Obstructive Coronary Stenosis Research Articles

Screening, risk stratification and CT imaging for assessment of coronary artery disease

Early treatment of cardiovascular risk factors and characterization of coronary plaques is essential to collect prognostic information about coronary artery disease (CAD) and prevent cardiovascular events. Discussion of the most important risk factors of CAD, basic diagnostic of CAD, prevention, and prognostic factors of CAD with focus on cardiac computed tomography (CT). Prevalence and prognostic impact of CAD risk factors; description of specific assessment of risk profiles; estimation of pretest probability; conventional prevention of CAD; prognostic assessment of CAD using the Calcium Scoring and coronary CT angiography. Assessment of risk profiles and estimation of pretest probability for obstructive coronary stenosis necessitates athorough evaluation of medical history and laboratory values. The composition and extent of calcified and noncalcified plaques in CT exams based on the criteria of the Coronary Artery Disease-Reporting and Data System give important prognostic information about the risk of cardiovascular events, which increases with high plaque burden and vice versa. Initial imaging with CT for evaluation of CAD leads to areduction of invasive coronary angiographies and catheter-associated complications. Besides early detection of cardiovascular risk factors, the additional assessment of plaque burden and significant stenosis in CT gives further prognostic information to facilitate effective therapies to prevent cardiovascular events and in the case of low plaque burden avoid invasive coronary angiography. However, systmatic screening using Calcium Scoring is not established yet due to insufficient data, although it could potentially be used for an early risk stratification in patients with multiple risk factors.

Dietary Composition, Angiographic Coronary Disease, and Cardiovascular Outcomes in the WISE Study (Women's Ischemia Syndrome Evaluation).

Studies relating diet to angiographic coronary artery disease (CAD) and subsequent major adverse cardiac events (MACE) in women are limited. Information on diet was collected in the Women's Ischemia Syndrome Evaluation (WISE), a prospective cohort study of symptomatic women referred for coronary angiography to evaluate suspected ischemic heart disease. A consecutive subgroup (n = 201 of 936) of enrolled women completed the modified Block food frequency questionnaire (FFQ). Data on outcomes were collected and adjudicated after 8-year follow-up. A set of logistic regression models were fitted for non-obstructive versus obstructive coronary stenosis (<50% versus ≥50%). Cox proportional hazard regression models were fitted for outcomes, with each dietary composition variable adjusted for the degree of coronary stenosis. At baseline, the subgroup cohort was 58 ± 12 years old with a body mass index (BMI) of 30 ± 7 kg/m2. An increased proportion of calories consumed from protein was associated with higher levels of baseline obstructive coronary stenosis. Those individuals who ate a higher amount of protein, carotene, and servings of vegetables and meat, however, were each associated with lower subsequent adverse outcomes, respectively. Among women undergoing coronary angiography for suspected CAD, a higher percentage of protein intake was associated with higher baseline stenosis severity; however, the amount of protein intake, vegetable, meat, and carotene intake, was conversely associated with subsequent lower adverse cardiovascular outcome risk.

Incremental prognostic value of downstream positron emission tomography perfusion imaging after coronary computed tomography angiography: a study using machine learning.

To evaluate the incremental value of positron emission tomography (PET) myocardial perfusion imaging (MPI) over coronary computed tomography angiography (CCTA) in predicting short- and long-term outcome using machine learning (ML) approaches. A total of 2411 patients with clinically suspected coronary artery disease (CAD) underwent CCTA, out of whom 891 patients were admitted to downstream PET MPI for haemodynamic evaluation of obstructive coronary stenosis. Two sets of Extreme Gradient Boosting (XGBoost) ML models were trained, one with all the clinical and imaging variables (including PET) and the other with only clinical and CCTA-based variables. Difference in the performance of the two sets was analysed by means of area under the receiver operating characteristic curve (AUC). After the removal of incomplete data entries, 2284 patients remained for further analysis. During the 8-year follow-up, 210 adverse events occurred including 59 myocardial infarctions, 35 unstable angina pectoris, and 116 deaths. The PET MPI data improved the outcome prediction over CCTA during the first 4 years of the observation time and the highest AUC was at the observation time of Year 1 (0.82, 95% confidence interval 0.804-0.827). After that, there was no significant incremental prognostic value by PET MPI. PET MPI variables improve the prediction of adverse events beyond CCTA imaging alone for the first 4 years of follow-up. This illustrates the complementary nature of anatomic and functional information in predicting the outcome of patients with suspected CAD.

