Obstructive Coronary Lesions Research Articles

Guidelines of the European Society of Cardiology on chronic coronary syndrome from 2024

The 2024 European Society of Cardiology (ESC) guidelines on chronic coronary syndrome comprehensively summarize the symptoms, diagnostics and treatment of coronary artery disease, excluding acute coronary syndromes. The processing always begins with an estimation of the clinical probability, which should include not only the symptom profile but also the number of cardiovascular risk factors and is further modified by any conspicuous findings in electrocardiography (ECG), exercise testing, or echocardiography. For further diagnostics, coronary angiography via computed tomography is the first-line approach if the probability lies between 5% and 50%. For probabilities of 50-85% procedures for imaging-based ischemia detection are indicated, while for even higher probabilities immediate invasive diagnostics are given priority. The treatment includes intensive risk modification, medicinal anti-anginal treatment and finally revascularization by coronary intervention or bypass surgery. In the absence of high-risk constellations a medication-based approach should be initially preferred, with revascularization indicated if symptoms persist. The new guidelines also extensively address angina and ischemia without obstructive coronary lesions. In this context, intensive risk modification and initial medication treatment are again recommended.

Myocardial Ischemic Syndrome: A Necessary Nomenclature Update of Coronary Artery Disease

The switch from the name coronary artery disease (CAD) to myocardial ischemic syndrome (MIS) signifies a more thorough comprehension of the mechanism and clinical presentations of heart disease. CAD largely addresses obstructive coronary lesions, whereas MIS includes a wider range of disorders leading to insufficient blood supply to the heart muscle, including microvascular dysfunction and coronary artery spasm. The revised terminology highlights the varied causes and manifestations of ischemic heart disease beyond conventional stenotic lesions, facilitating more precise diagnosis and tailored treatment approaches based on specific patient attributes. By acknowledging the dynamic characteristics of myocardial ischemia, healthcare providers can more effectively manage the intricate interactions of risk variables and customize interventions to enhance patient outcomes.

Abstract 4136274: A Case of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) Complicated by a Ventricular Septal Defect (VSD)

Case: A 69-year-old woman with a history of hypertension and tobacco use disorder presented with acute chest pain. The patient was found to have classic anterior ST elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) with high-sensitivity troponin of 12,772 ng/L and was taken emergently to the catheterization laboratory. Coronary angiography showed tortuous coronary vessels though without evidence of obstructive coronary artery disease, plaque rupture, ulceration, dissection, or vasospasm. Transthoracic echocardiogram showed an apical ventricular septal defect (VSD) with normal left ventricular systolic function of 60%. Cardiac computed tomography (CT), confirmed a discrete apical VSD that was 7.93 mm in diameter and multiple small VSDs distally in the septum. Right heart catheterization revealed severe left-to-right shunting with a ratio of pulmonary blood flow to systemic blood flow (Qp:Qs) of 2.8. Early surgical repair of the apical VSD was pursued despite known high operative risk given the hemodynamic significance of the shunt. The patient developed ongoing hemodynamic instability from cardiogenic shock with inability to ween from intra-aortic balloon pump (IABP). Unfortunately, because of the location of the residual VSDs and elevated panel-reactive antibody testing of 98%, the patient was deemed to not be a candidate for percutaneous closure or heart transplantation, respectively. Discussion: An acquired ventricular septal defect (VSD) is a rare and catastrophic complication of myocardial infarction, typically with a culprit obstructive coronary artery lesion identified on coronary angiography. Acquired VSDs in myocardial infarction with nonobstructive coronary arteries (MINOCA) is an even more rare phenomenon. Possible causes include low flow, inflammation, intimal disruption, or vasospasm of coronary arteries. Our case highlights that MINOCA can present with life-threatening complications similar to obstructive STEMI. The timing of intervention and treatment approach of acquired VSDs remains an area of debate. The life-threatening effects of VSDs make it critical to manage in a multidisciplinary manner involving advanced imagers, interventional cardiologists, cardiothoracic surgeons, and heart failure specialists. This case emphasizes the importance of maintaining a high index of suspicion for abnormal coronary anatomy, even in patients with MINOCA, and prompt interdisciplinary decision making to reduce mortality.

