Presence Of Significant Coronary Stenosis Research Articles

Type 2 diabetes rather than the presence of significant coronary stenoses is associated with quality of life in angiographied coronary patients

Abstract Chronic medical conditions such as type 2 diabetes (T2DM) or coronary artery disease (CAD) and their treatment have a crucial impact on patients’ daily life. The EQ-5D-5L questionnaire is a validated and widely used tool to measure the health-related quality of life (HRQL). We investigated and compared the HRQL in patients with or without T2DM and CAD. We included 481 consecutive patients undergoing coronary angiography for the evaluation of established or suspected stable CAD in a tertiary care setting in Central Europe. Patients’ HRQL was measured using the EQ-5D-5L, comprising the EQ index calculated from the domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A response rate of 88.1% was achieved. From our patients, 166 (34.5%) had T2DM according to ADA criteria, and 254 (52.8%) had significant CAD with stenoses ≥50% at angiography. Patients with T2DM showed significantly lower EQ index values than patients without T2DM (0.891 [IQR=0.783-0.970]) vs. 0.943, [IQR=0.861-1.0], p=0.002)). Regarding the different dimensions of the questionnaire, patients with T2DM reported to have significantly more problems with anxiety and depression (p=0.002) and mobility (p<0.001) than non-diabetic patients. EQ index values in contrast did not differ significantly between patients with vs. those without significant CAD. Accordingly, in analysis of covariance T2DM (F=7.38, p=0.007) but not significant CAD (F=1.74, p=0.183) predicted EQ index values after adjustment for age, sex and body-mass-index. We conclude that T2DM rather than the presence of significant CAD is associated with quality of life in angiographied coronary patients.

434-P: Type 2 Diabetes Rather than the Presence of Significant Coronary Stenoses Is Associated with Quality of Life in Angiographied Coronary Patients

434-P: Type 2 Diabetes Rather than the Presence of Significant Coronary Stenoses Is Associated with Quality of Life in Angiographied Coronary Patients

(015) Comparison of Penile Arterial Doppler-Ultrasound and Coronary Computed Tomography Angiography (CCTA) to Improve Cardiovascular Risk Assessment in Patients with Erectile Dysfunction

Abstract Introduction Erectile dysfunction (ED) has been shown to be an independent and early marker of future cardiovascular events, providing an important window of opportunity for cardiovascular preventive measures. However, there are several etiologies for ED (arterial, venous, hormonal, neurological, psychological), and earlier studies have not taken etiology into account when assessing cardiovascular risk. Arterial ED etiology share risk factors and pathophysiologic mechanisms with coronary and neurovascular diseases. Therefore, it can be assumed that patients with ED with arterial (atherosclerotic) etiology have a higher risk of future cardiovascular events than the general ED population. Objective To evaluate the predictive value of penile artery Doppler ultrasound (DUS) in cardiovascular risk assessment by comparing it with coronary atheroma screening by Coronary computed tomography angiography (CCTA) in patients with erectile dysfunction. Methods Men under 70 years of age, with ED and at least 1 cardiovascular risk factor (hypertension, dyslipidemia, diabetes, smoking, metabolic syndrome, obesity) were included. Patients with a primary cardiovascular event were excluded. Every patient had a penile DUS to assess penile arterial disease based on the maximum systolic velocity of the carvernous arteries after stimulation by intracavernous injection (A-Score), and a CCTA to assess coronary atheromatous arterial disease (CAD-RADS score). Results From October 2022 to June 2023, 72 consecutive patients were included. Mean age was 55 +/- 8.6 years. Mean IIEF5 score was 11 +/-5.3. N=34 (30%) were smokers, n=24 (33%) had hypertension, n=27 (37.5%) had diabetes, n=9 (11.1%) had obesity, n=10 (13.9%) had dyslipidemia. On penile artery DUS assessment n=62 (86%) patients had a positive A-Score. On CCTA, CAD-RADS scores were 0 in n=13 (18%) patients, 1 in n=18 (25%), 2 in n=19 (26%), 3 in n=17 (24%), and 4 in n=5 (7%) patients. We then analyzed the predictive value of A-Score as follows: 1. patients with coronary atheromatous plaques on CCTA (CAD-RADS ≥1, n=59), were significantly more likely to have a positive A-Score (n=56, 94.9%) than negative A-Score (n=13, 18%, p<.001, Chi2-test). The positive predictive value of the A-Score indicating penile arterial disease for the presence of coronary plaque, was 90.3%. 2. Patients with significant coronary stenosis (CAD-RADS ≥3, n=22) all patients n=22 (100%), had a positive A-Score and none a negative test (p=.026). The positive predictive value of the A-Score for the presence of significant coronary stenosis on CCTA was 100%. Conclusions The penile artery Doppler ultrasound A-Score has a good predictive value for coronary atheromatous artery disease in patients with erectile dysfunction, and allowed us to identify a sub-population at higher cardiovascular risk. When the A-Score is positive, the presence of coronary plaque is highly probable; when it is negative, the presence of significant coronary stenosis is highly unlikely. Disclosure No.