Construction and validation of a clinical prediction model for asymptomatic obstructive coronary stenosis in patients with carotid stenosis.

Coronary artery stenosis occurs frequently in patients with carotid artery stenosis. We developed a clinical predictive model to investigate the clinical risk of asymptomatic obstructive coronary artery stenosis in patients with carotid artery stenosis ≥ 50%. From January 2018 to January 2022, carotid stenosis patients hospitalized at the First Affiliated Hospital of Zhengzhou University's Department of Endovascular Surgery were subjected to a retrospective analysis of their clinical information and imaging results. Excluded criteria were patients with lacking data, symptomatic coronary stenosis, prior coronary artery bypass grafting, and coronary stent implantation. Patients were separated into case and control groups according to whether or not they had obstructive coronary stenosis. Independent predictors were screened using univariate and multivariate logistic regression, and their accuracy was confirmed using least absolute shrinkage and selection operator (LASSO) regression. A Nomogram prediction model was developed using the aforementioned filtered factors. The model's discrimination and specificity were evaluated using the receiver operating characteristic curve (ROC) and Hosmer-Lemeshow goodness-of-fit test. Internal validation employed the Bootstrap procedure. The clinical decision curve analysis (DCA) of the prediction model was developed to assess the clinical applicability of the model. The investigation included a total of 227 patients, of whom 132 (58.1%) had coronary artery stenosis. Hypertension, Grade I plaque, HbA1c ≥ 7.0%, MPV ≥ 9.2fl, and Fib ≥ 3.0 g/L were independent predictors, with OR values of (2.506, 0.219, 0.457, 1.876, 2.005), according to multivariate logistic regression. Risk factor screening and validation using lasso regression. The predictors chosen based on the optimal λ value are consistent with the predictors identified by multiple regression. The area under the ROC curve (AUC) of the model based on the above predictors was 0.701 (0.633-0.770), indicating that the model discriminated well. The calibration curve of the model closely matched the actual curve, and P > 0.05 in the Hosmer-Lemeshow goodness-of-fit test indicated the model's accuracy. The results of the DCA curve demonstrate the clinical applicability of the prediction model. Hypertension, grade I plaque, HbA1c ≥ 7.0%, MPV ≥ 9.2 fl, and Fib ≥ 3.0 g/L are predictors of asymptomatic coronary stenosis in patients with carotid stenosis ≥50%. The diagnostic model is clinically applicable and useful for identifying patients at high risk.

Histopathologic Validation of Stress T1 Mapping in Myocardial Ischemia: Another Step toward Clinical Translation?

Histopathologic Validation of Stress T1 Mapping in Myocardial Ischemia: Another Step toward Clinical Translation?

Influence of Obesity on Coronary Artery Disease and Clinical Outcomes in the ADVANCE Registry.

