of a CACS of 0 decreases significantly at younger ages. However, it is offset by their lower pretest probabilities, yielding high negative predictive values independently of age.

Particularities of coronary physiology in patients with atrial fibrillation: insights from combined pressure and flow indices measurements.

Symptoms suggestive of myocardial ischemia are frequently encountered in patients with atrial fibrillation (AF) even in the absence of obstructive coronary artery disease. Nevertheless, an in-depth characterisation of coronary physiology in patients with AF is currently lacking. We aim to provide an insight into the characteristics of coronary physiology in AF, by performing simultaneous invasive measurements of coronary flow- and pressure- indices in a real-life population of patients with AF and indication of coronary angiography. This is a prospective open label study including patients with permanent or persistent AF and indication of coronary angiography showing intermediate coronary stenosis requiring routine physiological assessment (n = 18 vessels from 14 patients). We measured FFR (fractional flow reserve), and Doppler-derived coronary flow indices, including CFR (coronary flow reserve) and HMR (hyperaemic microvascular resistance). From the analysed vessels, 18/18 vessels (100%) presented a pathological CFR (<2.5), indicative of coronary microvascular dysfunction (CMD), and 3/18 (17%) demonstrated obstructive epicardial coronary disease (FFR ≤ 0.8). A large proportion of vessels (15/18; 83%) showed discordant FFR/CFR with preserved FFR and low CFR. 47% of the coronary arteries in patients with AF and non-obstructive epicardial coronary disease presented structural CMD (HMR ≥ 2.5 mmHg/cm/s), and were associated with high BMR and an impaired response to adenosine. Conversely, vessels from patients with AF and non-obstructive epicardial coronary disease with functional CMD (HMR < 2.5 mmHg/cm/s) showed higher bAPV. The permanent AF subpopulation presented increased values of HMR and BMR compared to persistent AF, while structural CMD was more often associated with persistent symptoms at 3 months, taking into account the limited sample size of our study. Our findings highlight a systematically impaired CFR in patients with AF even in the absence of obstructive epicardial coronary disease, indicative of CMD. In addition, patients with AF presented more prevalent structural CMD (HMR ≥ 2.5 mmHg/cm/s), characterized by reduced hyperaemic responses to adenosine, possibly interfering with the FFR assessment.

Takotsubo cardiomyopathy prevalence and associated factors in patients presenting with a clinical picture of acute myocardial infarction in Palestine

BackgroundTakotsubo cardiomyopathy (TC) is a transient cardiac syndrome that manifests with symptoms resembling acute myocardial infarction (MI). It is characterized by temporary wall-motion abnormalities predominantly affecting the apical and mid-portions of the left ventricle, despite the absence of significant obstructive coronary disease. TC poses diagnostic challenges due to its resemblance to ST-segment elevation myocardial infarction.Our study aimed to determine the prevalence of TC and identify the factors associated with its occurrence in patients presenting with acute MI in Palestine.ResultsA retrospective analysis was conducted on a cohort of patients diagnosed with TC at Al-Makassed hospital. Women accounted for 90.7% of TC cases (95% CI 88.2–93.2%). The mean age of affected individuals ranged from 62 to 76 years. The most common presenting symptoms were chest pain (83.4%, 95% CI 80.0–86.7%) and dyspnea (20.4%, 95% CI 16.3–24.5%), often following an emotionally or physically stressful event. Electrocardiography (ECG) on admission indicated ST-segment elevations in 71.1% of cases (95% CI 67.2–75.1%), accompanied by mild elevations of Troponins in 85.0% of cases (95% CI 80.8–89.1%). Despite the initial severity, left ventricular ejection fraction (LVEF) improved from 20–49.9 to 59–76% within a mean time of 7–37 days. The in-hospital mortality rate was 1.7% (95% CI 0.5–2.8%), with complete recovery observed in 95.9% of cases (95% CI 93.8–98.1%) and rare recurrence. The underlying etiology is believed to involve exaggerated sympathetic stimulation.ConclusionsTC should be considered as a significant differential diagnosis in acute coronary syndrome (ACS) cases, particularly among postmenopausal women with a preceding stressful event. Our study provides insights into the prevalence and characteristics of TC in the Palestinian population. While stress has been recognized as a potential trigger for TC, further research is needed to explore if there are specific associations between occupation and other unique stressors in the Palestinian context and the prevalence of TC. The study’s results can raise awareness among healthcare professionals in Palestine about the prevalence and characteristics of TC in their patient population.

Retinal microvascular changes in patients with coronary artery disease and apnea.