The correlation between angio-IMR and thermodilution-based IMR in patients with ischemia and non obstructive coronary arteries

Abstract Background The diagnostic dilemma of angina with no obstructive coronary lesions (INOCA) poses remarkable challenges in clinical practice, and presents as a significant disease burden affecting up to 4 million people annually. Additionally, standard diagnostic tests such as angiography, do not reveal microvascular dysfunction despite clinical symptoms being present. Since the current Gold Standard of functional assessment is based on guidewire dependent measurements (i.e. CFR, IMR). As an invasive method, it is associated with an increased risk of adverse events such as arterial damage. Therefore new modalities are being introduced to improve patient safety, specifically, an angio-IMR (QMR, calculated based on angiography), shows a substantial promise as a potential diagnostic tool for INOCA patients. Purpose The aim of this study is to assess correlation between angio-IMR and thermodilution-based invasively measured IMR in INOCA patients. Methods In a group of INOCA patients who had undergone coronary angiography with concomitant thermodilution-based assessment of index of microcirculatory resistance (IMR) an additional angio-based IMR calculation was performed. The INOCA group consisted of 92 patients ranging in age from 49 to 80 years old, with a median age of 66 years. The majority of the patients were female (59.3%), predominantly with arterial hypertension (87%) and dyslipidemia (100%). Diabetes was present in 27% of cases. Angio-IMR (QMR) was determined by a qualitative angiography software using information about aortic pressures registered during angiography. Coronary microcirculatory dysfunction (CMD) was diagnosed according to current guidelines when IMR ≥ 25 or CFR < 2.0 were present. Results Increased IMR values were detected in 26% of patients. Median calculated value of angio-IMR value was 29 [IQR: 22,46], whereas the invasively measured IMR median value was 17 [IQR: 13,26]. A significant correlation between angio-IMR and invasive-IMR values was observed, Spearman Rho 0.29, p<0.001. Detailed scatterplot with histograms is presented in the figure. Conclusions Noninvasive methods, such as the Angio-IMR, represent a shift towards reducing the need for additional invasive procedures while still providing valuable diagnostic insights. Angio-IMR is significantly correlated with invasively measured IMR. When evaluated along with the clinical presentation, noninvasive approaches may therefore help mitigate certain risks and healthcare costs associated with invasive techniques.Figure.Correlation angio-IMR vs MR

Transient ischemic mitral regurgitation caused by non obstructive coronary lesion

Cases of transient ischemic mitral regurgitation caused by obstructive coronary artery stenosis have been reported in literature. But it can also be caused by non-obstructive coronary lesions. Diagnosis requires high suspicion and clinical acumen backed by a complete cardiac work-up that correlates with the timing of the coronary vasospasm.

Offline Assessment of the Quantitative Flow Ratio: Is it Useful in Clinical Practice?

Fractional flow reserve (FFR) has been established as the gold standard in the physiological assessment of coronary obstructions severity. However, the need to insert an intracoronary pressure guidewire is a factor that limits its use. Quantitative flow ratio (QFR) is a method that infers the value of FFR from 3-dimensional quantitative coronary angiography (3D-QCA), eliminating the use of a pressure wire and coronary hyperemia. The present study aims to evaluate the diagnostic accuracy of QFR and 3D-QCA in comparison with FFR for the identification of significant obstructive coronary lesions (FFR ≤.80) and the feasibility to assess QFR in a cohort of patients without dedicated angiographic acquisition. Consecutive patients with coronary angiography with moderate obstructive lesions that had previous FFR measurement were evaluated. Validation of QFR was assessed by the area under the curve (AUC) and other statistical tools, using FFR as the reference method. Seventy-five arteries from 69 patients were evaluated. The accuracy of the QFR to detect FFR ≤.80 was 84.0% (95% confidence interval, 75.6-92.4). The correlation and agreement between FFR and QFR were r=0.54 (P<.01) and mean difference was -0.02 ± 0.09 (P=.09), respectively. The AUC of QFR and 3D-QCA identifying stenosis >50% was 0.854 and 0.755, respectively (P=.09). QFR demonstrated good accuracy compared with FFR for the assessment of moderate obstructive coronary lesions in an unselected clinical practice population. However, many patients were excluded from the analysis and there was no statistical difference between the receiver operator characteristic curves of the QFR and percent diameter stenosis.