The relationship between body size and cardiovascular events is complex. This study utilized the ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) Registry to investigate the association between body mass index (BMI), coronary artery disease (CAD), and clinical outcomes. The ADVANCE registry enrolled patients undergoing evaluation for clinically suspected CAD who had >30% stenosis on cardiac computed tomography angiography. Patients were stratified by BMI: normal <25 kg/m2, overweight 25-29.9 kg/m2, and obese ≥30 kg/m2. Baseline characteristics, cardiac computed tomography angiography and computed tomography fractional flow reserve (FFRCT), were compared across BMI groups. Adjusted Cox proportional hazards models assessed the association between BMI and outcomes. Among 5014 patients, 2166 (43.2%) had a normal BMI, 1883 (37.6%) were overweight, and 965 (19.2%) were obese. Patients with obesity were younger and more likely to have comorbidities, including diabetes and hypertension (all P<0.001), but were less likely to have obstructive coronary stenosis (65.2% obese, 72.2% overweight, and 73.2% normal BMI; P<0.001). However, the rate of hemodynamic significance, as indicated by a positive FFRCT, was similar across BMI categories (63.4% obese, 66.1% overweight, and 67.8% normal BMI; P=0.07). Additionally, patients with obesity had a lower coronary volume-to-myocardial mass ratio compared with patients who were overweight or had normal BMI (obese BMI, 23.7; overweight BMI, 24.8; and normal BMI, 26.3; P<0.001). After adjustment, the risk of major adverse cardiovascular events was similar regardless of BMI (all P>0.05). Patients with obesity in the ADVANCE registry were less likely to have anatomically obstructive CAD by cardiac computed tomography angiography but had a similar degree of physiologically significant CAD by FFRCT and similar rates of adverse events. An exclusively anatomic assessment of CAD in patients with obesity may underestimate the burden of physiologically significant disease that is potentially due to a significantly lower volume-to-myocardial mass ratio.

Prognostic value of coronary computed tomography angiography compared to radionuclide myocardial perfusion imaging in patients With coronary stents.

The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents. Retrospective analysis. University Hospital, London, Ontario Canada. Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled. Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of >5% reversible myocardial perfusion defect. During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE (p = 0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p = 0.004 and p = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p = 0.062). Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years.

Atherosclerosis Imaging Quantitative Computed Tomography (AI-QCT) to guide referral to invasive coronary angiography in the randomized controlled CONSERVE trial.

We compared diagnostic performance, costs, and association with major adverse cardiovascular events (MACE) of clinical coronary computed tomography angiography (CCTA) interpretation versus semiautomated approach that use artificial intelligence and machine learning for atherosclerosis imaging-quantitative computed tomography (AI-QCT) for patients being referred for nonemergent invasive coronary angiography (ICA). CCTA data from individuals enrolled into the randomized controlled Computed Tomographic Angiography for Selective Cardiac Catheterization trial for an AmericanCollegeofCardiology(ACC)/AmericanHeartAssociation(AHA) guideline indication for ICA were analyzed. Site interpretation of CCTAs were compared to those analyzed by a cloud-based software (Cleerly, Inc.) that performs AI-QCT for stenosis determination, coronary vascular measurements and quantification and characterization of atherosclerotic plaque. CCTA interpretation and AI-QCT guided findings were related to MACE at 1-year follow-up. Seven hundred forty-sevenstable patients (60 ± 12.2 years, 49% women) were included. Using AI-QCT, 9% of patients had no CAD compared with 34% for clinical CCTA interpretation. Application of AI-QCT to identify obstructive coronary stenosis at the ≥50% and ≥70% threshold would have reduced ICA by 87% and 95%, respectively. Clinical outcomes for patients without AI-QCT-identified obstructive stenosis was excellent; for 78% of patients with maximum stenosis < 50%, no cardiovascular death or acute myocardial infarction occurred. When applying an AI-QCT referral management approach to avoid ICA in patients with <50% or <70% stenosis, overall costs were reduced by 26% and 34%, respectively. In stable patients referred for ACC/AHA guideline-indicated nonemergent ICA, application of artificial intelligence and machine learning for AI-QCT can significantly reduce ICA rates and costs with no change in 1-year MACE.

Determinants of perivascular adipose tissue stranding as a novel imaging marker and its relation to inflammatory biomarker high-sensitivity C-reactive protein.

