Prior History Of Coronary Artery Disease Research Articles

Retrospective Study on Short-Term Reverse Cardiac Remodeling in Obese Patients Undergoing Sleeve Gastrectomy

Severe obesity is closely associated with an increased risk of comorbidities and alterations in cardiac structure and function. The primary objective of this study was to investigate cardiovascular (CV) risk factors and ventricular remodeling in individuals from an obese population eligible for bariatric surgery. The secondary objective was to evaluate changes in anthropometric, clinical laboratory, and echocardiographic measurements 12 weeks after surgery compared to baseline values. This retrospective observational cohort study involved patients from a single specialized bariatric surgery center. A total of 35 patients were included (mean age 41.5 ± 10.3 years; BMI 43.4 ± 6.6 kg/m2), of whom 34.2% had a family history of coronary artery disease (CAD), 5.7% had a prior history of CAD, 8 had essential hypertension, 11.4% had dyslipidemia, 20% were smokers, and 8.6% were former smokers. Approximately 57% of the patients exhibited concentric left ventricular remodeling, and 14% had grade I diastolic dysfunction. At 12 weeks post-surgery, with an average weight loss of 25 kg and a mean BMI reduction of 8.5 kg/m2, 14% of the patients still exhibited concentric left ventricular remodeling, and about 11% had grade I diastolic dysfunction. Bariatric surgery contributes to the improvement of cardiac function and structure over time as a result of significant weight loss.

Diagnostic Value of Regional Wall Motion Abnormalities on Resting Transthoracic Echocardiography for Coronary Artery Disease.

Regional wall motion abnormality (RWMA) on transthoracic echocardiography (TTE) is used as a clinical decision-making tool to assess systolic function, but there is limited data regarding the validity of this tool to predict obstructive coronary artery disease (CAD). This study evaluates the utility of RWMA on TTE for detecting obstructive CAD in patients with no prior CAD history. We retrospectively reviewed charts of adults who underwent resting TTE and coronary angiography within 30days, analyzing RWMA in relation to angiographic luminal stenosis. Among 754 patients (mean age 62, 60% male), TTE sensitivity varied with timing relative to angiography: 68.7% after angiography versus 49.5% before. In ST-elevation myocardial infarction (STEMI) patients (n=126 after vs. n=4 before), sensitivity was 89.8%. RWMA correlated with CAD severity, particularly in STEMI cases. TTE specificity remains high, but sensitivity varies significantly by timing, with the highest sensitivity in STEMI patients. These findings could refine decision-making in uncertain STEMI cases, supporting TTE as a valuable adjunctive diagnostic tool.

Effectiveness of Resting Transthoracic Echocardiography at Detecting Significant Coronary Artery Disease in Adults

Abstract Background: Detection of the regional wall motion abnormalities (RWMA) on the transthoracic echocardiography (TTE) is commonly used to correlate with coronary artery disease (CAD) and often prompts a further workup, including cardiac computed tomography or cardiac catheterization. However, the RWMA do not consistently predict obstructive CAD. This study investigates the accuracy and reliability of the presence of the RWMA on the TTE at detecting significant CAD (≥70% vessel stenosis). Materials and Methods: A retrospective chart review was conducted on the adults seen by the Baylor Scott and White Temple Echocardiography Laboratory who received a resting TTE followed by a cardiac catheterization within 30 days over 4 years. The exclusion criteria included catheterization without coronary angiography and a prior history of CAD, percutaneous coronary intervention, or coronary artery bypass graft. We analyzed the RWMA on the TTE and atherosclerotic CAD on the cardiac catheterization to assess correlation. Results: Four hundred and thirty-five patients were included in the study, and 198 patients received ultrasound-enhancing agent (UEA). The sensitivity and specificity of the RWMA on the TTE for detecting CAD in the adults were 49.5% and 78.8%, respectively. The positive and negative likelihood ratios were 2.33 and 0.641, respectively. The use of UEA made no significant difference in the sensitivity or specificity. Discussion: Our results show that the presence of the RWMA on the TTE has a high ability to rule in CAD, but the absence of the RWMA displays a much lower ability to rule out CAD than previously reported. Our results also show UEA did not enhance or detract from the sensitivity or specificity of TTE on CAD. The clinicians should be aware that the presence of the RWMA on the resting TTE has a high association with obstructive CAD, but the absence of the RWMA does not sufficiently exclude CAD.