Lipid-Lowering Medication and Outcomes After Anatomical and Functional Imaging in Suspected Coronary Artery Disease.

Anatomical and functional imaging identify different phenotypes of coronary artery disease (CAD) that may have implications for lipid-lowering medication (LLM). The aim of this study was to assess the associations between LLM and long-term outcomes after combined anatomical and functional imaging in patients with suspected obstructive CAD. Consecutive patients (n=1,973; 41% men; median age: 63 years) underwent coronary computed tomography angiography (CTA) because of suspected CAD. Patients in whom obstructive CAD was not ruled out by CTA underwent ischemia testing by positron emission tomography. Data on LLM purchases were collected until 2 years, and the combined endpoints of death, myocardial infarction, and unstable angina pectoris were assessed at a median of 6.7 years. After imaging, LLM was used by 24% of patients with no CAD, 51% of patients with nonobstructive CAD, 72% of patients with obstructive CAD on CTA without myocardial ischemia, and 91% of patients with myocardial ischemia. The use of LLM decreased during follow-up, with 77% of patients with myocardial ischemia using LLM for 2 years. The use ofLLM was associated with a lower annual rate of adverse events in patients with myocardial ischemia (6.1% vs 2.8%; P= 0.032) or obstructive CAD without myocardial ischemia (2.9% vs 1.4%; P = 0.004) but not in patients with nonobstructive CAD (1.5% vs 1.4%; P = 0.89) or no CAD (0.3% vs 0.3%; P = 0.68). The CAD phenotype defined by anatomical and functional imaging guides the use of LLM. The presence of myocardial ischemia and anatomical obstructive coronary lesions were associated with a long-term outcome benefit from LLM.

Association of cardiac mechanical dyssynchrony indices with data of dynamic single-photon emission computed tomography of the myocardium: the role of the time interval between the stress test and recording

Introduction. According to ECG-synchronized myocardial perfusion imaging (MPI) mechanical dyssynchrony (MD) is a sensitive marker of impaired myocardial perfusion. However, its direct comparison with indicators of myocardial blood flow reserve (MFR) according to single-photon emission computed tomography (SPECT) was not carried out. Traditional MPI protocols imply a long gap between stress test and image acquisition, during which stress-induced changes may pass. It is potentially possible to reduce the time interval down to 5 minutes.Aim: To investigate the relationship between early and delayed MD indices and the data of MFR by means of SPECT.Material and Methods. The study included 20 patients with suspected coronary heart disease, preserved left ventricular ejection fraction (&gt; 55%) and without obstructive coronary artery lesions (&lt; 50%) according to multislice computed coronary angiography. All patients underwent dynamic SPECT (dSPECT) according to a two-day rest/stress protocol. Gated MPI was performed 60 minutes after radiopharmaceutical administration. Myocardial blood flow and reserve, as well as phase histogram standard deviation (PSD, degree) and phase histogram bandwidth (HBW, degree) from 5 minutes after radiopharmaceutical administration were obtained from the dSPECT data by postprocessing. Perfusion data as well as MD indices (PSD, HBW) were obtained from delayed images. Based on dSPECT data, patients were divided into 2 groups: with preserved (MFR ≥ 2.0) and reduced (MFR &lt; 2.0) myocardial blood flow reserve.Results. Correlation analysis showed that MD indices on stress test in early scan had a stronger association with MFR (PSD ρ = –0.68, p &lt; 0.001; HBW ρ = –0.68, p = 0.001) compared to those in delayed scan (PSD ρ = –0.38, p = 0.019; HBW ρ = –0.44, p = 0.005). According to multivariate regression analysis, PSD on stress test at early scan was the only independent predictor of reduced MFR (OR 1.29 (1.1; 1.53)). Stress PSD &gt; 22° obtained at early scanning had a sensitivity of 81% and specificity of 87% (AUC = 0.86, p &lt; 0.001) in predicting of reduced MFR.Conclusion. Left ventricular mechanical dyssynchrony indices obtained by early post-stress gated MPI have a stronger association with myocardial blood flow reserve indices.

Cardiac Sarcoidosis Presenting as Sustained Ventricular Tachycardia.

Sarcoidosis has many possible clinical presentations since it can affect any organ, most commonly the lungs. The hallmark of the disease consists of the formation of non-necrotising granulomas. Pathogenesis is thought to rely on the interplay of genetic, environmental and epigenetic factors. This case highlights the importance of a thorough clinical history and physical examination, and the correlation with imaging findings in the diagnostic work-up of the non-ischaemic cardiomyopathy. A 57-year-old woman was admitted due to the sudden onset of malaise, dizziness, and chest discomfort. Sustained monomorphic ventricular tachycardia was evidenced and the patient rapidly evolved with haemodynamic instability; she underwent successful electrical cardioversion. The electrocardiogram afterwards showed a high-risk electrocardiographic pattern. Invasive coronary angiography excluded obstructive epicardial coronary lesions. Physical examination revealed skin lesions on the lower limbs which raised suspicion for erythema nodosum and therefore a biopsy was performed. Transthoracic echocardiography and cardiac magnetic resonance imaging revealed features consistent with an inflammatory cardiomyopathy, and an implantable cardioverter-defibrillator was placed. The histologic examination of the cutaneous lesions showed a non-necrotising granulomatous inflammatory process. Radionuclide imaging was inconclusive. The patient underwent an endomyocardial biopsy, which confirmed the diagnosis of systemic sarcoidosis with cardiac involvement. Systemic sarcoidosis with cardiac involvement is a challenging diagnosis. The role of imaging techniques such as transthoracic echocardiography, cardiac magnetic resonance imaging and radionuclide imaging is essential in raising suspicion and diagnosing this pathology. Endomyocardial biopsy is the 'gold standard' for its diagnosis; however, it has a low diagnostic yield. Systemic sarcoidosis with cardiac involvement is a challenging diagnosis as it may present in many different ways.The case presented highlights the importance of a thorough clinical history and physical examination, and the correlation with imaging findings.Imaging techniques such as transthoracic echocardiogram, cardiac magnetic resonance and radionuclide imaging are essential in raising suspicion and diagnosing cardiac sarcoidosis.

Coronary Cascade Connecting Right Posterior and Left Anterior Descending Arteries: A Rare Coronary Anomaly

“Coronary cascades” or “coronary arcades” are congenital inter-coronary communications allowing uni- or bi-directional blood flow seen in the absence of obstructive coronary lesions. Coronary cascades take up the role of collaterals if atherosclerotic lesions develop. We present the angiogram images of a coronary cascade connecting left anterior and right posterior descending arteries (LAD and RPDA) in the distal interventricular groove in a patient with spontaneous coronary artery dissection and near total occlusion of LAD who presented with inferior wall myocardial infarction secondary to acute thrombotic occlusion of the right coronary artery. The presence of the arcade prevented a massive inferior or anterior wall myocardial infarction in our patient.

Kiosk 5Q-TA-01 - CMR as a Determinant Diagnostic Resource in Right Ventricle Infarction Without Obstructive Coronary Lesions

Kiosk 5Q-TA-01 - CMR as a Determinant Diagnostic Resource in Right Ventricle Infarction Without Obstructive Coronary Lesions

Impacts of illicit drug use on coronary angiographic findings in a multicenter registry of patients with acute coronary syndrome

Abstract Background Although illicit drug use may induce acute coronary syndrome (ACS), its impacts on coronary angiographic characteristics and the coronary artery disease (CAD) burden are a matter of debate. Purpose To assess the association between illicit drugs use and coronary angiographic findings in a multicenter patients with ACS. Methods From April 7 to 22, 2021, the Addiction in Intensive Cardiac Care Unit (ADDICT-ICCU) study included prospectively 1,499 patients admitted to ICCUs with a systematic urine multidrug test in 39 ICCUs across France. This prespecified study focuses on patients admitted for ACS with an angiography analysed by an independent Angiographic Core Laboratory. Patients with history of coronary artery bypass graft surgery were excluded. We compared coronary angiographic findings between illicit drugs users and others for the following parameters: the prevalence, location, type, and severity of CAD obstruction (stenosis≥50%), SYNTAX score, residual SYNTAX score, and the characteristics of percutaneous coronary intervention (PCI). Results Among the 283 patients with ACS (62±13 years, 77% men), 38 (13.4%) had a positive test for illicit drugs (cannabis: 12%, cocaine: 1.1%, MDMA: 0.7%). Drug users were younger than other patients (51±12 vs 64±12 years, p&amp;lt;0.001), but there were no significant difference in sex ratio (89.5% vs 75.5%, p=0.088). There was no significant difference in the rate of STEMI (52.6% vs 45.7%, p=0.535) and NTSEMI (47.4% vs 54.3%, p=0.535) between drug users and others. Regarding the CAD burden, drug users had significantly less obstructive coronary lesions (1.6±1.1 vs 2.2±1.4, p=0.012), less multivessel obstructive CAD (31% vs 61%, p=0.001), and a trend for a lower initial SYNTAX score (8.3±7.8 vs 10.8±8.4; p=0.084) compared to others. Concerning culprit lesion, drug users had less bifurcation lesions (p=0.008), a trend for more left anterior descending (LAD) artery lesions (p=0.091), a higher thrombus burden score (p=0.057), and less lesions above 20 mm (p=0.183). Conclusion In patients with ACS, recent illicit drug use is associated with less number of significant lesions and less multivessel CAD. Concerning culprit lesions, illicit drugs use is associated with less bifurcation lesions, with a trend for more LAD lesions and a higher thrombus burden score.ACS analysed with Core LaboratoryAngiographic findings according to drug

Longitudinal Strain Patterns in Stress (Takotsubo) Cardiomyopathy: Evidence of Global Myocardial Injury and Incomplete Recovery

BackgroundStress cardiomyopathy develops after abrupt sympathetic stimulation, likely from catecholamine-induced myocardial toxicity. The evolution of myocardial strain during and following an episode have not been previously characterized. We aimed to determine whether pre-existing contractile abnormalities may explain the observed regional dysfunction during an acute episode, and to investigate the persistence of strain abnormalities after clinical recovery. MethodsWe identified patients who were diagnosed with stress cardiomyopathy and had an echocardiogram performed prior to their episode, during their episode, and within 1 year after. Diagnosis was confirmed based on the absence of obstructive coronary lesions. Left ventricular (LV) longitudinal strain was calculated using speckle-tracking software and compared between baseline, episode, and follow-up echocardiograms. ResultsLV strain analysis was performed on 23 patients. LV ejection fraction was 64±8.7% at baseline, 45±12% during the episode, and 59±10% after a median follow-up of 46 days. LV global longitudinal strain was 24±4.7% at baseline, 11±4.9% during the episode, and 19±4.6% after follow-up. Mean ejection fraction (p<0.01) and global longitudinal strain (p<0.001) remained below baseline levels at follow-up. Longitudinal strain was reduced (<18%) in 80±23% of myocardial segments during an episode and 41±21% of myocardial segments at follow-up. During the acute episode, 35±6% of the abnormal segments were in the base, outside of the region of ballooning. ConclusionsOur findings suggests that stress cardiomyopathy is associated with global rather than regional myocardial injury, and that contractile abnormalities persist after clinical improvement. These findings challenge prior understanding of stress cardiomyopathy and may guide future pathophysiologic understanding of this complex disease.

