Presence Of Coronary Artery Disease Research Articles

Risk stratification of coronary artery disease using the artificial intelligence-enabled electrocardiogram

Abstract Background Atherosclerotic cardiovascular disease (ASCVD), of which coronary artery disease (CAD) is the primary manifestation, is the leading cause of death worldwide. The AHA/ACC Pooled Cohort Equation (PCE) facilitates risk stratification and initiation of primary prevention of ASCVD, however their performance is suboptimal. Purpose We develop an artificial intelligence-based electrocardiogram (ECG) analysis (AI-ECG) algorithm to detect different stages of CAD and assessed the value of AI-ECG over PCE to predict incident myocardial infarction (MI) and survival over 3-years. Methods Using electronic health record data from approximately 7 million patients seen at over 70 hospitals and clinics across 5 states in the USA, we created independent AI-ECG models to identify elevated coronary artery calcium (CAC) by computer tomography, the presence of obstructive CAD by stress test or angiography, and left ventricular regional akinesis by echocardiogram, presumed to represent prior MI. Deep structured data, AI-enabled natural language processing of unstructured data were used to ensure cohort, and physician review of labeling were used to ensure cohort accuracy. These models were ensembled into a single model that was used to assess the utility of AI-ECG for predicting new occurrence MI in PCE- and age-stratified cohorts of patient with no prior history of ASCVD, over a 3-year timeframe using Cox’s proportional hazards analysis. Results A total of 6,080 patients (15,192 ECGs) were labeled positive for CAC ≥ 300, 12,561 patients (18,915 ECGs) positive for obstructive CAD, and 10,767 patients (23,870 ECGs) positive for regional akinesis. AI-ECG for identifying elevated CACS, obstructive CAD, and regional akinesis achieved AUROCs of 0.86, 0.80, and 0.93, respectively. All AI-ECG models identified increased 3-year risk for MI and death in AI-ECG positive versus AI-ECG negative patients and subgroups with 2 or 3 positive results had stepwise increased risk (Figure A). In a 3-year survival analysis of all-comer patients, the hazard ratio for those that tested positive on 1, 2, or 3 versus 0 positive disease-specific models were 1.61 (1.53-1.69). 2.40 (2.27-2.55), 3.42 (3.21-3.65), respectively. Risk stratification was also observed in cohorts without prior ASCVD stratified by low and high PCE-derived 10-year ASCVD risk (Figure B) and in cohorts stratified by age, including under the age of 40. Conclusions AI-ECG has potential to address unmet need for accessible risk stratification in patients in whom PCE under, over, or insufficiently estimate ASCVD risk, and in whom risk assessment over periods of time shorter than 10 years is desired.

A specific molecular signature of extra-vesicles (EVs) was associated with cardiometabolic risk profile and atherosclerotic burden in patients with chronic coronary syndrome: a pilot study

Abstract Background microRNAs (miRs) are pivotal regulators of mRNA and protein expression. They critically contribute to cardiovascular pathophysiology and circulate in the blood using extra-vesicles (EVs) as delivery carrier. The role of EV-associated miRs in atherosclerotic cardiovascular disease, however, is unclear. Purpose The aim of this study was to detect Coronary Artery Disease (CAD)-related miRs carried by EVs in stable patients with Chronic Coronary Syndrome (CCS). In particular we aimed to assess whether a specific miRs signature is associated with the cardiometabolic risk profile and coronary atherosclerotic burden and plaque features, as evaluated by coronary computed tomography angiography (CTA) in these patients. Methods miRs with known effects in the cardiovascular system were analysed by real time-PCR in EVs isolated from CCS patients by density gradient centrifugation (n=21). All patients underwent coronary CTA to assess total, calcified, and noncalcified plaque volume (PV). Obstructive CAD was defined as the presence of stenoses >50% in at least one of the main coronary vessels. Results All CCS patients (n=21) were statin users and had coronary atherosclerosis documented by coronary CTA. Among the 25 miRs tested, 7 were detected within EVs and 4 of them, miR-145-5p, miR-30e5-p, miR-126-5p, miR-375, were significantly related with cardiometabolic profile, showing an alternative association with glucose and insulin, a positive correlation with HDL-Cholesterol and a negative correlation with triglycerides, BMI and waist circumference. No association was observed with Total-Cholesterol and LDL-Cholesterol (Figure1). These miRs were also not associated with the presence of obstructive CAD, but were significantly related with total, calcified, and noncalcified PVs (Figure1). Conclusions In CCS patients, among the 25 miRs studied and out of the 7 EV-associated, only 4 miRs were related with a specific cardiometabolic risk profile, characterized by insulin-resistance, obesity, high triglyceride and low HDL-Cholesterol levels. They were also associated with an increased coronary atherosclerotic burden. These results suggest a potential involvement of specific EV-associated miRs in molecular mechanisms of residual atherosclerotic risk.Figure 1

