Risk For Future Cardiac Events Research Articles

Change in Pd/Pa: Clinical Implications for Predicting Future Cardiac Events at Deferred Coronary Lesions.

Background: Cardiovascular events still occur at intermediate stenosis with fractional flow reserve (FFR) ≥0.81, underscoring the additional measure to evaluate this residual risk. A reduction in distal coronary artery pressure/aortic pressure from baseline to hyperemia (i.e., change in Pd/Pa) reflects lipidic burden within vessel walls. We hypothesized that this physiological measure might stratify the risk of future cardiac events at deferrable lesions. Methods: Lesion- (899 intermediate lesions) and patient-based (899 deferred patients) analyses in those with FFR ≥0.81 were conducted to investigate the association between change in Pd/Pa and target lesion failure (TLF) and major adverse cardiac events (MACE) at 7 years, respectively. Results: The occurrence of TLF and MACE was 6.7% and 13.4%, respectively. The incidence of target lesion-related non-fatal myocardial infarction was 0.6%. Lesions with TLF had greater change in Pd/Pa (0.11±0.03 vs. 0.09±0.04; P=0.002), larger diameter stenosis (51.0±9.2% vs. 46.4±12.4%; P=0.048), and smaller FFR (0.84 (0.82-0.87) vs. 0.86 (0.83-0.90); P=0.02). Change in Pd/Pa (per 0.01 increase) predicted TLF (odds ratio, 1.16; 95% confidence interval (CI), 1.05-1.28; P=0.002) and MACE (odds ratio, 1.08; 95% CI, 1.01-1.16; P=0.03). Lesions with change in Pd/Pa ≥0.10 had 2.94- and 1.85-fold greater likelihood of TLF (95% CI, 1.30-6.69; P=0.01) and MACE (95% CI, 1.08-3.17; P=0.03), respectively. Lesions with FFR ≤0.85 had substantially higher likelihood of TLF when change in Pd/Pa ≥0.10 (12.4% vs. 2.9%; hazard ratio, 3.60, 95% CI, 1.01-12.80; P=0.04). However, change in Pd/Pa did not affect TLF risk in lesions with FFR ≥0.86 (3.8% vs. 3.7%; hazard ratio, 0.56; 95% CI, 0.06-5.62; P=0.62). Conclusions: Despite deferrable FFR values, lesions and patients with change in Pd/Pa ≥0.10 had higher cardiovascular risk. Change in Pd/Pa might help stratify lesion- and patient-level risk of future cardiac events in those with FFR ≥0.81.

A roadmap for modelling radiation-induced cardiac disease.

Cardiac risk mitigation is a major priority in improving outcomes for cancer survivors as advances in cancer screening and treatments continue to decrease cancer mortality. More than half of adult cancer patients will be treated with radiotherapy (RT); therefore it is crucial to develop a framework for how to assess and predict radiation-induced cardiac disease (RICD). Historically, RICD was modelled solely using whole heart metrics such as mean heart dose. However, data over the past decade has identified cardiac substructures which outperform whole heart metrics in predicting for significant cardiac events. Additionally, non-RT factors such as pre-existing cardiovascular risk factors and toxicity from other therapies contribute to risk of future cardiac events. In this review, we aim to discuss the current evidence and knowledge gaps in predicting RICD and provide a roadmap for the development of comprehensive models based on three interrelated components, (1) baseline CV risk assessment, (2) cardiac substructure radiation dosimetry linked with cardiac-specific outcomes and (3) novel biomarker development.

Data-driven collaborative QUality improvement in Cardiac Rehabilitation (QUICR) to increase program completion: protocol for a cluster randomized controlled trial

BackgroundCoronary heart disease (CHD) is the leading cause of deaths and disability worldwide. Cardiac rehabilitation (CR) effectively reduces the risk of future cardiac events and is strongly recommended in international clinical guidelines. However, CR program quality is highly variable with divergent data systems, which, when combined, potentially contribute to persistently low completion rates. The QUality Improvement in Cardiac Rehabilitation (QUICR) trial aims to determine whether a data-driven collaborative quality improvement intervention delivered at the program level over 12 months: (1) increases CR program completion in eligible patients with CHD (primary outcome), (2) reduces hospital admissions, emergency department presentations and deaths, and costs, (3) improves the proportion of patients receiving guideline-indicated CR according to national and international benchmarks, and (4) is feasible and sustainable for CR staff to implement routinely.MethodsQUICR is a multi-centre, type-2, hybrid effectiveness-implementation cluster-randomized controlled trial (cRCT) with 12-month follow-up. Eligible CR programs (n = 40) and the individual patient data within them (n ~ 2,000) recruited from two Australian states (New South Wales and Victoria) are randomized 1:1 to the intervention (collaborative quality improvement intervention that uses data to identify and manage gaps in care) or control (usual care with data collection only). This sample size is required to achieve 80% power to detect a difference in completion rate of 22%. Outcomes will be assessed using intention-to-treat principles. Mixed-effects linear and logistic regression models accounting for clusters within allocated groupings will be applied to analyse primary and secondary outcomes.DiscussionAddressing poor participation in CR by patients with CHD has been a longstanding challenge that needs innovative strategies to change the status-quo. This trial will harness the collaborative power of CR programs working simultaneously on common problem areas and using local data to drive performance. The use of data linkage for collection of outcomes offers an efficient way to evaluate this intervention and support the improvement of health service delivery.EthicsPrimary ethical approval was obtained from the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH01093), along with site-specific governance approvals.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001239651 (30/11/2023) (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386540&isReview=true).

InterVFast—effectiveness and acceptance of intermittent fasting in cardiac rehabilitation patients: study protocol of a randomized controlled trial

BackgroundResearch on intermittent fasting has shown that it can improve a variety of health outcomes, including blood sugar control, blood lipid levels and blood pressure. Only few studies document longer periods of fasting, especially in rehabilitation participants. Cardiac inpatient rehabilitation follows a multidisciplinary approach including change of health behaviour to reduce patients’ risk of future cardiovascular events. To date, evidence suggests that intermittent fasting can be an effective way to improve health and well-being, but more research is needed to fully understand its long-term effects and factors that promote the implementation. Therefore, the aim of the ongoing InterVFast trial is to investigate the effectiveness of intermittent fasting amongst cardiac rehabilitation patients after 4-week inpatient rehabilitation as well as 3 and 12 months subsequently including patients’ perspective.MethodsThis single-centre randomized controlled trial evaluates the effectiveness of the InterVFast intervention in weight loss (primary outcome). We also examine patients’ acceptance and the effect on relevant outcomes as blood glucose and triglyceride levels, cholesterol and high-sensitivity C-reactive protein. Weight, blood samples and clinical data are collected as part of the initial and final examination during inpatient rehabilitation. During inpatient rehabilitation, participants daily note fasting intervals and meals eaten as well as practicability in a fasting diary. In addition, interviews about perceived advantages and disadvantages and acceptance are carried out with the participants in the IG. A standardized follow-up examination (weight, blood samples) will be carried out by the family doctor after 3 and 12 months (t2 and t3).DiscussionCompared to other weight-loss intervention studies, our study addresses patients with coronary heart disease and includes patients’ acceptance as well as long-term maintenance. It is hypothesized that participation in the InterVfast intervention will improve relevant health outcomes in a sample of cardiac rehabilitation patients and thus constitute a behavioural prevention strategy to reduce the risk of future cardiac events and improve overall health and quality of life.Trial registrationClinicalTrials.gov DRKS00023983. Registered on February 17, 2022.

Prediabetes and Associated Risk of Cardiovascular Events and Chronic Kidney Disease Among Adult Survivors of Childhood Cancer in the St Jude Lifetime Cohort.

Little is known about the prevalence of prediabetes and associated risk of cardiovascular events and chronic kidney disease (CKD) with this reversable condition in survivors. Prevalence of prediabetes (fasting plasma glucose 100-125 mg/dL or hemoglobin A1c 5.7%-6.4%) and diabetes was clinically assessed in 3,529 adults ≥5 years from childhood cancer diagnosis and 448 controls stratified by age. Cox proportional hazards regression estimated progression from prediabetes to diabetes, and risk of future cardiac events, stroke, CKD, and death. Among survivors, median age 30 years (IQR, 18-65), and the prevalence of prediabetes was 29.2% (95% CI, 27.7 to 30.7) versus 18.1% (14.5 to 21.6) in controls and of diabetes was 6.5% (5.7 to 7.3) versus 4.7% (2.7 to 6.6). By age 40-49 years, more than half of the survivors had prediabetes (45.5%) or diabetes (14.0%). Among 695 survivors with prediabetes and longitudinal follow-up, 68 (10%; median follow-up, 5.1 years) progressed to diabetes. After adjustment for demographic factors and body composition, risk of progression was associated with radiation exposure to the pancreatic tail ≥10 Gy (hazard ratio [HR], 2.7 [95% CI, 1.1 to 6.8]) and total-body irradiation (4.4 [1.5 to 13.1]). Compared with survivors with normal glucose control, adjusting for relevant treatment exposures, those with prediabetes were at increased risk of future myocardial infarction (HR, 2.4 [95% CI, 1.2 to 4.8]) and CKD (2.9 [1.04 to 8.15]), while those with diabetes were also at increased risk of future cardiomyopathy (3.8 [1.4 to 10.5]) or stroke (3.4 [1.3 to 8.9]). Prediabetes is highly prevalent in adult survivors of childhood cancer and independently associated with an increased risk of future cardiovascular and kidney complications. Prediabetes, a modifiable risk factor among childhood cancer survivors, represents a new target for intervention that may prevent subsequent morbidity and mortality.

Major adverse cardiovascular events in patients with ECG changes during dipyridamole infusion as a myocardial stress agent and normal MPI among filipino patients at a tertiary hospital

Abstract Introduction There is paucity and conflicting results of data regarding the prognostic significance of ST-segment depression during vasodilator stress testing in patients with normal myocardial perfusion imaging (MPI). It is even less well studied in minorities such as Filipino population. Purpose This study aims to determine the major adverse cardiovascular events (MACE) in patients with ECG changes during dipyridamole infusion as a myocardial stress agent and normal myocardial perfusion imaging. Methodology We performed a cross-sectional retrospective analysis of 266 adult patients aged 18 years and above who underwent dipyridamole MPI. Patients with abnormal baseline ECG, patients subjected to tests other than the Dipyridamole VST and those with missing clinical, electrocardiogram, or myocardial perfusion Imaging data were excluded. The primary endpoint was the composite MACE: of all-cause mortality, nonfatal MI, stroke, hospitalization because of heart failure, and revascularization. Results Among 226 included patients (mean age ‘61.11 + 10.72’ years; 58% women), those with ST segment depression >0.5mm were more likely to have MACE (OR 281.12; 95% CI 37.59 to 2101.82, p-value <0.001), female patients were more likely to have MACE compared to male patients (OR 2.1839; 95% CI 1.1373 to 4.1936; p-value 0.019), and patients with atypical type of chest pain were likely to have MACE (OR 2.1767; CI 1.1844 to 4.0003; p-value 0.012). During follow-up of 3 years, a total of 55 patients had MACE. All-cause mortality occurred in 3 patients, non-fatal MI in 40 patients, Hospitalization due to heart failure in 5 patients, stroke in 6 patients, and revascularization in 1 patient. Conclusion Dipyridamole-induced ischemic ST depression is more common in women, and is associated with increased risk for future cardiac events compared with similar patients without ECG evidence of ischemia. Ischemic ECG changes during dipyridamole MPI should warrant further evaluation and follow up, even when perfusion images are reassuring.

Osteoarthritis knee and modifiable cardiovascular risk factors: play in tandem.

To know the frequency of modifiable cardiovascular risk factors in knee osteoarthritis patients. Cross sectional study was done at Department of Rheumatology Indus Medical College, Tando Mohammad Khan from March 25, 2022 to November 24, 2022. Total 246 Osteoarthritis of knee cases with (Kellgren-Lawrence grad-II and above) on x-ray, were selected after demographic details, blood pressure, body mass index and physical examination was done, 5ml of venous blood was drawn by phlebotomist, sent for fasting blood sugar, serum lipids analysis and Framingham 10years risk score was calculated afterward for each participant. In this study males (126) and females (120). Overall (78%) had risk factors, Patients having one CVD risk factor were (22.8%), two risk factors in (21.1%), three in (21.5%), four (9.8%) and five factors in (1.6%) while frequency of modifiable cardiovascular risk shows obesity (45.5%) hypertension (40.2%) intermediate to high risk of framingham score (40%) diabetes mellitus (25%), smoking (17%), high low density lipoproteins (8.1%). In males obesity(54.2%), hypertension (47.5% ) and (45.8%) were on medication, diabetes mellitus(31.7%), smoker(31%), high risk FRS(39.2%), K-L grade-IV(58.4%) and in females: obesity (42%), hypertension (43.7%) and (40.5%) were on medication, diabetes mellitus in (19%), smoking (4%), high risk FRS (13.5%), K-L Grade-4 (42%), significant association of diabetes mellitus, smoking, FRS and K-L grades with gender (p<0.05). In OA knee there is high prevalence of modifiable cardiovascular risk factors and together these imposes a major health risk for future cardiac events and disability.

Technical note: Exploring the detectability of coronary calcification using ultra-high-resolution photon-counting-detector CT.

Coronary calcification is a strong indicator of coronary artery disease, and patients with a "zero" coronary calcification score have a much lower risk of future cardiac events than those with even small amounts of calcium. However, false-negative (incorrect zero scores) may occur if small calcifications are missed at CT due to limited spatial resolution. To demonstrate lower limits of detection for coronary calcification using an ultra-high-resolution (UHR) mode on a clinical photon-counting-detector CT (PCD-CT), compared to a conventional energy-integrating-detector CT (EID-CT). Chicken eggshell fragments (0.4-0.8mm) mimicking coronary calcifications were scanned on a clinical PCD-CT (NAEOTOM Alpha) in UHR mode and a conventional EID-CT (SOMATOM Force) with matched tube potential and radiation dose levels to the PCD-CT. PCD-CT images were reconstructed with a sharp kernel (Qr68) and a quantum iterative algorithm (QIR-3). Two sets of EID-CT images were reconstructed: routine clinical kernel (Qr36, ADMIRE-3) and a sharper kernel (Qr54) with similar noise to PCD-CT images. With institutional review board approval, in vivo exams performed with the PCD-CT in UHR mode were compared against patients' clinical EID-CT exams. The visibility of calcifications on PCD-CT and EID-CT images was assessed and compared qualitatively. PCD-CT images visualized all calcified fragments, while EID-CT failed to detect those below 0.6mm using a routine protocol. EID-CT with Qr54 improved visibility but distorted boundaries. Calcifications were less visible on EID-CT than PCD-CT as phantom sizes increased. 0.6- and 0.7-mm calcified fragments were barely visible on 35- and 40-cm phantom EID-CT images. Patient cases showed small calcifications missed on EID-CT but detected on PCD-CT. At matched radiation dose, PCD-CT in UHR mode provided higher spatial resolution and improved the detectability of small calcified fragments for different phantom/patient sizes in comparison to EID-CT.

Developing a brief intervention to communicate cardiovascular risk to patients presenting to the emergency department with chest pain: a co-production approach

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Brittish Heart Foundation Background The majority of patients who present to the Emergency Department with suspected acute coronary syndrome (ACS) will be discharged once ACS has been ruled out. High-sensitivity cardiac troponin (hs-cTn) is a highly specific biomarker for myocardial injury and is the biomarker of choice for the diagnosis of ACS. However, our previous research on hs-cTn has demonstrated that patients with elevated levels that do not meet the diagnostic threshold for ACS are at increased risk of future cardiac events. These patients are often discharged with no further investigation or understanding of their risk of future cardiac events, despite the potential benefits of preventative strategies. Purpose The aim of this study was to co-design a brief intervention with patients and healthcare professionals to promote cardiovascular health in patients where the diagnoses of ACS has been ruled out but hs-cTn concentrations indicate higher risk of future cardiac events. Methods Patients who presented to the Emergency Department with symptoms suggestive of ACS and a maximum high-sensitivity troponin between 5 ng/L and the 99th centile were invited to attend a focus group or participate in one-to one interviews. We also interviewed healthcare professionals involved in the care of this group. Patients were recruited using electronic medical records and staff were recruited through social media and posters. Recruitment continued until data saturation was reached. The data was analyzed using thematic analysis. We created protypes based upon the initial data which we presented back to patients and staff for feedback to help refine our brief intervention. Results We identified several themes from the data which included; experience of the Emergency Department, previous experience of cardiovascular risk communication, desired information, format of intervention, delivery mode of intervention, timing of delivery, language used and potential barriers. The patients did not have strong preferences on what information should be included in the intervention, however, most patients were receptive to receiving information about their cardiovascular risk guided by hs-cTn. Patients voiced that the intervention should not contain any medical terminology and information should be understood by a lay audience. Many patients and staff felt that the pressures currently faced in the Emergency Department may act as a barrier in delivering the cardiovascular brief intervention. Conclusion We have co-produced a cardiovascular brief intervention in collaboration with patients and healthcare professionals. The effect of this brief intervention on cardiovascular outcomes will be tested in a future randomised controlled trial.

Exploring how enrolment in the TARGET-CTCA clinical trial may modify patient perception of heart health

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background The TARGET-CTCA trial aims to determine whether the use of high-sensitivity cardiac troponin to target computed tomography coronary angiography (CTCA) improves outcomes in patients presenting to hospital with suspected acute coronary syndrome in whom myocardial infarction has been ruled out. What patients understand of their subsequent risk of cardiovascular disease in this setting, and how intervention with CTCA may influence this is unknown. Purpose To explore how trial participants perceive their heart health and whether this has been modified by trial participation. Methods The TARGET-CTCA trial randomises patients with intermediate high sensitivity cardiac troponin levels to standard care, or CTCA plus standard care. Patients receive CTCA scan results informing them if they have a normal heart or they have mild, moderate or obstructive coronary artery disease. Forty semi-structured interviews were conducted with trial participants across standard care and intervention arms ensuring representation across disease category, age, sex and socioeconomic status groups. Data were coded and organized into themes. Results Emergent themes from the data included insights into attitudes to future health, perception of heart health, and health education needs. While some participants displayed a proactive approach to maintaining health, the consideration of future health goals was often a reactive process in response to the initial chest pain episode or the CTCA findings. While some patients discussed personal responsibility for health maintenance others described a passive approached requiring direct management from a health professional. For some standard care participants, the absence of myocardial infarction was a sign of a healthy heart. Others were left with unanswered questions after the hospital assessment. Confirmation of the absence of coronary artery disease with CTCA gave patients great confidence and a positive change to health seeking behaviour patterns was reported. Patients differed in their interpretation of the terms mild, moderate and obstructive coronary artery disease. This affected their subsequent action with some using the presence of disease as an opportunity to appraise their risk of future cardiac events and begin a preventative approach. Others reported fear and reducing activity to avoid precipitating a possible event. Many patients reported a desire to implement lifestyle changes but did not have the knowledge to do so. Conclusion Exploring how the information contained in participant result letters may contribute to the understanding of risk of future cardiac events has provided valuable information for application of the trial intervention outside of the main trial setting.

Non-Invasive Assessment of Myocardial Perfusion Abnormality in Type 2 Diabetic Patients Without Symptoms of Coronary Artery Disease by SPECT-MPI

Introduction: Coronary artery disease (CAD) is the most common chronic macrovascular complication of diabetes mellitus. Diabetic patients have a high incidence of silent ischemia and MI due to autonomic neuropathy. SPECT imaging is a well-established, non-invasive procedure that offers perfusion and functional information for diagnosis and risk stratification, facilitating the early detection of CAD. Objective: To detect myocardial perfusion abnormality by SPECT-MPI in type 2 diabetic patients without symptoms of CAD. Methods: A total of eighteen diabetic patients with no history of typical CAD, with or without risk factors, underwent gated SPECT-MPI using 99mTc-sestaMIBI. A single-day stress–rest protocol with adenosine was done in each patient. Result: Six out of eighteen patients (33.3%) showed abnormal scans suggestive of myocardial ischemia or infarction. Four of these patients had reversible perfusion defects, one had a fixed perfusion defect, and one had a mixed defect. Among these patients, single vessel territory was involved in three patients, and three patients had involvement in double vessel territories. Regarding the summed stress score (SSS) value, most of the patients (four) had mild risk, whereas moderate and severe risk of a future cardiac event were observed in one patient each. In addition, two patients had left ventricular dysfunction (EF&lt; 45%). Five patients with normal MPI and two patients with abnormal myocardial perfusion scans had high transient ischemic dilatation (TID). Risk factors such as male sex, hypertension, hyperlipidemia, obesity, and family history of CAD were not significantly correlated with abnormal scans. But abnormal scans were significantly related to a longer duration of diabetes (P = 0.038). Conclusion: This study showed that despite being asymptomatic, a considerable portion of diabetic patients had perfusion abnormalities, not just ischemia but also infarctions. Moreover, some of these patients are at high risk for future cardiac events as assessed by SSS, TID, and LVEF. Bangladesh J. Nuclear Med. 25(2): 110-116, 2022