This study aimed to examine the relationship of perivascular adipose tissue (PVAT) stranding in coronary computed tomography angiography (CCTA) with high-sensitivity C-reactive protein (hsCRP) and the determinants of PVAT stranding in coronary artery disease (CAD) patients. This retrospective cross-sectional study was done by collecting data from CAD patients who were referred to Rajaie Cardiovascular Centre between January 2018 and September 2020, with CCTA and hsCRP test 72 hours apart from the CCTA. PVAT stranding was defined as irregular obscuration of PVAT adjacent to the coronary arteries. An attempt was made to find a correlation between included variables and PVAT stranding by comparing them between 2 groups: patients with and without PVAT stranding. From 92 patients, 31 participants had PVAT stranding, and statistically significant higher levels of hsCRP were detected in them (p = 0.007). We demonstrated significantly higher prevalence of history of hyperlipidaemia (OR = 3.83, p = 0.029), high-risk plaque features (OR = 11.80, p = 0.015), and obstructive coronary luminal stenosis (OR = 3.25, p = 0.025) in patients with PVAT stranding. Also, significantly higher PVAT attenuation was detected in patients with PVAT stranding (p < 0.001) independently from mean attenuation of epicardial fat. PVAT stranding could be used as a novel non-invasive marker in CCTA of CAD patients. More studies focusing on patient outcomes are required to better evaluate the reliability and prognostic value of this marker.

Endothelial dysfunction in patients with angina and non-obstructed coronary arteries is associated with an increased risk of mayor cardiovascular events. Results of the Spanish ENDOCOR registry

BackgroundCoronary endothelial dysfunction and vasospasm are potential causes of ischemia in patients without obstructive coronary stenoses (INOCA). ObjectiveTo evaluate the prevalence of endothelial dysfunction and the clinical profile of patients with INOCA in Spain, as well as to identify the predictors and the prognostic impact of endothelial dysfunction in this scenario. MethodsA total of 438 consecutive patients with INOCA in whom the acetylcholine test was performed were prospectively enrolled. Patients were followed up at 1 and 2 years. ResultsMean age was 62 ± 11 years with 60% female. Clinical presentation comprised 52.6% angina at rest, 61.2% exertional angina, and 31.7% dyspnea. There were no major complications of the acetylcholine test. Endothelial dysfunction was observed in 198 (45%) of patients, with severe vasoconstriction (defined as over 70% constriction), being observed in 101 (23%).Multivariable regression analysis showed that endothelial dysfunction was predicted by the presence of exertional angina (OR 2.2; CI95%1.01–2.55; p = 0.02), prior coronary disease (OR 2.46; CI95% 1.57–3.89; p < 0.01), and coronary intramyocardial bridging (2.35; CI95% 1.02–5.60; p = 0.04).Patients with endothelial dysfunction presented with worsening angina compared to those without endothelial dysfunction (25.6% vs. 12.8%) and also presented with increased levels of minimal effort angina (40% vs. 26,7%, p = 0.03) more frequently during the follow up than those without endothelial dysfunction. Endothelial dysfunction was also an independent predictor of the occurrence of myocardial infarction or unstable angina at one year (OR 2.85, CI 95% 1.01–9.25; p = 0.03). ConclusionsEndothelial dysfunction is present in almost half of patients with INOCA and is associated with worsening symptoms, as well as with a higher rate of adverse events.

Prediction of microvascular complications in diabetic patients without obstructive coronary stenosis based on peri-coronary adipose tissue attenuation model.

To investigate the predictive value of peri-coronary adipose tissue (PCAT) attenuation for microvascular complications in diabetic patients without significant stenosis and to develop a prediction model for early risk stratification. This study retrospectively included patients clinically identified for coronary computed tomography angiography (CCTA) and type 2 diabetes between January 2017 and December 2020. All patients were followed up for at least 1 year. The clinical data and CCTA-based imaging characteristics (including PCAT of major epicardial vessels, high-risk plaque features) were recorded. In the training cohort comprising of 579 patients, two models were developed: model 1 with the inclusion of clinical factors and model 2 incorporating clinical factors + RCAPCAT using multivariable logistic regression analysis. An internal validation cohort comprising 249 patients and an independent external validation cohort of 269 patients were used to validate the proposed models. Microvascular complications occurred in 69.1% (758/1097) of the current cohort during follow-up. In the training cohort, model 2 exhibited improved predictive power over model 1 based on clinical factors (AUC = 0.820 versus 0.781, p = 0.003) with lower prediction error (Brier score = 0.146 versus 0.164) compared to model 1. Model 2 accurately categorized 78.58% of patients with diabetic microvascular complications. Similar performance of model 2 in the internal validation cohort and the external validation cohort was further confirmed. The model incorporating clinical factors and RCAPCAT predicts the development of microvascular complications in diabetic patients without significant coronary stenosis. • Hypertension, HbA1c, duration of diabetes, and RCAPCAT were independent risk factors for microvascular complications. • The prediction model integrating RCAPCAT exhibited improved predictive power over the model only based on clinical factors (AUC = 0.820 versus 0.781, p = 0.003) and showed lower prediction error (Brier score=0.146 versus 0.164).