Left atrial functional assessment a prime clue in solving the puzzle of stable angina symptoms in suspected coronary artery disease patients

Abstract Background Assessing clinically for significant coronary artery disease (CAD) in stable angina patients presents a formidable task. Routinely performed echocardiography is limited in diagnosing CAD with provision for the regional wall motion abnormality (RWMA) for left ventricle (LV) systolic dysfunction and altered mitral inflow velocities for LV diastolic dysfunction. However, the advent of two-dimensional (2D) speckle-tracking technique has established the era of strain imaging, opening new possibilities in echocardiography. It is now possible to have a detailed functional assessment of left atrium (LA). We utilised speckle tracking imaging to obtain strain parameters for LA function. Combining these strain parameters with the doppler myocardial velocities and mitral inflow velocities, may prove useful mode of imaging to diagnose significant CAD in stable angina patients. Purpose To study the parameters of left atrial functions utilising echocardiographic strain imaging and evaluate their correlation with the syntax score-II in patients with symptoms of stable angina. Methods 103 patients with symptoms of stable angina undergoing coronary angiography for suspected coronary artery disease(CAD), were considered for LA function assessment and compared with their syntax-II score. Results The LA reservoir function parameters, peak atrial longitudinal strain (PALS) and peak global systolic strain rate (LAsSR), decreased with increasing syntax-II score (p values 0.011 and 0.001 respectively) and the parameter of LA conduit function, peak global early diastolic strain rate (LAeSR) increased (p value <0.001). The LA filling pressures reflected by E/e`, also increased with more severe syntax-II score (p value <0.001). We, further, configured cut off values of < 23.56 for PALS, < 1.15 for LAsSR, > -1.09 for LAeSR, and E/e` ratio > 10.39 as predictors of significant CAD, with good sensitivity and specificity. Therefore, stable angina patients who had significant CAD on coronary angiogram represented by severe syntax score-II, had higher LA filling pressures and deranged LA function with transition from more of reservoir chamber to merely a conduit. Conclusion Our study shows a significant association between LA strain parameters (PALS, LAsSR, and LAeSR) and LA filling pressures (E/e`), with the presence of significant CAD in these patients. The stable angina patients with more severe CAD as quantified by their severe syntax score-II, have an impaired LA reservoir and LA functions more as a conduit, with elevated filling pressures. This study establishes a significant association between LA deformation strain variables and severity of CAD and hence LA strain imaging can be a useful tool to diagnose significant CAD in stable angina patients.

Deep learning to predict long-term mortality from plain chest radiographs in patients referred for suspected angina

Abstract Background The chest radiograph (CXR) is a well-established and broadly used first line diagnostic tool in patients with suspected cardiac conditions. In previous literature, artificial intelligence (AI) based interpretation of CXR has been shown to predict follow-up mortality of patients screened for neoplastic disease. Purpose In this context, we summarize our experience with the training, testing, and validating (internally and externally) of a deep learning (DL) model purposefully designed for predicting, from a single projection (posteroanterior/anteroposterior) CXR, long-term mortality of patients referred for angina and suspected coronary artery disease (CAD). Methods Demographic, clinical, and follow-up data of patients referred for angina to our institution (located in southern Europe) and undergoing coronary angiography were analyzed retrospectively. A deep convolutional neural network (DCNN) was designed to predict follow-up mortality from CXRs. External validation was performed on patients referred to a different medical Institution (located in north-western Europe). Results 6031 was randomly divided for model training (70%; n=4259) and model fine-tuning/model validation (10%; n=602). Internal clinical validation (model testing) was performed with the remaining patients (20%; n=1170). Patients were stratified according to AI-based interpretation quartiles (DCNN-CXR risk score). Median follow-up was 6.1 years (IQR 3.3 – 8.7) with a Kaplan-Meier (KM) overall estimated mortality of 21.9% (CI 19.2%-24.5%). Estimated mortality increased significantly according to the DCNN-CXR risk score (Low-risk 5%, Moderate 17%, High 29%, Very High 46%; p<0.0001) (figure 1-A). At Cox regression, the AI-derived CXR-score was the strongest predictor of follow-up mortality (p<0.005; OR: 3.16; CI: 2.47-3.85) and had an AUC of 0.793 (95% AUC CI: 0.759-0.827, Sens. 78%, Spec. 0.68%), that was significantly better than that achieved when using coronary angiography findings (AUC: 0.569, 95% CI: 0.526-0.611) (p<0.001) and age (AUC 0.735, 95% CI: 0.694-0.776) (p<0.004) as predictors (figure 1-B). The DCNN-CXR mortality prediction model improved when age and CAD status at the referral time were included (AUC 0.81; CI: 0.775-0.843). Preliminary results on external validation confirmed the DCNN-CXR-risk prediction performance (AUC 0.712 CI: 0.495-0.928; Sens 0.838; Spec 0.338). Conclusion Our DCNN model predicted, from a CXR, long-term overall mortality of patients with suspected angina pectoris referred for coronary angiography. The performance has been confirmed at internal and external validation, on patients in a different European country. The DCNN CXR-risk score could stratify long-term mortality risk better than any other risk factor, including CAD presence and degree. These findings may be used to optimize screening and prevention actions for this very comorbid group of patients.