Optical coherence tomography angiography (OCT-A) allowed visualization of capillary level of retina; however, the relationship between coronary vascular status and retinal microvascular changes in patients with apnea is not known well. Our aim was to assess the retinal OCT-A parameters in patients with ischemia and angiographically proven microvascular disease and compare them with obstructive coronary disease in patients with apnea. Our observational study included 185 eyes of 185 patients, 123 eyes of patients with apnea (72 eyes from mild OSAS, 51 eyes from moderate to severe OSAS) and 62 eyes from healthy controls. Radial scans of the macula and OCT-A scans of the central macula (superficial (SCP) and deep (DCP) capillary plexuses) were performed on all participants. All participants had documented sleep apnea disorder within 2 years prior to coronary angiography. Patients were grouped by severity of apnea and coronary atherosclerosis (50 % stenosis cut-off value for obstructive coronary artery disease). Patients presented with myocardial ischemia and without coronary artery occlusion (<50 % diameter reduction or FFR > 0.80) constitute the microvascular coronary artery (INOCA) group. Compared to healthy controls, patients with apnea showed deterioration in vascular density in all regions of the retina, regardless of obstructive or microvascular coronary artery disease on the ischemia background. This study has provided important observations of a high prevalence of INOCA in patients with OSAS and the presence of OSAS was a significant independent predictor of functional coronary artery disease. The relative decreases in vascular densities were more pronounced in the DCP layer according to SCP layer of macula. Only FAZ area values were significantly different according to the severity of OSAS (0.27 (0.11-0.62) and 0.23 (0.07-0.50) (p = 0.012)). In patients with apnea, OCT-A can be used as a noninvasive tool to define coronary artery involvement, with similar retinal microvascular changes both in obstructive and microvascular coronary artery group. In patients with OSAS, we observed a high prevalence of microvascular coronary disease, supporting pathophysiological role of OSAS in ischemia of this group of patients.

Utilisation of primary healthcare services by Sjögren's syndrome patients in the Community of Madrid and associated factors: a population-based cross-sectional study.

To describe the utilisation of primary health care (PHC) services and factors associated with its use by patients diagnosed with Sjögren's syndrome (SS). Population-based cross-sectional cohort of SS patients in Madrid, Spain (SIERMA). Sociodemographic, diagnostic, clinical and PHC service utilisation variables were studied by bivariate analyses and regression models. A total of 4,778 SS patients were included, 65.2% classified as primary SS (pSS), while 34.8% associated with another autoimmune disease (associated SS). Mean age was 64.3 years, and 92.8% of the patients were women. A total of 87.5% used PHC services, with a mean of 19.8 consultations/year. The general practitioner was the most visited health professional, with a mean of 10.9 consultations/year, followed by the nurse, with a mean of 5.7. Characteristics associated with a greater use of PHC services in SS patients were associated SS, higher adjusted morbidity groups (AMG) risk level and older age. Additional factors included symptoms such as dry mouth, fatigue, dry vagina and joint and muscle pain; comorbidities such as atrial fibrillation, diabetes, hypertension, solid malignant neoplasms, coronary heart disease and chronic obstructive pulmonary disease; and treatments such as sterile saline solution, corticosteroids, opioids and biologic disease-modifying anti-rheumatic drugs. Most SS patients used PHC services during the study period, and the mean number of consultations was remarkably high. Utilisation was mainly associated with AMG risk level, ageing, glandular and extra-glandular symptoms, substantial comorbidities and various treatments. An optimised design of PHC policies will facilitate early diagnosis, improved management and better quality of life for SS patients.