Epicardial and pericoronary fat volume and attenuation, lipid lowering therapy and coronary high risk coronary plaque burden

Abstract Background Epicardial (EAT) and pericoronary adipose tissue (PCAT) are known as risk predictors of subclinical atherosclerosis and coronary artery disease. We aimed to evaluate the association of EAT and PCAT volume and attenuation with the presence of high risk coronary plaque burden in patients with vs. without lipid lowering therapy. Methods In the present retrospective analysis a total of 321 patients undergoing coronary CTA at the XXX were included. EAT and PCAT were manually traced from CT imaging for assessment of fat volume and attenuation. According to the SCCT guidelines for the interpretation of coronary CTA, each coronary segment was evaluated for the presence of high risk plaque features (napkin ring sign, spotty calcification, positive remodeling, and low attenuation plaque). Results Overall data from 321 patients (mean age: 55.5±14.7 years, 62% male) and a total of 5778 coronary segments were included in our analysis. The cohorts consists of 116 patients without plaque and stenosis, 96 patients with plaque but no significant stenosis and 109 patients with obstructive coronary stenosis. Highest rates of the presence of coronary plaque were detected in proximal LAD (17.9%), followed by mid LAD (12.9%) and proximal RCA (10.8%). Coronary stenosis was also most common in proximal LAD (14.6%), followed by mid LAD (12.1%) and proximal RCA (11%). High risk plaque features were found in 401 segments and were most frequently located in the proximal LAD (21.4%). EAT volume increased with higher rates of stenosis and plaque (44.7±25.2ml vs. 68,2±28,5ml vs. 85.2±31.7ml, p&amp;lt;0.001). Prevalence of high risk plaque increased by higher EAT volume (OR [95% CI]: 3.17 [2.33–4.33], p&amp;lt;0.0001) and remains stable after upon adjustment for risk factors (2.32 [1.46–3.7], p&amp;lt;0.0001). EAT attenuation also significantly associated with the presence of high risk plaques with 0.68-folded risk in the unadjusted (0.68 [0.53–0.88], p=0.003), and 0.62-folded risk in the multivariate (MV) adjusted regression analysis (0.62 [0.45–0.85], p=0.003). However, for PCAT only its volume but not its attenuation was significantly associated with presence of high risk plaques in MV-adjusted regression analysis (PCAT volume: 2.25 [1.02–4.96], p=0.044; PCAT attenuation: 0.84 [0.63–1.12], p=0.24). Furthermore, patients receiving lipid-lowering therapy showed a significantly lower probability for high risk plaque detection (0.17 [0.14–0.21], p&amp;lt;0.0001). These findings remained stable after multivariate adjustment (0.27 [0.21–0.35], p&amp;lt;0.0001). Conclusion EAT volume and attenuation as well as PCAT volume associate with high risk plaques independent of traditional cardiovascular risk factors. In contrast, we found no significant association of PCAT attenuation with high risk coronary atherosclerosis. Our results encourage further research to evaluate the interplay of lipid-lowering therapy and EAT on plaque composition. Funding Acknowledgement Type of funding sources: None.