Abstract 12525: Acute Pulmonary Edema, Mid-Ventricular Stress Cardiomyopathy and Cardiogenic Shock Following Intranasal Lidocaine/Epinephrine Administration During Septorhinoplasty

Case Presentation: A 19-year-old female presented for elective septorhinoplasty for nasal septal deviation and turbinate hypertrophy. After induction of anesthesia, and orotracheal intubation, pledgets soaked in 4% topical lidocaine with 1:1,000 epinephrine were placed in bilateral nares. Next, 1% lidocaine with 1:100,000 epinephrine was locally injected in the nasal mucosa to obtain hemostasis and analgesia. This resulted in transient hypertensive emergency, followed by undifferentiated shock requiring the initiation of norepinephrine. No signs of ischemia were seen on EKG. Chest X-ray revealed acute pulmonary edema. TTE showed reduced left ventricular systolic function, EF 30%, with mid-segment akinesis, consistent with mid-ventricular stress cardiomyopathy. Coronary angiography identified normal anatomy and patent arteries, supporting the diagnosis. Surveillance TTE after extubation and empiric treatment with metoprolol and losartan, showed improvement of EF to 45-50% and resolution of regional wall motion abnormalities. Discussion: Stress cardiomyopathy, also known as Takotsubo (TCM), is a rare form of cardiomyopathy accounting for 2-3% of ACS. The syndrome mainly affects the LV, causing a regional, transient, systolic dysfunction visualized on TTE or left ventriculography, that occurs in the absence of obstructive epicardial coronary lesions. Pathogenesis is poorly understood. Postulated mechanisms include catecholamine excess, coronary artery spasm and microvascular dysfunction. A systematic review found elevated norepinephrine levels in 74.3% of patients diagnosed with TCM, as was the case for our patient. Rapid systemic absorption of epinephrine can cause diffuse microvascular spasm and myocardial stunning. Catecholamine surge may also afflict direct myocardial toxicity, leading to disorganized cytoskeletal structures, excess extracellular matrix proteins and dysfunctional contractile properties of the myocardium.

Coronary Physiology Guidance vs Conventional Angiography for Optimization of Percutaneous Coronary Intervention: The AQVA-II Trial

BackgroundThe debate surrounding the efficacy of coronary physiological guidance compared with conventional angiography in achieving optimal post–percutaneous coronary intervention (PCI) fractional flow reserve (FFR) values persists. ObjectivesThe primary aim of this study was to demonstrate the superiority of physiology-guided PCI, using either angiography or microcatheter-derived FFR, over conventional angiography-based PCI in complex high-risk indicated procedures (CHIPs). The secondary aim was to establish the noninferiority of angiography-derived FFR guidance compared with microcatheter-derived FFR guidance. MethodsPatients with obstructive coronary lesions and meeting CHIP criteria were randomized 2:1 to receive undergo physiology- or angiography-based PCI. Those assigned to the former were randomly allocated to angiography- or microcatheter-derived FFR guidance. CHIP criteria were long lesion (>28 mm), tandem lesions, severe calcifications, severe tortuosity, true bifurcation, in-stent restenosis, and left main stem disease. The primary outcome was invasive post-PCI FFR value. The optimal post-PCI FFR value was defined as >0.86. ResultsA total of 305 patients (331 study vessels) were enrolled in the study (101 undergoing conventional angiography-based PCI and 204 physiology-based PCI). Optimal post-PCI FFR values were more frequent in the physiology-based PCI group compared with the conventional angiography-based PCI group (77% vs 54%; absolute difference 23%, relative difference 30%; P < 0.0001). The occurrence of the primary outcome did not differ between the 2 physiology-based PCI subgroups, demonstrating the noninferiority of angiography- vs microcatheter-derived FFR (P < 0.01). ConclusionsIn CHIP patients, procedural planning and guidance on the basis of physiology (through either angiography- or microcatheter-derived FFR) are superior to conventional angiography for achieving optimal post-PCI FFR values. (Physiology Optimized Versus Angio-Guided PCI [AQVA-II]; NCT05658952)

Triglyceride-glucose index is associated with severe obstructive coronary artery disease and atherosclerotic target lesion failure among young adults