Coronary artery calcification detected on low-dose computed tomography in high-risk participants of an Australian lung cancer screening program: A prospective observational study.

Coronary artery calcification (CAC) is a frequent additional finding on lung cancer screening (LCS) low-dose computed tomography (LDCT). Cardiovascular disease (CVD) is a major cause of death in LCS participants. We aimed to describe prevalence of incidental CAC detected on LDCT in LCS participants without prior history of coronary artery disease (CAD), evaluate their CVD risk and describe subsequent investigation and management. Prospective observational nested cohort study including all participants enrolled at a single Australian site of the International Lung Screen Trial. Baseline LDCTs were reviewed for CAC, and subsequent information collected regarding cardiovascular health. 5-year CVD risk was calculated using the AusCVD risk calculator. 55% (226/408) of participants had CAC on LDCT and no prior history of CAD, including 23% with moderate-severe CAC. Mean age of participants with CAC was 65 years, 68% were male. 53% were currently smoking. Majority were high risk (51%) or intermediate risk (32%) of a cardiovascular event in 5 years. 21% of participants were re-stratified to a higher CVD risk group when CAC detected on LCS was incorporated. Only 10% of participants with CAC received lifestyle advice (only 3% currently smoking received smoking cessation advice). 80% of participants at high-risk did not meet guideline recommendations, with 47% of this group remaining without cholesterol lowering therapy. LCS with LDCT offers the potential to identify and communicate CVD risk in this population. This may improve health outcomes for high-risk LCS participants and further personalize management once screening results are known.

Sex disparity of DAPT noncompliance in patients with left main stem PCI with DES.

This retrospective study aims to explore the sex disparity in dual antiplatelet therapy (DAPT) noncompliance among left main stem percutaneous coronary intervention (PCI) patients with drug-eluting stent (DES) and identify predictors associated with non-adherence. Data were collected from the medical records of 1585 patients, including 1104 males and 481 females, who underwent left main stem PCI with DES. Baseline characteristics, angiographic features, and DAPT compliance rates at 1 month and 12 months were analyzed. Univariate logistic regression was used to identify predictors of DAPT noncompliance. The overall DAPT noncompliance rate at 1 month was 8.5%, increasing to 15.5% at 12 months. Females exhibited slightly higher noncompliance rates than males at both 1 month (15.6% vs 14.5%) and 12 months (28.1% vs 19.0%), although the difference was not statistically significant. Smoking status showed a modest impact on non-adherence, with current smokers exhibiting a lower noncompliance rate (14.9% at 1 month). Prior coronary artery disease history was associated with increased noncompliance at 12 months (18.9%). Angiographic characteristics, including lesion location and Syntax score, had no consistent association with DAPT noncompliance. This study highlights sex disparity in DAPT noncompliance among patients undergoing left main stem PCI with DES. Comorbidities, socioeconomic status, smoking status, and prior coronary artery disease history were identified as predictors of non-adherence.

Footsteps to Wellness: A Systematic Review and Meta-Analysis of Walking Pace and Coronary Artery Disease Event.