P197 TAKO TSUBO SYNDROME IN MAN FOR ‘SMART WORKING’ COMPLICATED BY ACUTE HEART FAILURE AND SAM. PRESENCE OF MYOCARDIAL BRIDGE OF IVA ‘INNOCENT BYSTANDER’ OF THE CLINICAL PICTURE

Abstract Male, 59 years old with no significant pathological history or cardiovascular risk factors. Access to the ER ( 12.30 AM ) with infero–lateral STEMI (Killip I, 2 hours of symptom onset; haemodynamic and electrical stability): chest pain associated with profuse sweating and transient arterial hypotension, ST elevation in V3–V6 and inferior leads on the ECG and apical hypokinesia with slight reduction of LVEF (50%) on the Trans–Thoracic Echocardiography. Urgent coronary angiography: non–obstructive coronary arteries stenosis, short intramyocardial tract of DA with moderate systolic compression with ‘milking effect‘. Blood sampling: mild elevation of cardiac troponin hs value (479 pg / ml), mild anemia and thrombocytopenia; normal value of markes of liver and kidney function. Hospitalization in Cardiac ICU with standard antithrombotic and anti–ischemic therapy. 12 hours after admission (01.00 PM) acute low–flow heart failure with pulmonary edema treated with inotropic agent and need of endotracheal intubation and ventilatory support (ineffective attempt of NIV); ECG unchanged from the previous one and appearance of LVEF 25% for akinesia of septum, apex and lateral wall. Peak of troponin 2083 pg / ml III day: effective extubation with successive cycles of NIV and weaning from noradrenaline. Progressive recovery of LVEF with appearance of SAM with LVOT dynamic obstruction (v max&amp;gt; 4m / s at pulsed doppler) and moderate mitral regurgitation: stop inotropic agent and start beta–blocker therapy (atenolol) not tolerated for hypokinetic arrhythmias (also total BAV) and then successful replaced in the following days with low doses of bisoprolol. Post–Iintubation pneumonia treated with antibiotic therapy. X day: hemodynamic and electrical stability, disappearance of the SAM with complete recovery of the left ventricle contractile function, mild mitral regurgitation(minimal valve prolapse) Cardiac MRI: normal LVEF, absence of myocardial LGE with the exception of small areas of the papillary muscles due to traction of the mitral flaps. In the patient‘s medical history: stressful last months related to smart working and family problems; absence of a specific identifiable trigger. Conclusions Stress cardiomyopathy in man patient complicated by progressive acute heart failure and SAM with rapid restitutio ad integrum. Presence of DA myocardial bridge with absence of myocardial LGE on MRI.

Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction.

BackgroundIn the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown.Methods and ResultsFrom the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve >0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all‐cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD (P<0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HRadjusted], 2.88; 95% CI, 1.52–7.19; P=0.024; group 4: HRadjusted, 4.00; 95% CI, 1.41–11.35; P=0.009).ConclusionsIn stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long‐term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4‐fold difference in long‐term cardiovascular events.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.

Distribution of FFRCT in single obstructive coronary stenosis and predictors for major adverse cardiac events: a propensity score matching study

BackgroundFractional flow reserve derived from computed tomography (FFRCT) has been demonstrated to improve identification of lesion-specific ischemia significantly compared with coronary computed tomography angiography (CCTA). It remains unclear whether the distribution of FFRCT values in obstructive stenosis between patients who received percutaneous coronary intervention (PCI) or not in routine clinical practice, as well as its association with clinical outcome. This study aims to reveal the distribution of FFRCT value in patients with single obstructive coronary artery stenosis and explored the independent factors for predicting major adverse cardiac events (MACE).MethodsThis was a retrospective study of adults with non-ST-segment elevation acute coronary syndrome undergoing FFRCT assessment by using CCTA data from January 1, 2016 to December 31, 2020. Propensity score matching (PSM) method was used to account for patient selection bias. The risk factors for predicting MACE were evaluated by a Cox proportional hazards regression analysis.ResultsOverall, 655 patients with single obstructive (≥ 50%) stenosis shown on CCTA were enrolled and divided into PCI group (279 cases) and conservative group (376 cases) according to treatment strategy. The PSM cohort analysis demonstrated that the difference in history of unstable angina, Canadian Cardiovascular Society Class (CCSC) and FFRCT between PCI group (188 cases) and conservative group (315 cases) was statistically significant, with all P values < 0.05, while the median follow-up time between them was not statistically significant (24 months vs. 22.5 months, P = 0.912). The incidence of MACE in PCI group and conservative group were 14.9% (28/188) and 23.5% (74/315) respectively, P = 0.020. Multivariate analysis of Cox proportional hazards regression revealed that history of unstable angina (adjusted odds ratio (adjOR), 3.165; 95% confidence interval (CI), 2.087–4.800; P < 0.001), FFRCT ≤ 0.8 (OR, 1.632;95% CI 1.095–2.431; P = 0.016), and PCI therapy (OR 0.481; 95% CI 0.305–0.758) were the independent factors for MACE.ConclusionsHistory of unstable angina and FFRCT value of ≤ 0.8 were the independent risk factors for MACE, while PCI therapy was the independent protective factor for MACE.

Coronary volume to left ventricular mass ratio in patients with diabetes mellitus

BackgroundDiabetes mellitus is a major risk factor for coronary artery disease (CAD) and may provoke structural and functional changes in coronary vasculature. The coronary volume to left ventricular mass (V/M) ratio is a new anatomical parameter capable of revealing a potential physiological imbalance between coronary vasculature and myocardial mass. The aim of this study was to examine the V/M derived from coronary computed tomography angiography (CCTA) in patients with diabetes. MethodsPatients with clinically suspected CAD enrolled in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry and known diabetic status were included. Coronary artery volume and left ventricular myocardial mass were analyzed from CCTA and the V/M ratio was calculated and compared between patients with and without diabetes. ResultsOf the 3053 patients (age 66 ​± ​10 years; 66% male) with known diabetic status, diabetes was present in 21.9%. Coronary volume was lower in patients with diabetes compared to those without diabetes (2850 ​± ​940 ​mm3 vs. 3040 ​± ​970 ​mm3, p ​< ​0.0001), whereas the myocardial mass was comparable between the 2 groups (122 ​± ​33 ​g vs. 122 ​± ​32 ​g, p ​= ​0.70). The V/M ratio was significantly lower in patients with diabetes (23.9 ​± ​6.8 ​mm3/g vs. 25.7 ​± ​7.5 ​mm3/g, p ​< ​0.0001). Among subjects with obstructive CAD (n ​= ​2191, 24.0% diabetics) and non-obstructive CAD (16.7% diabetics), the V/M ratio was significantly lower in patients with diabetes compared to those without (23.4 ​± ​6.7 ​mm3/g vs. 25.0 ​± ​7.3 ​mm3/g, p ​< ​0.0001 and 25.6 ​± ​6.9 ​mm3/g vs. 27.3 ​± ​7.6 ​mm3/g, respectively, p ​= ​0.006). ConclusionThe V/M ratio was significantly lower in patients with diabetes compared to non-diabetics, even after correcting for obstructive coronary stenosis. The clinical value of the reduced V/M ratio in diabetic patients needs further investigation.

Relationship of epicardial adipose tissue with coronary artery disease, cardiovascular risk factors and patient outcomes

Introduction and objectivesThe epicardial adipose tissue (EAT) is a metabolically active fat depot that has shown to be implicated in the development of coronary artery disease (CAD) and the prediction of cardiovascular events. However, these findings might be influenced by body size since previous studies have demonstrated a strong correlation between the amount of epicardial fat and anthropometric measurements. Our objective was to assess the association between indexed-EAT (EAT-i) volume and the presence of CAD and cardiovascular events in a cohort of symptomatic patients. MethodsPatients referred for cardiac computed tomography from March 2010 to April 2017 were included. CAD was defined as the presence of obstructive coronary stenosis or a high amount of coronary calcium. EAT was assessed using a semiautomatic software and indexed to body surface area. A regression analysis was performed to determine the relationship between relevant CAD and EAT-i, age, sex, cardiovascular risk factors, and comorbidities. The association between EAT-i and cardiovascular events was analyzed with Cox regression models. ResultsA total of 179 patients were recruited (56±12 years, 57.5% male). EAT-i (P=.003), age (P<.001) and male sex (P<.001) were significantly and independently associated with CAD. During follow-up (5.5 years, 2.4–6.4) patients with elevated EAT-i showed an increased risk of events (HR, 2.44; 95%CI, 1.07–5.56; P=.033). ConclusionsIn symptomatic patients, an increased volume of indexed epicardial fat was associated with obstructive CAD as well as with cardiovascular events.