Adipokines and adipocytokines in men with coronary atherosclerosis and overweight

Aim To study concentrations of adipokines and their associations with proinflammatory cytokines in overweight men with coronary atherosclerosis.Material and methods This study included 79 men aged 45-60 years with atherosclerosis who had undergone coronary endarterectomy during a coronary bypass surgery, and were overweight (body weight index (BWI), 25.0-29.9 kg /m2). Based on a histological analysis of plaques, the patients were divided into two subgroups: 43 men with stable atherosclerotic plaques and 36 men with unstable plaques in coronary arteries. The control group consisted of 40 age- and BWI-matched men without clinical manifestations of IHD. Blood concentrations of adipokines, including adiponectin, adipsin, lipocalin-2, resistin, and plasminogen 1 activator inhibitor were measured by a multiplex analysis with a MILLIPLEX MAP Human Adipokine Panel 1. Concentrations of proinflammatory cytokines, including tumor necrosis factor α (TNF- α), interleukin (IL)-1β, IL-6, and C-reactive protein (CRP) were measured by enzyme immunoassay.Results The blood concentration of lipocalin -2 was higher in patients with coronary atherosclerosis and stable or unstable atherosclerotic plaques than in the control group (p<0.01). Both subgroups of men with coronary atherosclerosis were characterized by significant differences from the control group in concentrations of TNF-α (p<0.05), CRP, and IL-6 (p<0.01). The most significant direct correlations were found between adipokines and TNF-α, IL-6, and CRP (p<0.01). Results of a logistic regression analysis showed that relative odds for the presence of significant coronary stenoses increased with increasing blood concentrations of lipocalin-2 (OR=1.005, 95 % CI: 1.002-1.008, р=0.011) and IL-6 (OR=1.582 , 95 % CI: 1.241-2.017, р=0.001).Conclusion The changes in blood concentrations of adipokines associated with higher levels of proinflammatory cytokines may represent a factor that increases the probability of clinically significant coronary stenosis in overweight men with coronary atherosclerosis.

Coronary calcium score in symptomatic patients referred for a coronary computed tomographic angiography. Influence of diabetes

The benefit of the coronary artery calcium score (CACS) measured by cardiac CT is well documented in asymptomatic patients at intermediate risk, however is not known in symptomatic patients. The coronary CT angiography (CCTA) allows an anatomical evaluation of the coronary arteries. The objective was to determine, in symptomatic patients, with diabetes or not, the predictive value of CACS for the presence of significant coronary stenosis (CS > 50%) detectable by CCTA. The study included 52 patients (36 wemen/16 men), mean age 61 years (35–79 years), including 22 diabetics, who had a CACS measurement and a CCTA with a 64-slice cardiac CT with an atypical chest pain syndrome and without history of ischemic heart disease, revascularization by coronary angioplasty or coronary artery bypass grafting. The patients were divided into 5 groups according to the CACS: 0, 1–10, 11–100, 101–400, > 400 AU. The prevalence of CACS in patients was 65%. The CACS was: 0, 1–10, 11–100, 101–400, > 400 respectively in 18, 14, 5, 8, 8 patients. Fifteen patients (29%) had CS on the CCTA. The percentage of diabetics was somewhat higher among these patients than among the 37 without CS (60% vs. 37%, P = 0.09). CS was present in 2 of 18 patients with CACS = 0, 1/13 with CACS 1–10, 1/5 with CACS 11–100, 3/8 with CACS 101–400, and 8 patients with CACS > 400. Thus the prevalence of CS was 11% and 69% respectively among patients with CACS ≤ 100 or > 100 ( P < 0.001). Among patients with CACS > 100, CS was found in 7 diabetics and 4 of 9 non-diabetics. These data suggest that about 30% of patients with suspected angina have coronary stenosis detectable by CCTA, when a CACS is > 100 its predicts the presence of CS with a positive predictive value of 100% in diabetics (vs. 44% in no diabetics), while CS is present in approximately 10% of patients with CACS < 10, suggesting an atheroma with no or little calcification.

Accuracy of global and regional longitudinal strain at peak of dobutamine stress echocardiography to detect significant coronary artery disease

Dobutamine stress echocardiography (DSE) is sensitive but subjective diagnostic tool to detect inducible ischemia. Nowadays, speckle tracking allows an objective quantification of regional wall function. We aimed to investigate the feasibility and accuracy of global (GLS) and regional longitudinal strain (RLS) during DSE to detect significant coronary stenosis (SCS). We conducted a prospective observational multicenter study including patients undergoing DSE for suspected SCS. 50 patients with positive DSE underwent coronary angiography. Besides visual regional wall motion score index (WMSI), GLS and RLS were determined at rest and at peak stress by Automated Function Imaging. DSE GLS feasibility was 96%. Among 35 patients with SCS, 12 patients were affected by multivessel disease, 18 had stenosis of left anterior descending artery (LAD), 18 of left circumflex (LCX) and 15 of right coronary artery (RCA). At peak stress, both GLS reduction (p = 0.037) and WMSI worsening (p = 0.04) showed significant agreement with coronary angiography for detecting SCS. When single lesion was considered, peak stress GLS and LAD RLS were lower in the obstructed LAD regions than in normo-perfused territories (17.4 ± 5.5 vs. 20.5 ± 4.4%, p = 0.03; 17.1 ± 7.6 vs. 21.6 ± 5.5%, p < 0.02, respectively). Furthermore, the addition of RLS to regional WMSI was able to improve accuracy in LAD SCS prediction (AUC 0.68, p = 0.037). Conversely, in presence of LCX or RCA SCS, LS was less accurate than WMSI at peak stress. In conclusion, DSE strain analysis is feasible and may improve prediction of LAD SCS, whereas regional WMSI assessment performs better in presence of SCS of LCX and RCA.

The change in high-sensitivity troponin-T as a risk factor for significant coronary stenosis in patients with acute coronary syndrome.

Background/AimsHigh-sensitivity cardiac troponin (hs-TnT) assays detect very low levels of cardiac troponin. This study examined the interval change between initial and subsequent hs-TnT levels and evaluated its ability to predict significant coronary stenosis.MethodsThe study analyzed 163 patients who presented with acute coronary syndrome (ACS) and underwent coronary angiography (CAG) between April 2014 and May 2018. The 0 and 3-hour hs-TnT were checked. The patients were subdivided into positive (n = 32) and negative (n = 131) interval change groups. The presence of significant coronary artery stenosis on CAG in the two groups was compared.ResultsThe positive interval change group was older and had higher 0 and 3-hour hs-TnT and blood glucose levels than the negative interval change group. Significant coronary stenosis was more common in the positive interval change group than in the negative interval change group (68.8% vs. 23.7%, p = 0.001). However, vasospasm was more common in the negative interval change group (6.3% vs. 31.3%, p = 0.003). The positive interval change group had higher rates of bifurcation lesions and received more percutaneous coronary intervention. In multivariate analysis, age, interval change of serial hs-TnT and diabetes mellitus were independent predictors of significant coronary artery stenosis.ConclusionsThis study identified a relationship between the serial change in cardiac biomarkers and the presence of significant coronary stenosis in patients with ACS. Serial hs-TnT change was associated with real angiographic stenosis in patients with ACS.

Clinical Impact of High-Sensitivity Cardiac Troponin T on the Chronic Phase of Stable Angina after a Successful Initial Percutaneous Coronary Intervention.

The purpose of this study was to investigate the clinical significance of elevated plasma high-sensitivity troponin T (hs-TnT) in the chronic phase in patients with stable angina pectoris (SAP) who underwent a successful percutaneous coronary intervention (PCI). This study enrolled 158 consecutive SAP patients who underwent routine follow-up coronary angiography 9 months after a successful PCI with the implantation of a second-generation drug-eluting stent. Patients with previous coronary artery bypass graft and renal dysfunction were excluded. Patients were divided into two groups according to hs-TnT plasma level at follow-up: elevated hs-TnT (≥ 0.015 ng/ml) group and non-elevated hs-TnT group. Among the 158 subjects, 42 had an elevated hs-TnT level at follow-up. The elevated hs-TnT group had a significantly higher rate of any coronary lesion (in-stent restenosis and de novo lesions) in follow-up CAG (coronary angiography) than the non-elevated group (28.6% vs. 10.3%, p < 0.05). Multivariate analysis also showed that hs-TnT elevation was independently associated with the presence of significant coronary stenosis in the chronic phase (odds ratio: 3.99, 95% confidence interval: 1.38 to 11.53). The best cut-off value of the hs-TnT level at 9 months after a successful PCI to predict the presence of significant coronary stenosis was 0.016 ng/ml (sensitivity: 50.0%; specificity: 82.1%; area under the receiver operating characteristic curve: 0.67). hs-TnT elevation was independently associated with the presence of coronary stenosis in the chronic phase in SAP patients with successful PCI. Routine measurement of hs-TnT in the chronic phase may be useful to refine the risk of patients after PCI.

Discrepancy between abnormal ECG exercise test and scintigraphy without ischemia in suspected or known coronary artery disease patients

Only few data exist on discrepancies between positive ECG exercise test (ExT) results and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) without ischemia, in patients with suspected or known coronary artery disease (CAD). The aim was to assess coronary angiography results and early clinical outcome in patients with suspected or known CAD with discrepancy between an abnormal ECG ExT and a MPI without ischemia. In total, 30,620 consecutive patients with suspected or known CAD referred between May 2010 and October 2016 for exercise SPECT MPI with CZT camera were retrospectively evaluated. “True discrepancy” was defined in presence of exercise ECG changes highly suggestive of ischemia in contrast to SPECT MPI without ischemia. Significant stenosis on coronary angiography (CAG) performed within 3 months after MPI and major cardiovascular events (cardiac death, nonfatal myocardial infarction and revascularization) during follow-up were collected. The Kaplan–Meier and log-rank test was used to compare the time to cardiac event-free survival. Among 270 patients with true discrepancy, invasive coronary angiography and coronary CT angiography data were available in 142 patients with suspected (S group; 60 patients) or known (K group; 89 patients) CAD. No significant coronary stenosis and significant stenosis was present in 30 patients (50%) versus 30 patients (50%) in S group and in 42 patients (47%) versus 47 patients (55%) in K group, respectively. Major cardiac event rate was significantly different between patients with or without revascularization after CAG in S group (respectively, 17% versus 0%; P = 0.003), contrary to K group (15% versus 9.5%; P = 0.49). True discordant results occurred in 1% of exercise SPECT MPI and half of patients with anatomy assessment were associated in 50% of the cases with the presence of significant coronary stenosis.

Incidentally detected atherosclerosis in the abdominal aorta or its major branches on computed tomography is highly associated with coronary heart disease in asymptomatic adults

BackgroundAtherosclerotic lesions in the abdominal aorta or its major branches are often incidentally detected on abdominal CT. However, clinical implications and optimal subsequent management are mostly left undetermined. MethodsConsecutive, asymptomatic adults (age≥30) who underwent both abdominal CT and coronary computed tomography angiography as part of a self-referred health check-up were investigated (n = 1494). ResultsAdjusted for cardiovascular risk factors, abdominal atherosclerotic lesions with stenosis<25% were associated with significant coronary stenosis, especially in the abdominal aorta (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 0.99–11.45) and any common iliac artery (aOR 2.99, 95% CI 1.43–6.26). The association was higher in atherosclerotic lesions with stenosis≥25%, respectively (aOR 16.39, 95% CI 4.00–67.11; aOR 7.32, 95% CI 2.84–18.86). Furthermore, any major abdominal artery stenosis added predictive value to significant coronary stenosis (area under the receiver operating curve: 0.7598 vs. 0.8019, P < 0.001). The extent of arterial territory involvement was associated with the presence of significant coronary stenoses (P for trend <0.001). ConclusionStenotic atherosclerotic lesions in the abdominal aorta or its major branches incidentally detected on abdominal CT are relatively prevalent and carry high risk for asymptomatic coronary arterial disease.

Effects of hyperaemia on left ventricular longitudinal strain in patients with suspected coronary artery disease : Afirst-pass stress perfusion cardiovascular magnetic resonance imaging study.

AimsMyocardial perfusion imaging during hyperaemic stress is commonly used to detect coronary artery disease. The aim of this study was to investigate the relationship between left ventricular global longitudinal strain (GLS), strain rate (GLSR), myocardial early (E’) and late diastolic velocities (A’) with adenosine stress first-pass perfusion cardiovascular magnetic resonance (CMR) imaging.Methods and results44 patients met the inclusion criteria and underwent CMR imaging. The CMR imaging protocol included: rest/stress horizontal long-axis (HLA) cine, rest/stress first-pass adenosine perfusion and late gadolinium enhancement imaging. Rest and stress HLA cine CMR images were analysed using feature-tracking software for the assessment of myocardial deformation. The presence of perfusion defects was scored on a binomial scale. In patients with hyperaemia-induced perfusion defects, rest global longitudinal strain GLS (−16.9 ± 3.7 vs. −19.6 ± 3.4; p-value = 0.02), E’ (−86 ± 22 vs. −109 ± 38; p-value = 0.02), GLSR (69 ± 31 vs. 93 ± 38; p-value = 0.01) and stress GLS (−16.5 ± 4 vs. −21 ± 3.1; p < 0.001) were significantly reduced when compared with patients with no perfusion defects. Stress GLS was the strongest independent predictor of perfusion defects (odds ratio 1.43 95% confidence interval 1.14–1.78, p-value <0.001). A threshold of −19.8% for stress GLS demonstrated 78% sensitivity and 73% specificity for the presence of hyperaemia-induced perfusion defects.ConclusionsAt peak myocardial hyperaemic stress, GLS is reduced in the presence of a perfusion defect in patients with suspected coronary artery disease. This reduction is most likely caused by reduced endocardial blood flow at maximal hyperaemia because of transmural redistribution of blood flow in the presence of significant coronary stenosis.Electronic supplementary materialThe online version of this article (10.1007/s12471-017-1071-3) contains supplementary material, which is available to authorized users.

Diagnostic accuracy of low and high tube voltage coronary CT angiography using an X-ray tube potential-tailored contrast medium injection protocol.

To compare the diagnostic accuracy between low-kilovolt peak (kVp) (≤ 100) and high-kVp (> 100) third-generation dual-source coronary CT angiography (CCTA) using a kVp-tailored contrast media injection protocol. One hundred twenty patients (mean age = 62.6 years, BMI = 29.0 kg/m2) who underwent catheter angiography and CCTA with automated kVp selection were separated into two cohorts (each n = 60, mean kVp = 84 and 117). Contrast media dose was tailored to the kVp level: 70 = 40 ml, 80 = 50 ml, 90 = 60 ml, 100 = 70 ml, 110 = 80 ml, and 120 = 90 ml. Contrast-to-noise ratio (CNR) was measured. Two observers evaluated image quality and the presence of significant coronary stenosis (> 50% luminal narrowing). Diagnostic accuracy (sensitivity/specificity) with ≤ 100 vs. > 100 kVp CCTA was comparable: per patient = 93.9/92.6% vs. 90.9/92.6%, per vessel = 91.5/97.8% vs. 94.0/96.8%, and per segment = 90.0/96.7% vs. 90.7/95.2% (all P > 0.64). CNR was similar (P > 0.18) in the low-kVp vs. high-kVp group (12.0 vs. 11.1), as ws subjective image quality (P = 0.38). Contrast media requirements were reduced by 38.1% in the low- vs. high-kVp cohort (53.6 vs. 86.6 ml, P < 0.001) and radiation dose by 59.6% (4.3 vs. 10.6 mSv, P < 0.001). Automated tube voltage selection with a tailored contrast media injection protocol allows CCTA to be performed at ≤ 100 kVp with substantial dose reductions and equivalent diagnostic accuracy for coronary stenosis detection compared to acquisitions at > 100 kVp. • Low-kVp coronary CT angiography (CCTA) enables reduced contrast and radiation dose. • Diagnostic accuracy is comparable between ≤ 100 and > 100 kVp CCTA. • Image quality is similar for low- and high-kVp CCTA. • Low-kVp image acquisition is facilitated by automated tube voltage selection. • Tailoring contrast injection protocols to the automatically selected kVp-level is feasible.

Značaj relativne koronarne reserve protoka kod pacijenata sa mikrovaskulrnom disfunkcijom u proceni značajne koronarne stenoze

Introduction: Coronary flow reserve (CFR) is defined as a ratio of hyperemic-to-basal coronary flow velocity and it can be measured by a variety of methods. Transthoracic Doppler echocardiography (TTE) CFR became useful method to assess functional significance of coronary artery stenosis in both left anterior descending (LAD) and posterior descending coronary artery (PD). CFR is combined measure of the capacity of epicardial coronary artery and microcirculation to achieve maximal blood flow in response to hyperemic stimulation. Thus in patients with already impaired microcirculation and accordingly CFR, differentiation from presence of significant coronary stenosis is difficult without known coronary angiography. Case report: We present a case of patient with hypertrophic cardiomyopathy and diabetes, where relative CFR as the ratio of the CFRs of two coronary arteries helped us in decision making to do coronarography because of atypical chest pain and fatigue. Conclusion: In patients with known microvascular dysfunction and already impaired CFR, relative CFR might be helpful to differentiate presence of significant epicardial stenosis. Future studies are needed to obtain appropriate clinical implications of relative CFR in everyday practice.

Association of Arterial Pressure Volume Index With the Presence of Significantly Stenosed Coronary Vessels.

BackgroundA blood pressure (BP) monitoring system (PASESA®) can be used to easily analyze the characteristics of central and peripheral arteries during the measurement of brachial BP.MethodsWe enrolled 108 consecutive patients (M/F = 86/22, age 70 ± 10 years) who underwent coronary angiography (CAG) due to suspected coronary artery disease (CAD) in whom we could measure various parameters using PASESA® in addition to brachial-ankle pulse wave velocity (baPWV). The patients were divided into two groups: patients who did not have significantly stenosed coronary vessel disease (n = 33, non-SVD group) and those who had at least one significantly stenosed coronary vessel (n = 75, SVD group). The characteristics of central and peripheral arteries (arterial velocity pulse index (AVI) and arterial pressure volume index (API), respectively) and baPWV were measured. Estimated central BP (eCBP) was calculated from the data obtained from PASESA®, and CBP was also measured simultaneously by invasive catheterization.ResultsAPI, but not AVI and baPWV, in the SVD group was significantly higher than that in the non-SVD group. Although eCBP was significantly associated with CBP, there was no difference in eCBP between the groups. There were significant associations among API, AVI and baPWV, albeit these associations were relatively weak. A multivariate logistic regression revealed that API and β-blocker were significant independent variables that were associated with the presence of significant coronary stenosis. The cut-off level of API that gave the greatest sensitivity and specificity for the presence of SVD was 24 units (sensitivity 0.636 and specificity 0.667).ConclusionIn conclusion, API, but not AVI or baPWV, is associated with the presence of significant coronary stenosis.

Epicardial Adipose Tissue Thickness and Its Association With the Presence and Severity of Coronary Artery Disease in Clinical Setting: A Cross-Sectional Observational Study.

BackgroundObesity is an important risk factor for atherosclerotic cardiovascular disease (ASCVD). Estimation of visceral adipose tissue is important and several methods are available as its surrogate. Although correlation of epicardial adipose tissue (EAT) with visceral adipose tissue as estimated by magnetic resonance imaging (MRI) and/or CT is excellent, it is costlier and cumbersome. EAT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with acute coronary syndrome than in subjects without coronary artery disease (CAD) and in those with stable angina. It also carries advantage as index of high cardiometabolic risk as it is a direct measure of visceral fat rather than anthropometric measurements. The present study evaluated the relationship of EAT to the presence and severity of CAD in clinical setting.MethodsIn this prospective, single-center study conducted in the Department of Cardiology, LPS Institute of Cardiology, Kanpur, India, 549 consecutive patients with acute coronary syndrome or chronic stable angina were enrolled. Sensitivity, specificity, and receiver operating characteristic (ROC) curve were estimated to find cut-off value of EAT thickness for diagnosing CAD using coronary angiographic findings as gold standard.ResultsPatients were diagnosed as CAD group (n = 464, 60.30 ± 8.36 years) and non-CAD group (n = 85, 54.42 ± 11.93 years) after assessing coronary angiograms. The EAT was measured at end-systole from the PLAX views of three cardiac cycles on the free wall of the right ventricle. Lesion was significant if > 50% in left main and > 70% in other coronary arteries. The mean EAT thickness in CAD group was 5.10 ± 1.06 and in non-CAD group was 4.36 ± 1.01 which was significant (P = 0.003). Significant correlation was demonstrated between EAT thickness and presence of CAD (P < 0.003). Higher EAT was associated with severe CAD and presence of multivessel disease. By ROC analysis, EAT > 4.65 mm predicated the presence of significant coronary stenosis by 71.6% sensitivity and 73.1% specificity.ConclusionEAT thickness measured using transthoracic echocardiography (TTE) significantly correlates with the presence and severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Chronotropic response to vasodilator-stress in patients submitted to myocardial perfusion imaging: impact on the accuracy in detecting coronary stenosis.

A lower heart rate response (HRR) during vasodilator MPI has been shown to have a relevant adverse prognostic impact. We sought to evaluate the interaction among individual HRR to vasodilator stress and myocardial perfusion imaging (MPI) accuracy in patients with suspected ischemic heart disease (IHD). One hundred and sixty-five consecutive patients were submitted to vasodilator-stress MPI on a cardiac camera equipped with cadmium-zinc-thelluride detectors and coronary angiography. A coronary stenosis >70 % was considered significant. In every patient, the summed difference score (SDS) was computed from MPI images. Patients were categorized according to the tertiles of the distribution of individual HRR during dipyridamole: "Group 1" (HRR < 8 bpm; lowest tertile); "Group 2" (8 ≤ HRR ≤ 12 bpm; middle tertile); "Group 3" (HRR >12 bpm; highest tertile). Significant coronary artery disease (CAD) was present in 102 (62 %) patients. In the overall population, MPI showed a significant accuracy (AUC: 0.81, 95 % CI 0.74-0.86; p < 0.001) in unmasking the presence of significant coronary stenosis. Interestingly, in patients with a blunted HRR during dipyridamole ("Group 1") MPI showed a significantly lower sensitivity (68 %) in detecting CAD than in those with a higher HRR ("Group 3") (91 %, p = 0.007), despite a preserved specificity (76 % vs 77 %, P=NS). Similarly, the correlation among CAD extent and post-stress LV functional stunning was limited to "Group 3" patients, while it disappeared in those with blunted HRR. In patients with suspected IHD, MPI sensitivity is strongly influenced by the magnitude of patient heart rate increase to the pharmacologic stressor, suggesting an interaction among blunted HRR and lower accuracy in unmasking CAD.

Global Coronary Artery Plaque Area is Associated with Myocardial Hypoperfusion in Women with Non-ST Elevation Myocardial Infarction.

Background: Women with non-ST elevation myocardial infarction (NSTEMI) have similar extent of myocardial ischemia but less obstructive coronary artery disease (CAD) than their male counterparts. We tested the impact of global coronary artery plaque area and artery tortuosity on myocardial perfusion in NSTEMI patients.Methods: Coronary artery plaque area was determined by quantitative angiography in 108 patients (32% women) with NSTEMI. Myocardial perfusion was assessed by contrast echocardiography in the 17 individual left ventricular segments. Artery tortuosity was defined as ≥3 curves >45° in a main coronary artery.Results: Age, prevalence of hypertension, and diabetes did not differ between sexes (all nonsignificant). Women had lower prevalence of ≥50% coronary artery stenosis (74% vs. 91%, p<0.05), while global coronary plaque area (35±22 vs. 43±21mm2) and the number of segments with hypoperfusion (6.9±3.7 vs. 7.2±3.4) did not differ between sexes (both p>0.07). In multivariate analysis, larger coronary artery plaque area was associated with a 35% higher risk for having severe myocardial hypoperfusion (odds ratio 1.35 [95% confidence interval 1.01–1.80], p<0.05) in the total study population, while no association between artery tortuosity and myocardial ischemia was found. Similar results were obtained in separate analysis among women and men.Conclusion: In women and men with NSTEMI, the global coronary artery plaque area was an important determinant of the severity of myocardial hypoperfusion at rest independent of presence of significant coronary stenoses. These findings may expand current understanding of NSTEMI in patients with nonobstructive CAD.

Accuracy of multidetector computed tomography for detection of coronary artery stenosis in acute coronary syndrome compared with stable coronary disease: A CORE64 multicenter trial substudy

BackgroundMulti-detector computed tomography angiography (MDCTA) is a promising method for risk assessment of patients with acute chest pain. However, its diagnostic performance in higher-risk patients has not been investigated in a large international multicenter trial. Therefore, in the present study we sought to estimate the diagnostic accuracy of MDCTA to detect significant coronary stenosis in patients with acute coronary syndrome (ACS). MethodsPatients included in the CORE64 study were categorized as suspected-ACS or non-ACS based on clinical data. A 64-row coronary MDCTA was performed before invasive coronary angiography (ICA) and both exams were evaluated by blinded, independent core laboratories. ResultsFrom 371 patients included, 94 were categorized as suspected ACS and 277 as non-ACS. Patient-based analysis showed an area under the receiver-operating-characteristic curve (AUC) for detecting ≥50% coronary stenosis of 0.95 (95% CI: 0.88–0.98) in ACS and 0.92 (95% CI: 0.88–0.95) in non-ACS group (P=0.29). The sensitivity, specificity, positive and negative predictive values of MDCTA were 0.90(0.80–0.96), 0.88(0.70–0.98), 0.95(0.87–0.99) and 0.77(0.58–0.90) in suspected ACS patients and 0.87(0.81–0.92), 0.86(0.79–0.92), 0.91(0.85–0.95) and 0.82(0.74–0.89) in non-ACS patients (P NS for all comparisons). The mean calcium scores (CS) were 282±449 in suspected ACS and 435±668 in non-ACS group. The accuracy of CS to detect significant coronary stenosis was only moderate and the absence or minimal coronary artery calcification could not exclude the presence of significant coronary stenosis, particularly in ACS patients. ConclusionsThe diagnostic accuracy of MDCTA to detect significant coronary stenosis is high and comparable for both ACS and non-ACS patients.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 330 consecutive patients referred for balloon-expandable transcatheter aortic valve implantation