Coronary artery disease (CAD) poses a global health challenge, necessitating effective preventive strategies. Despite the pivotal role of physical activity in cardiovascular health, many fall short of recommended guidelines for daily physical activity. Simple and accessible, walking presents an opportunity, with increased pace emerging as a potential strategy for reducing the risk of cardiovascular diseases. Thus, we aimed to elucidate the potential association between walking pace and the risk of CAD events in adults without a prior history of CAD through a systematic review. We searched PubMed, Scopus, Web of Science, and ScienceDirect without publication date restrictions to identify prospective cohorts that analyzed walking pace and adult CAD events. The literature search conducted from April 02, 2023, to August 21, 2023, identified a total of four studies (six cohorts) for meta-analysis using random-effects models. The Newcastle-Ottawa Scale was used to assess study quality, and data extraction involved two independent reviewers. The analysis calculated overall relative risks (RRs) and 95% confidence intervals (CIs) for those with the quickest walking paces compared to those with the slowest walking paces. A funnel plot analysis for publication bias and subgroup analysis were also conducted. Results from the meta-analysis involving 160,519 participants and 3,351 CAD events demonstrated a 46% decreased risk for those walking at the quickest pace (pooled RR = 0.54, 95% CI = 0.45-0.66). No significant heterogeneity was observed. In conclusion, walking pace emerges as a significant risk factor for CAD events in adults without a prior history of CAD. It serves as a potential screening tool to identify individuals at higher risk. Promoting a faster walking pace as a daily activity may effectively mitigate the burden of CAD.

Abstract 15468: Factor VII Induced Coronary Thrombosis

Case Description: 69-year-old male with a history of factor VII deficiency and coronary artery disease (CAD) with a stent in the distal left anterior descending (LAD) artery, underwent diagnostic laparoscopy for suspected appendiceal carcinoma. He is a non-smoker, has good exercise tolerance and takes aspirin only three times a week, due to epistaxis. Post-surgery, he complained of 10/10 substernal chest pain. Initial troponin (TnI) was 0.11 ng/dL, peaking at >80 ng/dL in 2 hours. EKG was compatible with an anterior wall STEMI. An emergent coronary angiogram showed a patent distal LAD stent and a 99% occlusive lesion in the mid-LAD, which was treated with a drug-eluting stent. With careful clinical judgment and hematology consultation, dual antiplatelet therapy was continued despite a history of coagulopathy. On probing, it was discovered that the patient received two doses of recombinant factor VII (rVII) prior to the surgery to reduce operative bleeding. Discussion: Recombinant factor VII is known to cause serious arterial and venous thromboembolic events. This risk increases to almost 10% in patients who are elderly with concomitant vascular disease. In our patient with prior history of CAD and in the setting of acute surgical stress, exogenous factor VII unbalanced the coagulation system leading to a STEMI. Surgical teams should be aware of the detrimental consequences of administration of rVII in high cardiovascular risk patients and seek alternative hemostatic strategies. Prothrombotic agents should be used with caution and close monitoring for acute coronary syndromes, especially in patients with a high risk of CAD.

Association between diastolic dysfunction with coronary artery calcium score in stable coronary artery disease patients

Abstract Funding Acknowledgements Type of funding sources: None. Objectives Diastolic dysfunction is a common problem in patients with obesity, hypertension, diabetes, or coronary artery disease (CAD) including stable CAD. The coronary artery calcium score (CACS) is used to non-invasively evaluate cardiovascular risk in asymptomatic patients with a low to intermediate pre-test probability for CAD. The purpose of this study was to evaluate the association of diastolic dysfunction with an abnormal CAC score. Materials and Methods This study considered a cohort of patients > 18 years of age with normal ejection fraction who were admitted to the hospital with chest pain but low risk presentation for acute myocardial infarction. Patients then underwent cardiac CT for measurement of CAC score. Patients were excluded if they had prior history of CAD, ECG findings diagnostic of an acute coronary syndrome, an elevated troponin level, or hemodynamic instability. Results A total of 200 patients were included and 96 (48%) patients had echocardiographic evidence of diastolic dysfunction. Patients with diastolic dysfunction were more likely to have a higher mean calcium score (12,154.68 ± 17,588.30 vs 2,666.38 ± 9,725.82; p<0.001). Receiver operating characteristics (ROC) analysis showed the area under the curve was 86.3% and cut off was 129.5 with sensitivity 85% and specificity 74%. Conclusions Our study demonstrates that left ventricular diastolic dysfunction is associated with an abnormal CAC score. Patients without known CAD that present with chest pain with evidence of abnormal diastolic function on echocardiogram may warrant more thorough evaluation for coronary atherosclerotic disease with CAC score assessment.

PO-03-207 BUILDING A PREDICTION MODEL FOR SUDDEN CARDIAC DEATH IN A GENERAL POPULATION IN TAIWAN USING THE MACHINE LEARNING TECHNIQUE

Predicting the risk of sudden cardiac death (SCD) is of paramount importance in preventive medicine. However, it remains a major challenge to prevent SCD in the general population. This study aimed to develop a prediction model for sudden cardiac deaths in the general population using the community-based cohort in Taiwan. Chin-Shan Community Cardiovascular Cohort (CCCC) enrolled participants ≥ 35 years of the age since 1990-1991, and participants were followed up until 2005. Participants without 12-lead ECG, echocardiography, and carotid artery duplex sonography data were excluded from this study. A total of 2193 subjects in the CCCC were analyzed (Cohort 1: whole CCCC). Among Cohort 1, 2105 participants without a prior history of CAD and heart failure (HF) with reduced ejection fraction (HFrEF: left ventricular [LVEF] < 35%) were also studied (Cohort 2). For Cohort 1 & Cohort 2, we randomly selected 55% subjects to be the training dataset, 30% as the validation dataset, and 15% as the test dataset. Feature importance in machine learning (ML) was applied to assign a score to input features based on how important they are in predicting SCD events. Four ML algorithms were compared, including: (1) XGboost; (2) random forests; (3) logistic regression; and (4) DNN (deep neural network). The receiver operating characteristic curves and the area under curves (AUC) were used to summarize the prediction performance. The cumulative incidence of SCD was 1.50% in Cohort 1. The AUC of the CCCC-SCD-Score (previously published by our research team) in predicting SCD risks was 0.888. Using the ML analysis, we established novel prediction models to predict SCD events. For Cohort 1 and Cohort 2, the AUC is within the range of 0.81-1.00 (using the algorithms of XGboost and random forests algorithms (Figure). The scores of feature importance for variable factors in Cohort 1 and Cohort 2 are shown in the Figure. For Cohort 1, coronary artery disease (CAD) diagnosed by electrocardiography (ECG) or history was the most significant determinant of SCD among all factors; For Cohort 2, CCCC-SCD scores established by our research team was the most significant determinant of SCD among all factors. Using the ML analysis, we established excellent prediction models for predicting SCD events of SCD via XGboost and random forests. Careful evaluation and management for subjects with risk factors of SCD may be useful in preventive medicine.

The value of pre-transplant coronary angiography findings in kidney transplant candidates at high risk for cardiovascular disease.

Cardiovascular disease is a significant cause of mortality after kidney transplantation. Whether pre-transplant screening for coronary artery disease (CAD) in asymptomatic kidney transplant candidates (KTCs) is beneficial is unclear. We conducted a retrospective cohort study evaluating post-transplant cardiovascular events in 192 high-risk KTCs who underwent pre-transplant CAD evaluation. The study aimed to identify risk factors associated with finding severe CAD on pre-transplant angiography, and to assess the relationship between screening strategies and post-transplant cardiovascular events. At five years post-transplant, cardiovascular events occurred in 23.9% of subjects. Prior CAD history and left ventricular ejection fraction (LVEF) < 50% were associated with higher odds of finding severe CAD on pre-transplant angiography. Severe CAD on angiography was associated with a higher risk of early cardiovascular events within six months of transplantation. However, coronary intervention in KTCs with severe CAD was not associated with lower rates of post-transplant cardiovascular events. Pre-transplant coronary angiography to identify severe CAD is of highest yield in KTCs with a history of CAD or an LVEF < 50%. Our findings indicate that the identification of severe CAD in KTCs has prognostic significance for the early post-transplant period. Optimization of medical therapy in these high-risk KTCs may improve post-transplant cardiovascular outcomes.

Atherosclerotic Cardiovascular Disease in Adults With Congenital Heart Disease

BackgroundThe effect of atherosclerotic cardiovascular disease (ASCVD) on cardiovascular death in adults with congenital heart disease (CHD) is not well understood. ObjectivesThe purpose of this study was to determine the prevalence and prognostic implications of ASCVD risk factors in adults with CHD. We hypothesized that ASCVD risk factors were associated with cardiovascular events defined as heart failure hospitalization, heart transplant, and cardiovascular death. MethodsThis is a retrospective cohort study of adults with CHD at the Mayo Clinic (2003-2019). Patients with a history of coronary artery disease (CAD) were excluded. ASCVD risk factors were defined as hypertension, hyperlipidemia, diabetes, obesity, smoking, and family history of premature CAD. ResultsThere were 5,025 patients without a prior history of CAD. The mean age was 35 (23-45) years, and 2,558 (51%) were males. Of 5,025 patients, 2,382 (47%) had ≥1 ASCVD risk factors at baseline, and 16% developed additional ASCVD risk factors within 5 years (new-onset ASCVD risk). ASCVD risk factors at baseline (hazard ratio 1.27, 95% confidence interval 1.06-1.38) and new-onset ASCVD risk factors during follow-up (hazard ratio 1.06, 95% confidence interval 1.02-1.11) were associated with cardiovascular events. ConclusionsASCVD factors were associated with cardiovascular events in adults with CHD. Since interventions that modify ASCVD risk have been shown to decrease cardiovascular death in the general population, it is logical to expect that such interventions would also improve clinical outcomes in the CHD population.

The role of Dobutamine stress echocardiography in patients evaluated for liver transplant to predict latent cardiac disease

BackgroundDobutamine stress echocardiography (DSE) is a frequently used diagnostic tool in the cardiac assessment of patients evaluated for liver transplant. But it's precision to predict obstructive coronary artery disease (CAD) or cardiomyopathy has been subject to much debate. AimThe aim of this study is to assess the efficacy of DSE in diagnosing latent CAD in pre-liver transplant evaluation. MethodsThis is a prospective, single center, observational study. 109 patients with no prior history of CAD, and baseline normal left ventricular function, who underwent DSE as a part of pre-transplant work-up from December 2016 to June 2018 were included in our study. Left ventricular ejection fraction (LVEF) at peak stress, new wall motion abnormalities, achievement of contractile reserve (CR) were noted. Coronary angiography (CAG) was performed in patients who had either positive DSE or significant risk factors for CAD. Patients were observed post operatively up to their discharge for cardiac events. ResultsOnly one patient with positive DSE had CAD by angiogram (16.6%) whereas 46.4% (n=13) with negative DSE had CAD. Among the patients with normal epicardial coronaries, 83.3% (n=5) had positive DSE (‘p’=0.016). The sensitivity of DSE was 7%, specificity of DSE was 64%, positive predictive value was 16% and negative predictive value was 40 %. In-hospital mortality was 16% (n=15). Among them none had a positive DSE and all 6 patients with positive DSE were alive at the time of discharge (p= 0.26). ConclusionThe performance accuracy of DSE to detect latent CAD in patients undergoing liver transplant is poor.

Development and Internal Validation of a Practical Model to Identify “Observe” Patients of the European Society of Cardiology 0/1-h Algorithm at Low Risk of a Coronary Diagnosis

Background: Patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) assigned to the “observe” zone of the European Society of Cardiology (ESC) 0/1-h algorithm form a heterogeneous group known to have an unfavourable prognosis. We aim to elucidate the clinical characteristics and management of these patients and generate a model that is predictive of a coronary diagnosis at index visit to the emergency department (ED). Methods: A retrospective observational cohort study, including adult patients presenting to the ED with suspected NSTE-ACS assigned to the “observe” zone of the ESC 0/1-h algorithm. Multivariable logistic regression analysis was performed for the prediction of a coronary diagnosis. Internal validation was performed using bootstrap resampling. Results: A total of 750 patients were included; mean age 66 ± 13 years, 35% women, 50% with prior history of coronary artery disease (CAD). In 372 (50%) patients a diagnosis was established within 30 days of index presentation, of whom 169 (45%) patients had a coronary-related event. Multivariable logistic regression analysis generated a 12-point risk score incorporating 5 variables for the prediction of such event, including type of angina, chest pain occurring during inspiration, prior history of CAD, ST-segment deviation on electrocardiogram, and estimated glomerular filtration rate <60. The final model had an optimism-corrected c-statistic of 0.78 (95% confidence interval [CI]: 0.74–0.82). A score <6 ruled out a coronary event in 276 (37%) patients, with a sensitivity and negative predictive value of 90% (95% CI: 84–94) and 94% (91–96), respectively. Conclusion: A score <6 identifies patients at low risk of a coronary diagnosis and can guide clinical decision-making in choosing the appropriate diagnostic test.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

BackgroundThe relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. MethodsThe study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. ResultsA total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005). ConclusionsMajority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

Abstract 14321: A Validation Study of Myocardial Elastography Against Coronary Computed Tomography Angiography in Patients With Coronary Artery Disease

Introduction: Myocardial Elastography (ME) is a new quantitative strain imaging method capable of detecting ischemia due to Coronary Artery Disease (CAD). ME has been compared to nuclear perfusion imaging with good agreement. Coronary Computed Tomography Angiography (CCTA) has been shown to have superior accuracy to nuclear perfusion imaging for CAD staging. In this study, ME is compared to CCTA in CAD patients. Methods: High framerate (300 fps) echocardiography in five patients presented with chest pain or shortness of breath symptoms, or having prior history of CAD. Standard short-axis views were acquired at the mid-, basal, and apical left-ventricular (LV) levels using a research ultrasound system (Vantage, Verasonics) with a phased array (P4-2, Philips). ME radial systolic strain (ε) was imaged to evaluate wall thickening using 2D cross-correlation and gradient-based methods on the raw (RF) signals. Average ε within each perfusion territory (LAD, RCA, LCX) was then computed N=45. CCTA was performed using an AcquilionOne Scanner (Canon) with Iohexol (Omnipaque, GE) for contrast. Echocardiograms were coregistered with CCTA using anatomical landmarks. Results: Good qualitative agreement between ε (ME) and stenosis level (CCTA) was obtained (Fig. 1A). ME was sensitive in detecting moderate to severe stenosis showing reduced ε. At mild stenosis, despite a trend of ε reduction, some territories maintained mechanical functionality, possibly due to collateral engagement, demonstrating that both structural (CCTA) and functional (ME) properties are complementary in informing on myocardial viability and functionality, especially at mild stenosis. Future work will entail incorporation of FFR CT measurements as an additional functional reference measurement to validate ME strain.

Low Pain Tolerance Is Associated With Coronary Angiography, Coronary Artery Disease, and Mortality: The Tromsø Study.

BackgroundThe initial presentation to coronary angiography and extent of coronary artery disease (CAD) vary greatly among patients, from ischemia with no obstructive CAD to myocardial infarction with 3‐vessel disease. Pain tolerance has been suggested as a potential mechanism for the variation in presentation of CAD. We aimed to investigate the association between pain tolerance, coronary angiography, CAD, and death.Methods and ResultsWe identified 9576 participants in the Tromsø Study (2007–2008) who completed the cold‐pressor pain test, and had no prior history of CAD. The median follow‐up time was 10.4 years. We applied Cox‐regression models with age as time‐scale to calculate hazard ratios (HR). More women than men aborted the cold pressor test (39% versus 23%). Participants with low pain tolerance had 19% increased risk of coronary angiography (HR, 1.19 [95% CI, 1.03–1.38]) and 22% increased risk of obstructive CAD (HR, 1.22 [95% CI, 1.01–1.47]) adjusted by age as time‐scale and sex. Among women who underwent coronary angiography, low pain tolerance was associated with 54% increased risk of obstructive CAD (HR, 1.54 [95% CI, 1.09–2.18]) compared with high pain tolerance. There was no association between pain tolerance and nonobstructive CAD or clinical presentation to coronary angiography (ie, stable angina, unstable angina, and myocardial infarction). Participants with low pain tolerance had increased risk of mortality after adjustment for CAD and cardiovascular risk factors (HR, 1.40 [95% CI, 1.19–1.64]).ConclusionsLow cold pressor pain tolerance is associated with a higher risk of coronary angiography and death.

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.

The Comparison of Quantitative Evaluation Results of the MPS SPECT/CT and Coronary Angiography: Determining the Most Valuable Quantitative Evaluation Score

Objectives:This study aimed to determine the most important perfusion score in patient selection for coronary angiography (CA) by quantitatively evaluating myocardial perfusion scintigraphy (MPS).Methods:Patients who underwent MPS single-photon emission computerized tomography/computed tomograph imaging in our clinic between December 2017 and January 2019, without coronary artery disease (CAD) history, followed by CA were included in the study. CA was considered positive when there is a stenosis of 70% or more in at least one coronary vessel. The summed stress score, rest score, and differential score; total perfusion deficit (TPD); and the defect’s extent obtained from non-attenuation-corrected (NC) and attenuation-corrected (AC) images of 80 patients were evaluated using the Mann-Whitney U test. A p value of <0.05 was considered significant. Receiver operating characteristic (ROC) analysis was performed.Results:The scores obtained from NC and AC images showed a significant difference between the two groups for all scores except for the extent and TPD scores at rest from AC images. The applied ROC curves’ highest diagnostic value was determined as the TPD score at stress (TPDS) obtained from NC images (area under the curve: 0.880, 95% confidence interval, 0.807-0.952, p<0.001). The cut-off value obtained for the TPDS from the ROC curve was found to be 5.5.Conclusion:The scores obtained from NC images have more power to detect CAD than those obtained from AC images. Patients with no prior CAD history with TPDS score higher than 5 in MPS should be referred for CA with priority.

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing.

The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary arterydisease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.

Myocardial infarction with non-obstructive coronary artery disease, a retrospective cohort study: Are plaque disruption and other pathophysiological mechanisms the same disease?

Backgound/Aim: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an increasingly recognized entity. Recent studies have shown that MINOCA is not a benign syndrome, with younger MINOCA patients having outcomes comparable to their myocardial infarction with obstructive coronary artery disease (MI-CAD) counterparts. In this study, we will describe the demographic, clinical and angiographic characteristics of MINOCA patients in our hospital. Methods: In this retrospective cohort study, all patients who underwent coronary angiography with the diagnosis of acute coronary syndrome during September 2016-April 2019 were screened and those with MINOCA were detected. We described the demographic, clinical, and angiographic characteristics of MINOCA patients and compared the etiologic and pathophysiological mechanisms. Results: A total of 3855 patients with acute coronary syndrome were screened and 155 were diagnosed with MINOCA, with a total prevalence of 4.02%. Among them, 48.4% were female and the overall mean age was 55.04 (13.57) years. Plaque disruption was the most common cause of MINOCA (48.4%), which was followed by microvascular dysfunction and slow flow (9.7%). We compared plaque disruption and other causes to find that age (58.31 (13.76) vs 51.89 (12.68) P=0.003), hypertension (37 (48.7%) vs 25 (31.6%) P=0.034), prior coronary artery disease history (16 (21.1%) vs 2 (2.5%) P=0.001) and creatinine clearance (67.35 (IQR: 25.8) vs 74.0 (IQR: 28.58) P=0.009) were higher in patients with plaque disruption than those without. Conclusion: MINOCA is a diagnosis of exclusion with numerous potential causes. The etiological and pathophysiological mechanisms of plaque disruption are different from other causes of MINOCA and the correct treatment approach determines the prognosis.