Abstract 12552: Unmasking Unstable Angina: The Crucial Influence of Chest Pain Perception in Hospital Management Strategies

Introduction: Managing unstable angina (UA) poses a significant challenge due to its subjective diagnosis and underrepresentation in pivotal clinical trials that have greatly influenced current practices. The aim of this study is to determine the key variables that impact the management of UA in a referral cardiology hospital. Hypothesis: In addition to prognostic scores, other factors such as the nature of chest pain may have a relevant role in the management of UA. Methods: This retrospective cohort study enrolled patients consecutive hospitalized with a diagnosis of UA from July 16, 2018 to February 28, 2020. The primary objective was to analyze the factors associated with the utilization of either an invasive or non-invasive strategy. The secondary objective sought to identify the factors associated with the presence of obstructive coronary artery disease (CAD) or ischemia, as determined by the results of complementary tests. Between-group comparisons were performed using multiple logistic regression analysis, with statistical significance set at a 5% level. Results: A total of 729 patients were included in the study, with a mean age of 62.9 years, with a male predominance (64.6%). Factors significantly associated with an invasive strategy were smoking (p = 0.001), type of chest pain (p < 0.001), angina "in crescendo" (p = 0.006), TIMI risk (p = 0.006), and HEART score (p = 0.011). In the multivariate analysis, current smokers (OR 2.23, CI 95% 1.13-4.8) and type A chest pain (OR 3.39, CI 95% 1.93-6.66) were independently associated with the invasive strategy. Regarding the presence of obstructive CAD or ischemia, male gender (p = 0.032), exertional chest pain (p = 0.037), Diamond-Forrester (p = 0.026) and TIMI risk (p = 0.001) showed significant associations. In the multivariate analysis, the type of chest pain (type B chest pain: OR 0.6, CI 95% 0.38-0.93, p = 0.026) and presence of previous CAD (OR 1.42, CI 95% 1.01-2.0, p = 0.048) were independently associated with obstructive CAD or ischemia. Conclusion: Chest pain type is not only instrumental in diagnosing UA but also critical in shaping the suitable treatment approach. Our study emphasizes the significance of integrating pain traits with guidelines-endorsed scoring systems for optimal management.

Abstract 16384: Interaction of Socioeconomic Status With Polygenic Risk for Coronary Artery Disease in a Novel Biobank

Introduction: Socioeconomic status (SES) has a measurable and significant impact on cardiovascular disease incidence and outcomes. Study of its potential interactions with other known risk factors, such as genetics, remains an area for further research. Aim: To examine the interaction of polygenic risk for coronary artery disease (CAD) with socioeconomic status, as represented by income bracket. Methods: We utilized the NIH All of Us biobank, which integrates whole genome sequencing, electronic health record, and survey data. A previously-validated PRS for CAD (Inouye et al., 2018) was calculated for each patient. We subsetted the sample into high, medium, and low genetic risk groups per z-scores for the PRS: z-score >1, between 1 and -1, and <-1 respectively. Income information was derived from the survey data. Multivariable logistic regression was used to assess the performance of the PRS in this sample, with outcome defined as presence of CAD. The model was adjusted for PRS, age, gender, and the first 4 principal components of ancestry. Both income and the interaction of PRS by income were included as covariates. Results: In this sample of 97,405 individuals, this PRS is strongly associated with CAD prevalence: adjusted odds ratio for CAD per SD of the PRS was 1.96 (95% CI, 1.83-2.10). We then observed a differential effect of income on CAD. In the low and medium genetic risk groups, increasing income was associated with lower CAD prevalence. In the high genetic risk group, this protective effect was lost and CAD prevalence was overall similar across income brackets. Conclusions: These findings suggest a complex interaction between genetic risk of CAD and SES. High risk individuals may not derive the same benefit of improved SES and its material benefits. This unique subgroup will require uniquely targeted interventions, highlighting the need for deeper study of genetic risk in order to actualize the promises of precision medicine.