Quantification of myocardial blood flow using stress cardiac magnetic resonance for the detection of coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): GE Healthcare. Background Myocardial blood flow (MBF) analysis using stress cardiac magnetic resonance (CMR) has been shown to detect obstructive coronary artery disease (CAD); however, evaluation of its diagnostic performance has primarily been limited to single-center studies. AQUA-MBF (Assessment of QUAntitative MBF using stress CMR) is an international study with the goal of assessing the diagnostic performance of stress MBF for the detection of CAD. In this study, we aim to determine how stress MBF assessment compared against visual analysis (VA) of stress CMR images for the detection of CAD. Methods. 144 individuals (89 (62%) men, age 62±16 years, 97 (68%) hypertension, 54 (38%) diabetes, 92 (64%) hyperlipidemia) from 9 centers who underwent dual sequence stress CMR (1.5T or 3.0T GE Healthcare) and also had either a coronary computed tomography angiography (CTA, n=31), invasive coronary angiogram (ICA, n=95), or low pre-test probability for CAD (n=18) were included. CAD was defined as the presence of: (1) a stenosis ≥50% in the left main coronary artery or ≥70% in the 1 major vessel based on ICA or CTA or (2) an invasive fractional flow reserve (FFR) ≤ 0.8. Absence of obstructive coronary disease (NOCAD) was defined as a no history of myocardial infarction and stenosis &amp;lt;50% by ICA or CTA, 50–70% stenosis with FFR&amp;gt;0.8, or a young individual with no cardiac risk factors. Myocardial perfusion imaging was performed during first pass perfusion of a gadolinium-based contrast agent following the administration of adenosine or regadenoson with a low-resolution image acquired to assess the arterial input function and 2–3 short axis slices acquired to assess myocardial perfusion. VA was performed by 2 experienced cardiologists who assigned a grade of 1–5 based on the probability a study was abnormal. Stress MBF values were determined for each of the 16 myocardial segments using Fermi deconvolution (CircleCVI). The global stress MBF was calculated as the average value of two segments with the lowest values from each of the three coronary artery territories. Unpaired t-test was used to compare stress MBF values between CAD vs NOCAD. Receiver-operating characteristics curves were used to determine diagnostic performance. Results. 60 patients had CAD (20: 1-vessel, 26: 2-vessel, and 14: 3-vessel) (Figure 1A) while 84 had NOCAD (Figure 1B). The global stress MBF in CAD was lower than in NOCAD (1.63±0.52ml/g/min vs 2.41±0.68ml/g/min, p&amp;lt;0.0001) (Figure 2A). Stress MBF had a higher AUC than VA (reader 1 – 0.83 vs 0.73, p = 0.07: reader 2–0.83 vs 0.71, p = 0.02). The optimal stress MBF cut-off value for detecting CAD was 2.05ml/g/min (Figure 2B). Conclusions. In this multicenter study, we show that global stress MBF reported as a single value can identify patients with CAD at least as accurately as VA performed by physicians experienced in the interpretation of stress CMR images.

Revascularization Strategies in Patients with Coronary Artery Disease and Chronic Obstructive Lung Disease.

This paper assesses recent literature on the impact of chronic obstructive pulmonary disease (COPD) in patients with coronary artery disease (CAD) undergoing revascularization. Specifically, to determine if there is an optimal revascularization strategy for this patient population, and if there are other modalities to assess the risks. There are limited new data in the last year addressing this clinical question. Recently there have been a series of studies which reinforced that COPD is a key independent risk factor for adverse outcomes after revascularization. There is no optimal revascularization strategy; however, there was a nonsignificant signal of potential benefit with percutaneous coronary intervention (PCI) with short-term outcomes in the SYNTAXES trial. Currently, pulmonary function tests (PFT) are limited in clarifying risk assessments prior to revascularization, and there are investigations into the use of biomarkers to provide further insight into this increased risk of adverse outcomes in patients with COPD. COPD is a key risk factor for poor outcomes in patients requiring revascularization. More investigations are needed to determine the optimum revascularization strategy.

Favourable Outcomes of Patients With Acute Myocarditis Diagnosed by Cardiac Magnetic Resonance Imaging: A Retrospective Study of 196 Patients

Acute myocarditis (AM) is increasingly being recognised in the era of sensitive diagnostic techniques, and cardiac magnetic resonance imaging (cMRI) is central to the diagnosis of this condition. This study aimed to measure the outcome of patients with AM detected by cMRI. All cMRI for Auckland City Hospital patients (scanned at the Auckland University Centre for Advanced MRI) between June 2012 and June 2022 were retrospectively reviewed. Patients with a diagnosis of AM based on cMRI criteria and clinical assessment were included. A total of 196 patients were included. The mean age was 42 (SD, 18) years and 155 (79%) were male. Chest pain was the most common symptom (80%), followed by fevers or viral prodrome (48%), and dyspnoea (27%). One patient presented with cardiac arrest. The mean peak C-reactive protein was 58 mg/L and high-sensitivity troponin T 709 ng/L. Electrocardiographic abnormalities included ST-segment elevation (32%) and bundle branch block (9%). Coronary angiography was performed in 54% and none had obstructive coronary disease. In-hospital arrhythmia occurred in 12%. Five patients required admission to the intensive care unit (ICU). Mean cMRI left ventricular ejection fraction (LVEF) was 56% and nine patients (5%) had LVEF <40%. Median follow-up duration was 5.7 years and recurrent AM occurred in 15 patients (8%). Three patients died from malignancy and there were no cases of cardiovascular death. Patients with AM diagnosed by cMRI had favourable short- and medium-term outcomes. Severe left ventricular dysfunction and ICU admission were rare. cMRI should be considered in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA).