Presence Of Significant Coronary Artery Disease Research Articles

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.

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.

Association of Klotho with Coronary Artery Disease in Subjects with Type 2 Diabetes Mellitus and Preserved Kidney Function: A Case-Control Study.

Circulating Klotho levels are significantly reduced in subjects with type 2 diabetes mellitus (T2DM) and in kidney disease patients. In this work, the relationship between Klotho levels and the coronary artery disease (CAD) burden in subjects with T2DM and preserved kidney function was analyzed. For this, we performed a cross-sectional case-control study involving 133 subjects with T2DM and 200 age-, sex- and CAD-incidence-matched, non-diabetic patients undergoing non-emergency diagnostic coronary angiography. All of them were non-albuminuric and with normal glomerular filtration rates. The concentrations of serum Klotho, fibroblast growth factor 23, and inflammatory markers were also measured. As expected, the serum Klotho concentration was lower in the T2DM group (12.3% lower, p = 0.04). However, within the group of patients with T2DM, those subjects with CAD presented significantly higher Klotho levels than those without significant coronary stenosis (314.5 (6.15-562.81) vs. 458.97 (275.2-667.2) pg/mL; p = 0.02). Multiple regression analysis revealed that serum Klotho was positively related with stenosis values exclusively in subjects with T2DM (adjusted R2 = 0.153, p < 0.01). Moreover, logistic regression analysis showed that Klotho was positively associated with the presence of significant CAD in the group of T2DM patients (OR: 1.001; p = 0.041). Our data suggest that higher levels of circulating Klotho in subjects with T2DM and preserved kidney function are associated with the presence of significant CAD.

Global Longitudinal Strain Measured by 2D Speckle Tracking Echocardiography in Stable Angina Patients and Their Angiographic Correlation

Introduction &amp; Objective: Myocardial strain assessed by Speckle Tracking Echocardiography (STE) quantifies myocardial deformation which appears earlier than wall motion abnormality. Thus Global Longitudinal Strain (GLS) assess myocardial function in early stage of ischemic evolution. The aim of the study was to estimate GLS in coronary angiography undergoing intermediate to high risk stable angina patients which could correlate GLS with significant Coronary Artery Disease (CAD), determine cut-off value for identifying significant CAD and find sensitivity and specificity for the GLS cut-off value. Methods: This was a cross-sectional study which included stable angina patients with normal left ventricular ejection fraction who were otherwise indicated to undergo coronary angiography. All the patients underwent STE and their GLS value was calculated. The coronary artery angiography findings were then correlated with GLS using appropriate statistics. Results: A total of 89 patients were included. There was a strong negative correlation (r = -0.824) between GLS value and presence of significant CAD. The mean values of GLS for single vessel disease, double vessel disease and triple vessel disease were -15.94 ± 7.30, -15.28 ± 0.58 and -11.59 ± 1.35 (P &lt;0.001) respectively. The GLS cut-off value ≤ -18.5 identified significant CAD and the sensitivity, specificity and area under curve for this cut-off value was 96.8%, 85.2% and 0.937 respectively (P&lt;0.001). Conclusion: Global longitudinal strain is a sensitive, specific and excellently accurate modality that had a strong negative correlation with presence and severity of significant CAD.

158-OR: Ceramides Predict the Development of Type 2 Diabetes

Ceramides recently have attracted interest as a marker of cardiovascular event risk. However, only little is known about their role in the development of type 2 diabetes (T2DM). 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). At baseline, the CerRatio was significantly higher in T2DM (n=239) than in nondiabetic patients (4.6e-2 vs. 3.9e-2, p&amp;lt;0.001). During follow-up, diabetes was newly diagnosed in 71 patients, i.e. in 11% of the initially nondiabetic 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&amp;lt;0.001) and HbA1c (r=0.137, p&amp;lt;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. We conclude that ceramides strongly and independently predict the development of diabetes. Disclosure A. Leiherer: None. A. Muendlein: None. T. Plattner: None. A. Vonbank: None. A. Mader: None. L. Sprenger: None. M. Maechler: None. B. Larcher: None. P. Fraunberger: None. H. Drexel: None. C.H. Saely: None.

Global Myocardial Work Combined with Treadmill Exercise Stress to Detect Significant Coronary Artery Disease

Myocardial work (MW) derived from the left ventricular pressure-strain loop is a novel and noninvasive method for assessing left ventricular function that accounts for loading conditions. We aimed to explore whether global MW combined with treadmill exercise stress could detect significant coronary artery disease (CAD) in patients with angina pectoris. Eighty-five patients with angina pectoris and no prior CAD history were included. All patients underwent treadmill exercise stress echocardiography and coronary angiography. Global MW was constructed from speckle-tracking echocardiography indexed to the brachial systolic blood pressure. The association between MW parameters and the presence of significant CAD was assessed with logistic regression. The discriminative power of MW parameters to detect CAD was assessed with receiver operative characteristic curve, net reclassification improvement, and integrated discrimination improvement analysis. Twenty-five patients had a positive exercise echocardiogram, while significant coronary artery stenosis (≥70% in one or more major epicardial vessels or ≥50% in the left main coronary artery) was observed in 41 patients. The global wasted work (GWW) and global work efficiency (GWE) were significantly higher or lower, respectively, in patients with significant CAD compared with those of nonsignificant CAD at the peak exercise and during recovery periods (P<.05 for all). Multivariate logistic regression analysis demonstrated that peak GWE and recovery GWW could predict significant CAD. Peak GWE had the highest area under the receiver operating characteristic curve (AUC) among all global MW parameters (AUC=0.836). Furthermore, a model comprising peak GWE and recovery GWW performed better for the identification of significant CAD than peak GWE alone (AUC=0.856). Peak GWE could detect significant CAD. The new model, incorporating peak GWE and recovery GWW, not only identified but also provided additional value for estimating the probability of significant CAD. Global MW parameters combined with exercise stress perform as an accurate noninvasive screening before the invasive diagnostic technique.

Prognostic impact of the presence and management of coronary artery disease in patients undergoing TAVI

Abstract Introduction Approximately half of transcatheter aortic valve implantaton (TAVI) candidates have coronary artery disease (CAD). Controversial results have been reported regarding the effect of the presence/severity of CAD and its management on clinical outcomes post-TAVI. Aim To describe the presence, extension, severityand management of CAD pre-TAVIand to evaluate its impact on 2-yearmortality in areal world all comers population. Methods and population Single centre retrospective analysis from a prospectively collected institutional registry (VCROSS) including 517 patients that underwent TAVI for severe aortic stenosis between January 2009 and December 2018. Patients who underwent pre TAVI CA in the context of ACS or at other institution were excluded n=138. Ultimately 380 entered the analysis. Obstructive CAD was defined as stenosis &amp;gt;50% in in major epicardial vessels (&amp;gt;2.5 mm). The total number of major epicardial with obstructive CAD was reported as was assessed the number of those left untreated. Univariate analysis was performed to assess 1) differences between patients with or without CAD and between those with significant CAD who have or have not undergone PCI, 2) variables associated with 2-year mortality. Binary logistic regression was performed to identify independent predictors of 2-year mortality including the presence of significant CAD and the type of management. Results A total of 380 patients were included, 55.3% male with an average age of 83YO (±6.3), mean Euroscore II of 4.35. 76 had previous coronary artery bypassgrafting (CABG) and 136 had previous PCI (43 had both). 55 patients (14.4%) presented with normal coronary arteries, 120 (31.6%) with non-obstructive CAD and 205 (54%) with obstructive CAD. Out of the latter, 112 (29.5%) underwent PCI. Statistically significant differences were found between obstructive CAD vs non-obstructive patients in terms of age, previous history of ICP and CABG. In the subgroup population with obstructive CAD, no statistically significant differences was found in the PCI vs non PCI group, apart from previous history of ICP and CABG – Figure 1. Diabetes mellitus, previous history of percutaneous coronary intervention (PCI) and reduced ejection fraction (rEF – defined has &amp;lt;50% echocardiographically) had a negative prognosticimpact in the 2 year mortality of the 380 patients. 2-year mortality was 14,5% (55 patients).The presence and management of CAD pre TAVI had no impact in 2-year mortality, when accounting for the differences in previous ICP history, CABG, age, and rEF. Conclusion The presence and type of management of obstructive CAD in this real world all comers registry did not impact the prognosis at 2 years. Funding Acknowledgement Type of funding sources: None.

Homozygosity of the TT methylenetetrahydrofolate reductase C677T genotype is an independent long-term predictor of cardiac death in patients with premature myocardial infarction

Background Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism is the main genetic modulator of homocysteine. Data suggest a potential association of homozygosity for the TT MTHFR genotype with premature myocardial infarction (MI). We explored whether TT homozygosity is associated with long-term prognosis in patients with premature ST-segment elevation MI (STEMI). Methods A total of 265 consecutive patients who had survived their first STEMI ≤35 years of age were followed for a median of 8 years (5–12). Primary endpoints were cardiac death and secondary endpoints were hospitalizations for acute coronary syndrome, myocardial revascularization, arrhythmic event or ischemic stroke. Serum lipids, homocysteine, folate levels were measured at baseline and all patients were also tested for the MTHFR C677T polymorphism. Results During follow-up 14 patients died (cardiac death) [5.3%] while 84 (31.7%) met the secondary endpoints. In univariate Cox regression analysis TT homozygosity predicted the occurrence of cardiac death (Hazard ratio (HR): 4.071; 95% confidence interval (CI): 1.404–11.809, p = .010) but not the occurrence of secondary endpoints (HR: 0.877; 95% CI: 0.479–1.605, p = .669). TT homozygosity remained an independent predictor of cardiac death after adjustment for conventional risk factors (i.e., sex, diabetes mellitus, hypertension, family history of premature coronary artery disease [CAD]) [HR: 4.350; 95% CI: 1.472–12.856, p = .008]. The association also remained after adjustment for left ventricular ejection fraction or the presence of significant CAD. Conclusions Homozygosity for the TT MTHFR is an independent long-term predictor of cardiac death in patients with premature STEMI.

Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement

Background/purposeDespite the high prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS), the optimal management of concomitant CAD, including revascularization before transcatheter aortic valve replacement (TAVR), remains controversial. Contemporary, real-world practice patterns have not yet been described. We aimed to characterize the burden of CAD in contemporary TAVR patients and evaluate revascularization practices at a high-volume center. Methods/materialsWe retrospectively analyzed all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant CAD and subsequent management were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing, and pre-TAVR computed tomography (CT) imaging were analyzed. ResultsA total of 394 patients with severe AS were referred for TAVR. Thirty-nine patients (9.9%) instead underwent surgery, of whom only 5 (1.3%) received coronary artery bypass grafting. Of the remaining 355 patients, 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments, and a third underwent ischemia testing before PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who underwent PCI. ConclusionsOnly 1 in 25 contemporary TAVR patients had significant CAD and angina requiring intervention, calling into question the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms, ischemia testing and possibly pre-TAVR CT is needed to guide the need, timing, and strategy of revascularization.

Abstract 15171: Predictive Value of the Wellens’ Sign in an Ethnically Diverse Urban Population

Introduction: Wellens’ sign is a characteristic finding on ECG, often found to be indicative of severe proximal Left anterior descending artery (LAD) stenosis. Our study sought to identify the prevalence of the Wellens’ sign in the ethnically diverse population of the Bronx, NY and elucidate its relationship to the presence of significant CAD. Methods: We retrospectively analyzed an ECG database at Montefiore Medical Center of over 1.7 million ECGs, using six diagnostic codes for anterior ischemia to identify ECGs that resemble the Wellens’ sign. Of the six diagnostic codes, the ECGs of the two highest yielding codes, were identified, then manually reviewed by an electrophysiologist. Patient’s charts and demographics were reviewed and Chi Square test was used to test statistical significance of the data. Results: Of the 1,756,742 ECGs done on 433,218 patients between 2012-2019, 26,624 ECGs were isolated. Subsequently, 2186 of these ECGs were manually reviewed. Wellens’ sign was identified in 448 (0.1%) patients, of which, 229 patients underwent cardiac catheterization, while 219 patients were managed medically. There was no statistical difference seen in the prevalence of Wellens’ Type A and B pattern across various ethnic groups (P = 0.213). Significant LAD stenosis was seen in 80 (35%) patients of whom 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while 14 (6%) patients had diffuse LAD disease. Two-vessel disease was seen in 46 (20%) of the patients, and triple-vessel disease was seen in 23 (10%) of the patients. Most common indication for cardiac catheterization was NSTEMI. Takotsubo cardiomyopathy was diagnosed in 19 (8%) patients who had either no or non-obstructive CAD. Among patients with the Wellens’ sign on the ECG but did not undergo cardiac catheterization, majority had a non-ACS presentation. Conclusions: No statistical difference in the prevalence of Wellens’ sign was seen among the various ethnic groups. In our study population, Wellens’ sign was a rare ECG pattern with a prevalence of 0.1%. When seen in conjunction with a clinical setting suggestive of angina there is a high probability of underlying CAD. Although significant LAD stenosis is the known most common underlying pathology, multivessel CAD may also occur.

Compared presentation, management and long-term outcomes after acute myocardial infraction in men and women &amp;lt;50 years of age. The FAST-MI programme

Abstract The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme. Methods FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%). Results Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08). All in-hospital complications except reinfarction (1.8 vs 0.6%, p&amp;lt;0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P&amp;lt;0.001); PCI was less often used (74% vs 85.5%, P&amp;lt;0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P&amp;lt;0.001), even in patients with significant CAD (46% vs 55%, P=0.004). Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke. Conclusion There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender. Five-year mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca

Epicardial fat tissue: a new tool for identification of coronary artery disease patients?

Abstract Introduction Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD. Purpose To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD. Methods We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis &amp;gt;50%. Results One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p&amp;lt;0.001), PLAXM (r=0.372, p&amp;lt;0.001), PSAXB (r=0.445, p&amp;lt;0.001) and PSAXM (r=0.372, p&amp;lt;0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p&amp;lt;0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p&amp;lt;0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p&amp;lt;0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p&amp;lt;0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p&amp;lt;0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%. Conclusions In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction. Figure 1 Funding Acknowledgement Type of funding source: None

Combined evaluation of regional coronary artery calcium and myocardial perfusion by 82Rb PET/CT in predicting lesion-related outcome.

Cardiac imaging with positron emission tomography/computed tomography (PET/CT) allows measurement of coronary artery calcium (CAC), stress-induced myocardial ischemia and myocardial perfusion reserve (MPR). We evaluated the prognostic role of the combined assessment of regional CAC score, ischemic total perfusion defect (ITPD) and MPR in predicting lesion-related outcome in patients with suspected coronary artery disease (CAD). We studied 206 patients with suspected CAD referred to 82Rb PET/CT cardiac imaging and available coronary angiographic data. The outcome end points were cardiac death, target vessel-related myocardial infarction or coronary revascularization. Compared to vessels without event, those with event showed higher CAC score and ITPD, and lower hyperemic myocardial blood flow and MPR (all p < 0.001). At Cox regression multivariable analysis, significant CAD (≥50% stenosis) (p < 0.001), CAC score ≥ 300 (p < 0.01) and MPR <2 (p < 0.01) were independent predictors of events. The decision trees analysis for the identification of events produced five terminal nodes. The initial split was on CAC score values. For vessels with CAC <300 and MPR ≥2, no further split was performed, while vessels with CAC <300 and MPR <2 were further stratified by ITPD. For vessels with CAC ≥300 a further stratification was performed only by MPR. The worst prognosis was observed in vessels with CAC ≥300 and MPR <2 and in vessels with CAC <300, MPR <2 and ITPD ≥5%. The combination of CAC score and MPR is useful to predict the lesion-related outcome in the presence of significant CAD.

Association of Carotid Intima Media Thickness with the severity of Coronary Artery Disease in patients undergoing Coronary Artery Bypass Graft Surgery in a tertiary care center

Background and Aims: Atherosclerosis is an inflammatory process involving arteries in various organs. Carotid intima medial thickness (CIMT) can be useful noninvasive tool to detect atherosclerosis for diagnosis of significant cardiovascular disease. We aim to study the association of CIMT with severity of Coronary Artery Disease (CAD).&#x0D; Methods: This was a cross sectional, observational study conducted in 81 patients with mean age of 59.9± 8.5 years with a diagnosis of CAD undergoing coronary artery bypass graft (CABG) surgery. The CIMT was measured with B-mode ultrasound in all patients and association with severity of CAD was measured.&#x0D; Results: The prevalence of increased CIMT in our study group was 31% and carotid plaque was 69%. Presence of carotid plaque was significantly associated with severe grade CAD stenosis (t = 4, p &lt; 0.001) and presence of Chronic Total Occlusion (CTO) (p = 0.028). There was no significant correlation between mean CIMT and severity of CAD expressed as mean percentage stenosis (r = 0.179, p = 0.11) but patients with CTO had higher mean CIMT value than non-CTO group (0.86 ± 0.21 Vs 0.73 ± 0.18; p = 0.027). We found that diabetic population had greater mean CIMT values than nondiabetic population (0.82 ± 0.21 Vs 0.72 ± 0.17; p = 0.017) and higher prevalence of carotid plaque (p = 0.02). Similarly, females were more likely to have increased CIMT than males (p=0.004).&#x0D; Conclusion: We found that increased CIMT was associated with presence of CTO. Presence of carotid plaque was associated with severe grading of CAD and CTO. Carotid ultrasound can be useful noninvasive modality to predict presence of significant CAD.

P2721FFRct analysis for screening of obstructive coronary artery disease: a propensity score adjusted study

Abstract Background Guidelines recommend functional assessment in stable coronary artery disease (CAD) to guide further treatment. Computed tomography fractional flow reserve (FFRCT) has been proposed for non-invasive assessment of stable CAD. A cutoff value of FFRCT ≥0.8 has been shown cost-effective, and allowing to avoid inappropriate invasive coronary angiography (ICA). However, no results from real-life hospital registries have been reported yet. Purpose We aimed to compare the impact of FFRCT with conventional coronary CT angiography (CTA) for detecting obstructive CAD in the daily practice of a tertiary referral hospital. Methods Patients referred to CTA for suspected CAD between 2013 and 2017 were included. FFRCT analysis was introduced in 2015 and performed at the discretion of the radiologist by Heartflow Inc. FFRCT was considered abnormal if FFR was &lt;0.8 in at least one of 3 main vessels. Obstructive CAD was defined on both CTA and ICA by the presence of a stenosis ≥50% in at least one of 3 main vessels, or an invasive FFR&lt;0.8. Propension to perform a FFRCT was modeled, based on gender, cardiovascular risk factors, completion of stress test and echocardiography and presence of a lesion of more than 50% stenosis on CTA. A logistic regression adjusted for the propensity score was then performed on the use of ICA, the presence of significant CAD on ICA and revascularization rate either by PCI or CABG. Results 2906 patients (50% of male, 56±12) were included in this registry. Diabetes, hypertension, dyslipidemia and smoking were present in respectively 12.3, 30.5, 27.5 and 9% of patients. A stress ECG and a transthoracic echo were obtained in respectively 37.1 and 49% of patients. FFRCT was performed in 757 (26%) and was abnormal in 323 (42.7%) of the patients. An ICA was performed in 622 (21.4%) patients and was abnormal in 292 (46.9%). After propensity score weighting, FFRCT was associated with an increase in ICA (OR=1.58, 95% CI: 1.23–2.02, p&lt;0.01). There were no significant changes regarding ICA showing obstructive CAD with FFRCT (OR=1.13, 95% CI: 0.78–1.66, p=0.5) but a trend towards an increase of revascularization (OR=1.48, 95% CI: 0.98–2.24, p=0.06). In patient undergoing an ICA, a FFRCT ≥0.8 was decreasing the presence of significant CAD (OR=0.27, 95% CI: 0.16–0.48, p&lt;0.001), whereas a FFRCT &lt;0.8 increased the rate of revascularization (OR=24.7, 95% CI: 12.3–49.7, p&lt;0.001). Conclusion These real life data showed that, adding FFRCT to conventional CTA, and interpreting only the numerical values of FFRCT, would increase the use of ICA in patients suspected of CAD. A trend towards an increase in revascularization was also observed. Therefore, another index than the minimal FFRCT should be used to improve discrimination regarding the presence of obstructive CAD. However, normal values of FFRCT were strong predictors of the absence of significant CAD, and abnormal values of FFRCT for the need of a revascularization.

Validation of the echocardiographic assessment of epicardial adipose tissue thickness at the Rindfleisch fold for the prediction of coronary artery disease

Background and AimEchocardiography is a promising technique for the assessment of epicardial adipose tissue (EAT). Increased EAT thickness is associated with different cardiac diseases, including; coronary artery disease (CAD). Since several different echocardiographic approaches have been proposed to measure EAT, the identification of a standardized method is needed. We propose the assessment of EAT maximal thickness at the Rindfleisch fold, the reproducibility of this measurement and its correlation with EAT thickness and volume assessed at cardiac magnetic resonance (CMR). Finally, we will test the predictive role of this measurement on the presence of significant CAD. Methods and ResultsIn 1061 patients undergoing echocardiography, EAT thickness was measured at the level of the Rindfleisch fold. In 70 patients, we tested the relationship between echo-EAT thickness and EAT thickness and volume assessed at CMR. In 499 patients with suspected CAD, undergoing coronary artery angiography, we tested the predictive value of EAT on the presence of significant CAD.Echo-EAT thickness measurements had an excellent reliability as indicated by the inter-observer (ICC:0.97; 95% C.I. 0.96 to 0.98) and intra-observer (ICC:0.99; 95% C.I. 0.98 to 0.99) reliability rates. Echo-EAT thickness significantly correlated with CMR-EAT thickness and volume (p < 0.001). An EAT thickness value >10 mm discriminated patients with significant CAD at coronary angiography (p < 0.001). At multivariable analysis, including demographic data and cardiovascular risk factors, EAT thickness was an independent predictor of significant CAD and showed an additive predictive value over common atherosclerotic risk factors. ConclusionsEchocardiographic assessment of EAT thickness at the level of the Rindfleisch fold represents a simple and trustworthy method. An increased EAT thickness shows an additive predictive value on CAD over common atherosclerotic risk factors, thus suggesting its potential clinical use for CAD risk stratification.

Feasibility of myocardial perfusion assessment with contrast echocardiography: can it improve recognition of significant coronary artery disease in the ICU?

BackgroundDiagnosis of significant coronary artery disease (CAD) and acute coronary artery occlusion in ICU can be difficult, and an inappropriate intervention is potentially harmful. Myocardial contrast perfusion echo (MCPE) examines ultrasound contrast intensity replenishment curves in individual myocardial segments measuring peak contrast intensity and slope of return as an index of myocardial blood flow (units = intensity of ultrasound per second [dB/s]). MCPE could possibly serve as a triage tool to invasive angiography by estimating blood flow in the myocardium. We sought to assess feasibility in the critically ill and if MCPE could add incremental value to the clinical acumen in predicting significant CAD.MethodsThis is a single-centre, prospective, observational study. Inclusion criteria were as follows: adult ICU patients with troponin I > 50 ng/L and cardiology referral being made for consideration of inpatient angiography. Exclusion criteria were as follows: poor echo windows (2 patients), known ischaemic heart disease, and contrast contraindications. Seven cardiologists and 6 intensivists blinded to outcome assessed medical history, ECG, troponin, and 2D echo images to estimate likelihood of significant CAD needing intervention (clinical acumen). Clinical acumen, quantitative MCPE, and subjective (visual) MCPE were assessed to predict significant CAD.ResultsForty patients underwent MCPE analysis, 6 (15%) had significant CAD, and median 11 of 16 segments (IQR 8–13) could be imaged (68.8% [IQR 50–81]). No adverse events occurred. A significant difference was found in overall MCPE blood flow estimation between those diagnosed with significant CAD and those without (3.3 vs 2.4 dB/s, p = 0.050). A MCPE value of 2.8 dB/s had 67% sensitivity and 88% specificity in detecting significant CAD. Clinical acumen showed no association in prediction of CAD (OR 0.6, p = 0.09); however, if quantitative or visual MCPE analysis was included, a significant association occurred (OR 17.1, p = 0.01; OR 23.0, p = 0.01 respectively).ConclusionsMCPE is feasible in the critically ill and shows better association with predicting significant CAD vs clinical acumen alone. MCPE adds incremental value to initial assessment of the presence of significant CAD which may help guide those who require urgent angiography.

Evaluation of SERENE-CAG score for assessing suitability for coronary angiography preoperatively in patients undergoing valve replacement surgery

AimsThe aim of this study was to identify better selection criteria for subjecting patients of rheumatic heart disease (RHD) to preoperative coronary angiography (CAG) based on indigenous scoring system (SERENE-CAG [Selecting Patients Of Rheumatic Heart Disease Undergoing Valve Surgery For Presurgical Coronary Angiography]). MethodsThis prospective study included all consecutive 798 patients of RHD patients undergoing preoperative CAG from January 2016 to December 2017 over a duration of 2 years. Multivariate logistic regression analysis was performed with the presence of significant CAD [coronary artery disease] as the dependent variable with traditional risk factors of CAD. An additive score was developed using coefficient derived logistic regression for those variables that were significant. Receiver-operator curve analysis was performed to assess the ability of this score to predict diseased vs normal CAG. ResultsA total of 798 patients had a mean age of 51.7 ± 12.5 years. Significant CAD requiring revascularization along with valve surgery was identified in 50 (6.26%) patients. Male gender was found as significant predictors of CAD with odds ratio 2.6. A SERENE CAG SCORE of >2.8 resulted in sensitivity of 80% and specificity of 36.9% of predicting CAD in RHD patients with positive and negative predictive value of 7.8% and 96.5%, respectively. ConclusionThe prevalence of CAD in RHD patients is low. Patient risk can be minimized by exploring noninvasive modalities for screening of CAD and by more appropriate selection of patients for invasive coronary angiogram. Using threshold SERENE-CAG score of >2.8 would result in deferring 34.6% of normal angiograms.

Mitral annular calcification predicts coronary artery disease in end-stage renal disease patients on hemodialysis

Background Mitral annulus calcifi cation ( MAC) is a chronic, degenerative process of the fi brous support structure of the mitral valve. The reported prevalence of MAC is between 8 and 15%, but it signifi cantly increases with age and in patients with multiple cardiovascular risk factors or chronic kidney disease. Aim The aim of this study was to determine whether MAC predicts coronary artery disease in a group of end-stage renal disease patients. Patients and Methods Twenty-three patients with ESRD on hemodialysis referred for coronary angiography were prospectively studied. Results This study included 23 patients, MAC was seen in nine patients (39%). Seven patients had significant coronary artery disease (CAD) (30%). Ten patients had impaired left ventricular function (LVEF Conclusion MAC occurs in a proportion of patients with ESRD and is associated with increased mortality and the presence of significant CAD.

Relación entre las situaciones clínicas que llevan al tratamiento exclusivamente farmacológico del SCASEST y su pronóstico

Introduction and objectivesA large proportion of patients with non—ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis. MethodsPatient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality. ResultsMedical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P<.001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR=1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR=1.90; 95%CI, 1.23-2.95) compared with revascularized patients. ConclusionsMedically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population.Full English text available from:www.revespcardiol.org/en