Abstract 13306: Substantial Variation in the Rate of Coronary Artery Disease Among Ontario Immigrants

Immigrants constitute a substantial proportion of the population in Western Europe and North America. Although prior studies have suggested that a "healthy immigrant effect" exists, little is known about the extent and variation of stable obstructive coronary artery disease (CAD) among immigrants. We evaluated the association of country of origin and the rates of stable CAD among immigrants. We assembled a cohort of immigrants and non-immigrants who received elective cardiac catheterization in Ontario, Canada, between April 1, 2012 and March 31, 2021. Immigrants were categorized by their country of origin into 7 regions: Africa, Caribbean, Latin America, Western Countries, East Asia, South Asia, and Middle East. Our main outcome was the rate of obstructive CAD (left main stenosis ≥50% or major epicardial vessel stenosis ≥70%). Multivariable logistic regression analyses adjusting for age, cardiac risk factors, and socioeconomic status was used to study the association of country of birth with presence of CAD. The study included 208,363 non-immigrants and 36,139 immigrants: 13,503 from South Asia, 6,839 from Western Countries, 5,036 from East Asia, 4,374 from the Middle East, 2,481 from Latin America, 2,320 from Caribbean, and 1,586 from Africa. Obstructive CAD was found in 47.1% of immigrants and 47.4% of non-immigrants. Immigrants from South Asia had the highest rate of obstructive CAD at 53.7% and those from the Caribbean had the lowest rate at 32.5%. South Asian men and women had the highest odds of obstructive CAD compared to non-immigrants (Figure). Despite the conventional belief that immigrants have better health status, we found that immigrants in Canada had higher odds of obstructive CAD than non-immigrants. In addition, significant variation exists among patients by country of origin even after accounting for the traditional cardiac risk factors.

Abstract 12258: Ceramides Predict the Development of Type 2 Diabetes

Introduction: Ceramides recently have attracted interest as a marker of cardiovascular event risk. Hypothesis: We hypothesize that they play a role in the development of type 2 diabetes (T2DM). Methods: We analyzed the ceramide ratio Cer d18:18/Cer d 18:24:0 (CerRatio) in 894 consecutive Caucasian patients who were referred to angiography for the evaluation of established or suspected stable coronary artery disease (CAD). T2DM was diagnosed according to ADA criteria. The incidence of T2DM was recorded over a follow-up time of up to 16 years (median: 13 [8-14] years). Results: At baseline, the CerRatio was significantly higher in T2DM (n=239) than in non-diabetic patients (4.6e-2 vs. 3.9e-2, p<0.001). During follow-up, diabetes was newly diagnosed in 71 patients, i.e. in 11% of the initially non-diabetic subjects. The CerRatio strongly predicted the incidence of T2DM both univariately (standardized OR 1.47 [1.11-1.96]; p=0.008) and in a multivariately adjusted model (figure) comprising age, sex, BMI, the presence of significant CAD at angiography, and hemoglobin A1c (HbA1c; OR=1.45 [1.07-1.98]; p=0.018). Though the CerRatio was significantly correlated with BMI (r=0.138, p<0.001) and HbA1c (r=0.137, p<0.001), applying a mediation analysis revealed that BMI and HbA1c had only marginal indirect effects (5,7% and 3.6%, respectively) on the association of the CerRatio with T2DM incidence. Conclusions: We conclude that ceramides strongly and independently predict the development of diabetes.

Abstract 13692: Incidence, Recurrence, and Ethnicity Specific Risk Factors for Premature Coronary Artery Disease in South Asians and Europeans