BackgroundEarly diagnosis and treatment effectiveness of early-onset coronary artery disease (EOCAD) are crucial, and non-invasive predictive biomarkers are needed for young adults. We aimed to evaluate the usefulness of the triglyceride-glucose (TyG) index, a novel marker of insulin resistance, in identifying young CAD patients and predicting their risk of developing target lesion failure (TLF).MethodsWe recruited EOCAD patients (luminal narrowing ≥ 70%) and controls free from CAD (luminal narrowing < 30%), both aged 45 years or younger, from 38 hospitals in China between 2017 and 2020. EOCAD patients who underwent successful percutaneous coronary intervention were followed for incident TLF. TyG index was defined as Ln [fasting triglyceride (mg/dL) × fasting blood glucose (mg/dL)/2]. We used logistic regression and Cox proportional hazards modeling to evaluate the association of TyG index with prevalent EOCAD and incident TLF, respectively. The discriminatory ability of TyG index was assessed by the area under the receiver-operating characteristic curve (AUC).ResultsAmong the included 1513 EOCAD patients (39.6 ± 4.4 years, 95.4% male) and 1513 age-matched controls (39.0 ± 4.4 years, 46.4% male), TyG index was positively associated with the prevalence of EOCAD (adjusted odds ratio: 1.40, 95% confidence interval [CI] 1.23–1.60, per standard deviation [SD] increase in TyG index). The addition of TyG index to an empirical risk model provided an improvement in diagnostic ability for EOCAD, with a net reclassification improvement of 0.10 (95% CI 0.03–0.17, p = 0.005). During a medium of 33 month (IQR: 31–34 months) follow-up, 43 (3.3%) patients experienced TLF. Multivariate Cox regression model revealed that TyG index was an independent risk factor for TLF (adjusted hazard ratio [HR]: 2.410, 95% CI 1.07–5.42 comparing the top to bottom TyG index tertile groups; HR: 1.30, 95% CI 1.01–1.73, per SD increase in TyG index). Compared with a model of conventional risk factors alone, the addition of the TyG index modestly improved the AUC (0.722–0.734, p = 0.04) to predict TLF.ConclusionsTyG index is positively associated with prevalent EOCAD and incident TLF. TyG index appeared to be a valuable component of future efforts to improve CAD risk stratification and TLF outcome prediction among young adults.

Management of myocardial infarction and ischemia without obstructive coronary arteries: insights from a case series

Acute coronary syndromes typically result from the formation of atherosclerotic lesions in a large epicardial vessel, which restrict blood flow either partially or completely. These lesions can be identified through angiography, an invasive imaging technique that enables visualization of the coronary arteries. However, a small percentage of patients, usually ranging from 5% to 10%, experience symptoms and/or signs of myocardial ischemia, either acute or chronic, without significant obstructive coronary lesions visible on angiography. This condition is particularly prevalent in young women and is characterized by two distinct forms: myocardial infarction with no obstructive coronary arteries (MINOCA) and myocardial ischemia with no obstructive coronary arteries (INOCA). MINOCA can be caused by a variety of heterogeneous mechanisms, including coronary vascular spasm, microvascular disease, spontaneous coronary dissection, and plaque rupture or erosion. Conversely, coronary vasospasm and microvascular dysfunction account for the majority of patients with INOCA. We here present three cases of MINOCA/INOCA that were evaluated using optical coherence tomography, coronary flow reserve, index of microcirculatory resistance, and acetylcholine provocative test. These diagnostic tests allowed us to identify a specific condition and adopt a targeted treatment for each patient.

Features of diagnosis and treatment of coronary heart disease in patients without obstructive atherosclerotic lesions of the coronary arteries

In half of cases during coronary angiography (CAG), obstructive coronary artery lesions aren’t detected in patients with chronic coronary artery disease. Such patients mostly have vasospastic angina (VSA) and/or microvascular angina (MVA). These patients can be performed repeated diagnostic tests, including selective coronary angiography, but as a result they are never diagnosed correctly. This review presents modern pathogenetic mechanisms for the development and methods of diagnosing of ischemia with non-obstructive coronary artery disease. It also highlights choice of treatment tactics in accordance with the identified pathophysiological mechanism for the development of chronic coronary artery disease.