Purpose: The aim of this study was to assess the evaluability and diagnostic accuracy of the multidetector computed tomography (MDCT) coronary angiography in patients referred for transcatheter aortic valve implantation (TAVI). MDCT is playing an increasingly role in patients scheduled for TAVI, providing detailed anatomic assessment of the aortic root and valve annulus and of iliofemoral access. However, the diagnostic performance of MDCT coronary angiography has not been well investigated. Methods: 330 consecutive patients scheduled for invasive coronary angiography (ICA) and 64-slice MDCT for the screening protocol before TAVI were enrolled (42 patients with previous coronary artery bypass graft (CABG), 49 with previous coronary stenting, 233 without previous revascularizations). All MDCT coronary angiography were performed using the same data set dedicated to the standard MDCT evaluation of aortic annulus, obtained with retrospective ECG triggering. Coronary arteries evaluability by MDCT coronary angiography and its diagnostic accuracy parameters in comparison with ICA as gold standard were evaluated. Results: In the remaining 325 patients, the mean HR during the scan was 61±9 bpm. The MDCT evaluability of native coronary arteries was 95.6%. The leading cause of unevaluability was the beam-hardening artifact due to large coronary calcifications (109 cases), followed by slice misalignments (56 cases) due to HR variability or premature heart beats during the scan and motion artifacts (40 cases). In the segment-based analysis, sensibility, specificity, positive predictive value, negative predictive value and accuracy were 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. MDCT correctly assessed the patency of all CABG, without graft classified as non evaluable. The MDCT evaluability of coronary stents was 82.1%. In the segment-based analysis, MDCT showed sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥ 50% luminal narrowing of 94.1%, 86.7%, 66.7%, 98.1% and 88.3%, respectively. Conclusions: MDCT coronary angiography allows to correctly rule out the presence of significant coronary stenosis in patients referred for TAVI, demonstrating and excellent negative predictive value also in patients with previous CABG or stents.

Feasibility and Diagnostic Accuracy for Assessment of Coronary Artery Stenosis of Prospectively Electrocardiogram-gated High-pitch Spiral Acquisition Mode Dual-source CT Coronary Angiography in Patients with Relatively Higher Heart Rates: in Comparison with Catheter Coronary Angiography

Objective To prospectively investigate the diagnostic accuracy for coronary artery stenosis of prospectively electrocardiogram-triggered spiral acquisition mode (high pitch mode) dual-source computed tomography coronary angiography (CTCA) in patients with relatively higher heart rates (HR) compared with catheter coronary angiography (CCA). Methods Forty-seven consecutive patients with relatively higher HR (>65 and <100 bpm) (20 male, 27 female; age 55±10 years) who both underwent dual-source CTCA and CCA were prospectively included in this study. All patients were performed CTCA using high pitch mode setting at 20%-30% of the R-R interval for the image acquisition. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a three-point scale (1: excellent to 3: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). Considered CCA as the standard of reference, the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Radiation dose values were calculated using the dose-length product. Results Image quality was rated as being score 1 in 92.4% of segments, score 2 in 6.1% of segmentsand score 3 in 1.5% of segments. The average image quality score per segment was 1.064±0.306. The HR variability of patients with image score 1, 2 and 3 were 2.29±1.06 bpm, 5.17±1.37 bpm, 8.88±1.53 bpm, respectively. The average HR variability of patients with different image scores were significantly different (F=170.402, P=0.001). The sensitivity, specificity, positive and negative predictive values were 92.6%, 97.0%, 87.6%, 98.3%, respectively, per segment and 90.0%, 95.2%, 85.3%, 96.9%, respectively, per vessel and 100%, 63.6%, 90.0%, 100%, respectively, per patient. The effective radiation dose was on average 0.86±0.16 mSv. Conclusion In patients with HR more than 65 bpm and below 100 bpm without cardiac arrhythmia, the prospectively electrocardiogram-gated high-pitch spiral acquisition mode with image acquired timing set at 20%-30% of the R-R interval provides a high diagnostic accuracy for the assessment of coronary stenoses combined with a 1.5% of non-diagnostic coronary segments and a radiation dose below 1 mSv.