Introduction: Premature coronary artery disease (CAD) incidence is increasing globally. South Asians (SA) have a disproportionately high burden of atherosclerotic cardiovascular disease (ASCVD). However, the effect of SA ethnicity on the risk of recurrent events in patients with premature CAD has not been prospectively evaluated. Methods: Patients in the SAVEBC and UK biobank (UKB) registries were enrolled and stratified by ethnicity and presence of premature CAD. The co-primary outcomes were to compare proportion of premature CAD and the incidence of recurrent ASVCD events. Secondary exploratory outcomes included describing demographic, physical, biochemical variables between cohorts. Results: 11,136 patients were included, 1,129 (143 SA; 21%) were from SAVEBC and 10,007 (400 SA; 4.0%) from UKB. There was a higher proportion of premature CAD in SA compared to Caucasians in UKB (5.2% vs. 2.0%, p < 0.001). Similarly, SA were overrepresented in SAVEBC (21% of cohort vs. 7.9% of British Columbia population). SA compared to Caucasians with premature CAD had increased prevalence of diabetes (SAVEBC: 20.1% vs 13.8%, p=0.08; UKB: 37.5% vs 18.0%, p<0.001), and lower mean HDL cholesterol (SAVEBC: 1.4±0.4 vs 1.5±0.4, p=0.21; UKB: 1.1±0.3 vs 1.2±0.3, p<0.001). SA had more diffuse disease reflected by more coronary segments affected (4.9±3.0 vs. 4.1±2.6, p=0.05), and a trend towards more affected coronary vessels compared to Caucasians (1.31±1.4 vs. 0.61±0.91, p=0.14). SA had greater incidence of recurrent ASCVD vs. Caucasians (4.19 vs. 3.08 events per 100 P-Y; incidence rate ratio p-value < 0.001). SA had higher risk of recurrent ASCVD events (HR 1.35, 95% CI 1.13,1.61, p<0.001). SA ethnicity remained a predictor of recurrent events on adjusted COX regression (HR 1.24, 95% CI 1.03,1.48, p=0.02). Conclusion: Using two prospective registries, SA had a higher proportion of premature CAD and recurrent cardiovascular events with shorter time to recurrent events. Some risk may be explained by adverse cardiometabolic profiles, however significant risk mechanisms are yet to be elucidated. Understanding the unique mechanisms of cardiovascular risk in SA is critical to appropriately identify high-risk individuals and initiate contemporary preventative therapies.

Absence of Coronary Artery Disease is a Strong Negative Predictor of Major Adverse Cardiovascular Events in Patients with Chronic Kidney Disease.

To investigate the interplay between chronic kidney disease (CKD) and coronary artery disease (CAD) on the incidence of cardiovascular events in patients with suspected chronic coronary syndrome (CCS). Patients with suspected CCS who underwent first-time coronary angiography in Western Denmark between 2003 and 2016 were included in this cohort study. Moreover, an age- and sex-matched general population cohort was established. Patients were stratified according to estimated glomerular filtration rate (eGFR). Presence of CAD was defined as ≥1 obstructive stenosis or non-obstructive diffuse disease. Major adverse cardiovascular events (MACE) were defined as a composite of myocardial infarction, ischemic stroke, and cardiac death. A total of 42,611 patients were included with a median follow-up of 7.3 years. Patients without and with CAD had MACE rates per 100 person-years that were 0.52 and 1.67 for eGFR ≥90 mL/min/1.73 m2, 0.68 and 2.09 for eGFR 60-89 mL/min/1.73 m2, 1.27 and 3.85 for eGFR 30-59 mL/min/1.73 m2, and 2.27 and 6.92 for eGFR <30 mL/min/1.73 m2. Comparing to eGFR ≥90 mL/min/1.73 m2, the adjusted incidence rate ratios for MACE were 1.29 (1.10-1.51) for eGFR 60-89 mL/min/1.73 m2, 1.86 (1.49-2.33) for eGFR 30-59 mL/min/1.73 m2, and 3.57 (1.92-6.67) for eGFR <30 mL/min/1.73 m2 in patients without CAD, and 1.11 (1.03-1.20), 1.71 (1.55-1.90), and 2.46 (1.96-3.09) in patients with CAD. The inverse relationship between kidney function and risk of MACE was confirmed when comparing patients with and without CAD to matched individuals in the general population. Absence of CAD is a strong negative predictor of major adverse cardiovascular events in patients with CKD.

Predictive value of machine learning algorithm of coronary artery calcium score and clinical factors for obstructive coronary artery disease in hypertensive patients

BackgroundThe addition of coronary artery calcium score (CACS) to prediction models has been verified to improve performance. Machine learning (ML) algorithms become important medical tools in an era of precision medicine, However, combined utility by CACS and ML algorithms in hypertensive patients to forecast obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) is rare.MethodsThis retrospective study was composed of 1,273 individuals with hypertension and without a history of CAD, who underwent dual-source computed tomography evaluation. We applied five ML algorithms, coupled with clinical factors, imaging parameters, and CACS to construct predictive models. Moreover, 80% individuals were randomly taken as a training set on which 5-fold cross-validation was done and the remaining 20% were regarded as a validation set.Results16.7% (212 out of 1,273) of hypertensive patients had obstructive CAD. Extreme Gradient Boosting (XGBoost) posted the biggest area under the receiver operator characteristic curve (AUC) of 0.83 in five ML algorithms. Continuous net reclassification improvement (NRI) was 0.55 (95% CI (0.39–0.71), p < 0.001), and integrated discrimination improvement (IDI) was 0.04 (95% CI (0.01–0. 07), p = 0.0048) when the XGBoost model was compared with traditional Models. In the subgroup analysis stratified by hypertension levels, XGBoost still had excellent performance.ConclusionThe ML model incorporating clinical features and CACS may accurately forecast the presence of obstructive CAD on CCTA among hypertensive patients. XGBoost is superior to other ML algorithms.