Coronary angiographic profile in non ST elevation acute coronary syndrome: risk stratification and management strategy

Abstract Funding Acknowledgements Type of funding sources: None. Background It has been reported that risk scores like GRACE and TIMI scores in NSTE-ACS are associated with more complex coronary anatomy and predict worse outcomes. No data from Iraq regarding how these scores reflect severity of coronary obstruction. Purpose We aimed to investigate how obstructive coronary lesions are related to GRACE or TIMI risk class in NSTE-ACS. Methods Patients with NSTE-ACS were prospectively recruited and stratified according to TIMI and GRACE risk scores into high, intermediate and low classes. Their coronary angiography findings were recorded, and results classified accordingly into: Normal coronaries, non-critical coronary lesion&amp;lt;70% and critical coronary lesion (obstruction≥70% of coronary artery). Results n=150, among whom 65.33% were referred for coronary catheterization. For patients catheterized within 2 hours: 20% have normal coronary angiography (all in lower risk category), 80 % have obstructive coronary lesions. Moreover, those who were catheterized within&amp;gt;24 hours were 74 patients, among whom; 16.21 % had normal coronary angiography and 81.08% had obstructive (Critical) coronary lesions. However, there was no statistical significance for types of coronary lesions considering timing to intervention or risk category. In 29.59% of those who were referred for catheterization, they had PCI at same session and 29.59% had been referred for CABG. Patients with higher GRACE scores were more frequent to be referred for CABG. Conversely, on classifying patients according to TIMI score, those with intermediate TIMI scores were more to be referred for CABG. Conclusions Higher TIMI and GRACE scores were associated with more significant angiographic coronary lesions and with more referral for CABG than lower risk patients. This finding supports the importance of referring higher risk patients for catheterization according to guideline recommendation especially in resource-limited settings in Iraq where proper risk stratification is crucial to choose those who will benefit the most from invasive strategy.

Angiographic Findings in Unstable Angina and Prediction of 1-Year Risk of Recurrent Acute Coronary Syndrome or Death: A Nationwide Machine Learning Study

Background: We studied whether machine learning could predict survival, risk of future acute coronary syndrome (ACS) and coronary angiographic (CAG) findings in patients with unstable angina (UA). We also studied whether high-sensitivity troponin levels within normal range can predict the presence of obstructive coronary lesions, risk of future ACS and death. Methods: We used the SWEDEHEART registry to include patients admitted to the coronary care unit due to chest pain, with normal highsensitivity cardiac troponin T or I (hs-cTnI, hs-cTnT), who underwent CAG and did not receive a final diagnosis of acute myocardial infarction (AMI). We studied CAG findings on segmental level, developed machine learning models predicting the risk of ACS or death within 1-year, and angiographic findings. The latter model predicted CAG resulting in interventions (any) or eliciting further assessments after CAG. Models for ACS and death included 130 candidate predictors and models for angiographic findings included 110 predictors. Results: We included 9’314 patients; 1-year rate of death was 0.9% (n=78) and ACS was 2.7% (n=251). A total of 5455 (61.5%) of CAG resulted in no intervention and no further assessment afterwards, with 40% without significant stenosis. There was a strong association between hscTnI (within normal range) and severity of coronary atherosclerosis; e.g 32.4% in patients with hs-cTnI 26-35 ng/L had >50% stenosis in segment 6, as compared with 12.6% in those with hs-cTnI 0-5 ng/L. All segments displayed similar associations with troponin levels. Among 17 predictors for atherosclerosis, hs-cTnI was the strongest predictor of having >50% stenosis in the left anterior descending artery (LAD). Mortality increased at hs-cTnI levels above 10 ng/L for men, but not women. Age and sex adjusted hazard ratio for hs-cTnI 25-35 vs hs-TnI 0-5 was 5.73 (2.14- 15.35) for 1-year mortality. No association was noted for hs-cTnT. The strongest predictors of 1-year mortality were C-reactive protein, body mass index, estimated glomerular filtration rate. Conclusion: Troponin levels within normal range exhibit a strong association with obstructive CAD and survival.