Coronary Artery Calcium Scoring and Invasively Confirmed Obstructive Coronary Stenoses Among Outpatients and Hospitalized Patients with Suspected Coronary Artery Disease

Coronary Artery Calcium Scoring and Invasively Confirmed Obstructive Coronary Stenoses Among Outpatients and Hospitalized Patients with Suspected Coronary Artery Disease

Ratio of transmitral early filling velocity to early diastolic strain rate predicts obstructive coronary stenosis

ObjectiveThe aim was to evaluate the use of ratio of transmitral early filling velocity (E) to left ventricular early global diastolic strain rate (E′sr) (E/E′sr ratio) as a novel noninvasive predictor of obstructive coronary artery disease (OCAD) in patients with chronic coronary syndrome (CCS).BackgroundE′sr derived by speckle tracking echocardiography reflected global relaxation and filling pressure. Coronary artery disease caused early impairment of diastolic deformation.Patients and methodsIn all, 90 patients with CCS underwent coronary angiography in Mansoura Specialized Medical Hospital, Mansoura University. Patients were divided into two groups, which were age and sex matched: 55 patients with OCAD and 35 patients with normal coronary angiography. Global longitudinal strain (GLS), systolic strain rate (S′sr), and E′sr were measured by speckle tracking echocardiography.ResultsPatients with OCAD had significantly lower E′sr. On the other hand, they expressed significantly higher E/E′sr ratio, GLS, and S′sr. There was no significant difference between both groups regarding ejection fraction, E velocity, tissue Doppler-derived mitral annular velocity (E′ velocity), and E/E′ ratio. In patients with OCAD, significant positive correlation between E/E′sr ratio and E/E′ ratio, GLS, and Gensini and SYNTAX scores was observed. Independent predictors of OCAD in patients with CCS included diabetes mellitus, S′sr, and E/E′sr ratio. The ideal cutoff value of E/E′sr ratio of more than 154.29 cm predicted OCAD in patients with CCS.ConclusionTo the best of our knowledge, our study might be the first to show the possibility of use of E/E′sr ratio as a noninvasive predictor of OCAD in patients with CCS.

Characteristics of patients presenting with acute myocardial injury with non-obstructive coronary arteries in Sfax, Tunisia

In approximately 4–10% of patients with acute myocardial infarction, coronary angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA). Therefore, mechanisms are not unequivocal and there are a variety of aetiologies grouping ischemic and non-ischemic causes, for this reason the generic term for MINOCA should be replaced with acute myocardial injury with non-obstructive coronary arteries (aMINOCA). Prospective study including all patients presenting aMINOCA, between 2019 and 2020. Other imaging tests such as echocardiography and CMR were used to better support the aetiological diagnosis. Among 1032 consecutive patients admitted for acute myocardial infarction, aMINOCA was identified in 31 (4%) patients and clinical presentation was more often STEMI than NSTEMI (52% vs. 48%). Median age was 47.3 years, male predominance (81%). Two patients presented with cardiogenic shock. Tobacco use was the most noted risk factor (67.7%). According to a clinical diagnostic algorithm using 2D STE and CMR imaging, diagnostic accuracy was 90% to identify causes of aMINOCA (38.7% myocarditis, 32.3% MI, and 19.4% Takotsubo cardiomyopathy). Peak troponin levels were significantly higher in the MI group (21.5 ± 29.24 vs. 10 ± 21.4, P = 0.035). However, CRP was significantly higher in myocarditis group (36 ± 45 vs. 4.7 ± 4, P = 0.007). There was no difference between MI and myocarditis groups in clinical presentation with or without ST elevation, in the mean left ventricular ejection fraction and in the LV Global longitudinal systolic strain. At follow-up, one death was noted in Takotsubo group. Non-obstructive coronary myocardial injury is a rare clinical entity that affects a particularly young population, with a predominance of men in our country. Clinical diagnosis algorithm with echocardiography and CMR imaging established a diagnosis in almost 9 of 10 cases.