The relationship of diagonal earlobe crease (Frank's sign) and obstructive coronary artery disease in patients undergoing coronary angiography.

Traditional risk factors for cardiovascular disease (CVD) play an important role in the clinical evaluation of patients with symptoms suggestive of coronary artery disease (CAD). The utility of the diagonal earlobe crease (DELC) in predicting the presence of CAD is controversial. To investigate the association between DELC, traditional CVD risk factors, and obstructive CAD. This prospective study included 1377 patients (mean age 65 ± 10years, 64% male) who underwent invasive coronary angiography for suspected acute or chronic coronary syndromes. In addition to routine clinical assessment, all patients underwent visual examination of both earlobes for the presence of DELC. All assessments were made by three independent readers, with amajority vote in the case of disagreement. Obstructive CAD was defined by invasive coronary angiography as > 50% stenosis of the left main coronary artery or > 70% stenosis in any other major epicardial coronary artery. Bilateral DELC was observed more frequently in patients with obstructive CAD than in those without it (67% vs. 33%, p = 0.022). In the multivariate logistic regression model, bilateral DELC was independently associated with CAD (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.07-1.74), along with smoking (OR 1.86, 95% CI 1.44-2.38), diabetes mellitus (OR 1.67, 95% CI 1.29-2.15), male sex (OR 2.04, 95% CI 1.61-2.58), and dyslipidemia (OR 1.54, 95% CI 1.12-2.30); however, the diagnostic accuracy of DELC was modest and resembled that of traditional CVD risk factors. Despite being independently associated with obstructive CAD, DELC is not areliable stand-alone clinical marker of CAD due to modest diagnostic accuracy.

Atherogenic Index of Plasma Predicts Obstructive Coronary Artery Disease in Patients with Stable Angina Pectoris.

Chronic coronary syndrome is associated with several risk factors, such as dyslipidemia and hypertension. The atherogenic index of plasma (AIP) has been demonstrated to be a biochemical risk factor for coronary artery disease (CAD). This study aimed to determine whether the AIP is an effective parameter for estimating obstructive CAD. A total of 345 patients (with a mean age of 62.2 ± 10.3; 63% male) who underwent coronary angiography were included in this study. Obstructive CAD is defined as having one or more vessels with a stenosis level of ≥50%. Depending on the presence of obstructive CAD, all patients were divided into two groups. The mean AIP value was found to be 0.538 ± 0.26 in the study group. The AIP values were significantly higher in the obstructive coronary artery group (AIP; 0.49 ± 0.26 vs. 0.58 ± 0.27, p = 0.002). According to a univariable analysis, AIP values were significantly associated with obstructive coronary artery disease [OR: 3.74 (CI 95% 1.62-8.64), p = 0.020]. The AIP was further adjusted for confounding risk factors in three multivariable analysis models and, all three models showed a significant association. According to an ROC analysis, 0.49 is the cut-off value for AIP, and a value above 0.49 indicates 50% coronary artpery stenosis. The AIP may be used in the assessment of cardiovascular risk for patients with stable angina pectoris, and it may also be used to estimate obstructive CAD.

Coronary Artery Disease: A Key Issue in Type 2 Myocardial Infarction: Systematic Review and Recent Findings.

Underlying coronary artery disease (CAD) is increasingly considered to be a key issue in the pathophysiology of type 2 myocardial infarction (T2MI). In T2MI, which is attributable to a mismatch between oxygen supply/demand, CAD is common and appears to be more severe than in type 1 myocardial infarction (T1MI). Little is known about the heterogeneous mechanisms that cause supply/demand imbalance and non-coronary triggers leading to myocardial ischemia or about how they are potentially modulated by the presence and severity of CAD. CAD seems to be underrecognized and undertreated in T2MI, even though previous studies have demonstrated both the short and long-term prognostic value of CAD in T2MI. In this literature review, we attempt to address the prevalence and severity of CAD, challenges in the discrimination between T2MI and T1MI in the presence of CAD, and the prognostic value of CAD among patients with T2MI.

Temporal trends and outcomes of patients with chronic limb-threatening ischemia with and without history of coronary artery disease: insights from the us national inpatient sample database.

The burden and prognostic significance of coronary artery disease (CAD) in adults with peripheral artery disease and chronic limb-threatening ischemia (CLTI) is unknown. Temporal trends in prevalence of significant CAD (history of myocardial infarction or coronary revascularizations) in hospitalizations for CLTI were determined using the 2000 to 2018 National Inpatient Sample (NIS) database. A multivariable regression analysis of outcomes was performed based on presence or absence of CAD. Among 13 575 099 hospitalizations for CLTI (41% female, 69% white, mean age 69 years), 23% had concomitant CAD, of which 11% underwent lower extremity arterial revascularization (43.6% endovascular and 56.4% surgical). The prevalence of concomitant CAD with CLTI increased from 15.3% in 2000 to 23.1% in 2018. Furthermore, the frequency of endovascular revascularization in adults with CAD and CLTI increased from 15.1% to 48.3%, while there was a decreasing trend of surgical revascularization, from 84.9% to 51.7%. After multivariate adjustments, CLTI with CAD was associated with increased risk of in-hospital mortality (OR, 1.40; 95% CI, 1.32-1.47; P less than .0001) and bleeding requiring transfusion (OR, 1.10; 95% CI, 1.06-1.12; P less than .0001) compared with patients with CLTI without CAD. As compared with surgical revascularization, endovascular revascularization was associated with lower risk of in-hospital mortality in both patients with CLTI with CAD (OR, 0.69; 95% CI, 0.63-0.76; P less than .001) and CLTI without CAD (OR, 0.71; 95% CI, 0.67-0.76; P less than .001). Prevalence of CAD has increased in adults presenting with CLTI and is associated with poor outcomes, warranting the need for effective interventions and secondary prevention in this high-risk population.

Coronary Computed Tomographic Angiography With Fractional Flow Reserve in Patients With Type 2 Myocardial Infarction

BackgroundType 2 myocardial infarction (T2MI) related to a supply/demand imbalance of coronary blood flow is common and associated with poor prognosis. Coronary artery disease (CAD) may predispose some individuals to T2MI and contribute to its high rate of recurrent cardiovascular events. Little is known about the presence and extent of CAD in this population. ObjectivesThe goal of this study was to evaluate the presence and characteristics of CAD among patients with T2MI. MethodsIn this prospective study, consecutive eligible individuals with Fourth Universal Definition of Myocardial Infarction criteria for T2MI were enrolled. Participants underwent coronary computed tomography angiography (CTA), fractional flow reserve derived with coronary CTA (FFRCT), and plaque volume analyses. ResultsAmong 50 participants, 25 (50%) were female, and the mean age was 68.0 ± 11.4 years. Atherosclerotic risk factors were common. Coronary CTA revealed coronary plaque in 46 participants (92%). A moderate or greater stenosis (≥50%) was identified in 42% of participants, and obstructive disease (≥50% left main stenosis or ≥70% stenosis in any other epicardial coronary artery) was present in 26%. Prevalence of obstructive CAD did not differ according to T2MI cause (P = 0.54). A hemodynamically significant focal stenosis identified by FFRCT was present in 13 participants (26%). Among participants with a stenosis ≥50% (n = 21), FFRCT excluded lesion-specific hemodynamically significant stenosis in 8 cases (38%). ConclusionsAmong individuals with adjudicated T2MI, CAD was prevalent, but the majority of patients had nonobstructive CAD. Mediators of ischemia are likely multifactorial in this population. (Defining the Prevalence and Characteristics of Coronary Artery Disease Among Patients with Type 2 Myocardial Infarction using CT-FFR [DEFINE TYPE 2 MI]; NCT04864119)

Assessment of Inflammatory Hematological Ratios (NLR, PLR, MLR, LMR and Monocyte/HDL-Cholesterol Ratio) in Acute Myocardial Infarction and Particularities in Young Patients.

Cardiovascular disease, particularly coronary artery disease (CAD), remains a predominant cause of mortality globally. Factors such as atherosclerosis and inflammation play significant roles in the pathogenesis of CAD. The nexus between inflammation and CAD is underscored by the role of immune cells, such as neutrophils, lymphocytes, monocytes, and macrophages. These cells orchestrate the inflammatory process, a core component in the initiation and progression of atherosclerosis. The activation of these pathways and the subsequent lipid, fibrous element, and calcification accumulation can result in vessel narrowing. Hematological parameters derived from routine blood tests offer insights into the underlying inflammatory state. Recent studies have highlighted the potential of inflammatory hematological ratios, such as the neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, monocyte/lymphocyte ratio and lymphocyte/monocyte ratio. These parameters are not only accessible and cost-effective but also mirror the degree of systemic inflammation. Several studies have indicated a correlation between these markers and the severity, prognosis, and presence of CAD. Despite the burgeoning interest in the relationship between inflammatory markers and CAD, there remains a paucity of data exploring these parameters in young patients with acute myocardial infarction. Such data could offer valuable insights into the unique pathophysiology of early-onset CAD and improve risk assessment and predictive strategies.

Epicardial Fat Volume as a Good Predictor for Multivessel Coronary Artery Disease.

Epicardial adipose tissue may have an important role in the pathogenesis of coronary artery disease (CAD). We aimed to study the association between epicardial fat volume (EFV) and presence of obstructive as well as multivessel CAD. A total of 87 adult subjects with suspected CAD who underwent both quantified by multidetector computerized tomography (MDCT) and Invasive Coronary Angiography (ICA) were enrolled in this observational study. EVF was measured by MDCT by calculating the sum of cross- sectional areas of fat multiplied by slice thickness. EFV measurement and its association with the presence of obstructive CAD (defined as coronary artery stenosis > 70%) was evaluated. Overall, 89.6% patients had obstructive CAD with higher EFV as compared to 10.3% patients with non-obstructive CAD (57 ± 20.14 cm3 vs. 44 ± 7.4 cm3; P < 0.001). Furthermore, EFV was significantly increased in group II as compared with group I (74 ± 24.3 ml vs. 53 ± 16.2 ml; P < 0.003). On the hand, the coronary calcium score (CAC) was insignificantly increased in group II as compared with group I (486.1 vs. 211.2; P = 0.10). Multivariate analysis revealed that, EFV might be an independent risk factor for not only the presence of obstructive CAD (odds ratio [OR], 1.062; 95% CI 1.018- 1.108; P < 0.005) but also in predicting multivessel disease affection. Our results demonstrated that, EFV was significantly increased not only with obstructive CAD, independent of other traditional risk factors and CAC score, but also it can be considered a good predictor of multivessel disease occurrence.

Aortic root diameter, main pulmonary artery diameter/aortic root diameter and pericardial fat volume as predictors of occlusive coronary artery disease.

The clinical relevance of aortic root diameter (ARD), main pulmonary artery diameter (MPAd), or pericardial fat volume (PFV) in the assessment of coronary artery disease (CAD) is largely unknown. We aimed to assess the relationship of PFV, ARD, MPAd, and MPAd/ARD ratio with occlusive CAD (stenosis >50%).This cross-sectional study included patients who had chest pain suggestive of CAD and underwent a 64-multislice multi-detector computed tomography angiography exam to exclude occlusive CAD presence. A total of 145 patients were enrolled in this study. The mean age was 54±10 years, and 51% were males. The mean PFV, ARD, MPAd, and MPAd/ARD ratio in all patients were 155 cm3, 29.9 mm, 23.4 mm, and 0.8, respectively. On univariate analysis, PFV [odds ratio (OR) (confidence interval, CI)=1.1 (1.01-1.3), p<0.01], ARD [OR (CI)=1.2 (1.1-1.4), p<0.01], and MPAd/ARD ratio [OR (CI)= 0.2 (0.1-0.5), p=0.02] showed significant association with occlusive CAD presence. After adjusting for cardiac risk factors, only PFV [OR (CI)=1.1 (1.02-1.3), p<0.01], but not ARD [OR (CI)=0.9(0.3-2), p=0.85] or MPAd/ARD ratio [OR (CI)=0.1(0.1-2), p=0.69], was independently associated with occlusive CAD. In conclusion, increased PFV, but not ARD or MPAd/ARD ratio, showed a significant and independent association with occlusive CAD presence in patients with chest pain suggestive of CAD.

Coronary artery disease and its management in TAVI

ObjectiveAortic stenosis and coronary artery disease (CAD) are frequently associated. The preprocedural evaluation and indications for treatment in patients undergoing transcatheter aortic valve intervention (TAVI) remain controversial.This study sought to 1) determine the prevalence and angiographic characteristics of CAD in TAVI candidates, along with revascularization patterns, and 2) to evaluate the impact of the presence and complexity of CAD, as well as angiography-guided percutaneous coronary intervention, on prognosis after TAVI. MethodsSingle-center retrospective study from a prospectively collected institutional registry that included all patients that underwent TAVI between 2009 and 2018 and pre TAVI coronary angiography (CA) in our institution in the context of pre-procedure work-up. A multivariate analysis was performed to determine the effect of CAD and PCI on 2-year mortality. ResultsA total of 379 patients were included: 55 patients (14.5%) presented with normal coronary arteries, 120 (31.6%) with non-obstructive CAD, and 204 (53.8%) with obstructive CAD (the mean SxS was 8.2). Ultimately, 110 patients (29%) underwent PCI. Two-year survival after TAVI was decreased in patients with complex coronary lesions (SS > 22), while it was not affected by the overall presence of non-obstructive CAD, obstructive CAD, residual SxS, or pre-TAVI PCI of angiographically significant lesions (OR 0.631, 95%CI 0.192-1.406). ConclusionIn our population, the overall presence and management of obstructive CAD did not appear to impact mortality at 2 years after TAVI. Survival was decreased in patients with baseline complex coronary anatomies.