Protocol: Can coronary artery calcium score identified on thoracic planning CT scans be used and actioned to identify cancer survivors at high risk of cardiac events: A feasibility study in cancer survivors undergoing radiotherapy in Australia

IntroductionA coronary artery calcium (CAC) CT scan can identify calcified plaque and predict risk of future cardiac events. Cancer survivors undergoing thoracic radiotherapy routinely undergo a planning CT scan, which...

Prevalence of Erectile Dysfunction among Type-2 Diabetes Mellitus &amp; Availability of Treatment Options in Pakistan

Introduction Erectile dysfunction has been defined as failure to obtain and maintain an erection sufficient for sexual intercourse or decreased erectile turgidity on 75% of sexual occasions, lasting for at least six months. Estimates of the prevalence of erectile dysfunction (ED) in men with diabetes range from 20% to 85% [1]. Type 2 Diabetes patients have a high risk of sexual dysfunction in men; three times increased risk of ED was seen in diabetic compared with nondiabetic men. There are multiple risk factors which include, obesity, age-related hormonal changes metabolic syndrome in young patients, it is associated with a greater increase in the risk of future cardiac events as compared to its first detection in older males. Aim The aim of the study is to determine the relative prevalence of Erectile Dysfunction in the Pakistani population attending diabetes with help of the SHIMS score/IELTS. To establish further management of this commonly under-recognized, under-discussed, and commonly untreated complication of diabetes. But it is also one of the most treatable diabetic complications. It is a “couple’s disorder,” affecting both the patient and his partner. In Pakistan, there is not much evidence &amp; options for treatment are not ideally available inclusive of the availability of PD5 drugs. Methodology Male patients with diabetes mellitus having poor glycemic control, hypertension, and hyperlipidemia with or without active complaint of Erectile Dysfunction attending The Diabetes Centre (TDC) during the study period were enrolled in the study. 319 males with diabetes were examined by the Diabetologist, endocrinologist, and clinical psychologist. Patients were surveyed using the five items version of the International Index of Erectile Dysfunction questionnaire, also known as the Sexual Health Inventory of Men (SHIM) to determine the presence and severity of ED and the efficacy of ED treatment conditions. Discussion and Results In the study, a total of 319 diabetic patients were enrolled and assessed/examined. Those with severe ED were found to have poor glycemic control, abnormal lipid profile, with BMI. 19%, 15%, and 31% of patients scored as severe, moderate, and mild to moderate ED respectively; 65% were scored as suffering in ED, whereas 20% of diabetic male patients have a higher proclivity of developing server ED. Male patients with poor glycemic control &amp; hyperlipidemia were suffering from severe erectile dysfunction. Conclusion The accumulated percentage of diabetic male patients who have signs of ED is higher therefore the prevalence of ED is too high in diabetic male patients. In addition, there are no appropriate management options like the availability of safe drugs and treatment in Pakistan.

Troponin in acute chest pain to risk stratify and guide effective use of computed tomography coronary angiography (TARGET-CTCA): a randomised controlled trial

BackgroundThe majority of patients with suspected acute coronary syndrome presenting to the emergency department will be discharged once myocardial infarction has been ruled out, although a proportion will have unrecognised coronary artery disease. In this setting, high-sensitivity cardiac troponin identifies those at increased risk of future cardiac events. In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, this trial aims to investigate whether outpatient computed tomography coronary angiography (CTCA) reduces subsequent myocardial infarction or cardiac death.MethodsTARGET-CTCA is a multicentre prospective randomised open label with blinded endpoint parallel group event driven trial. After myocardial infarction and clear alternative diagnoses have been ruled out, participants with intermediate cardiac troponin concentrations (5 ng/L to 99th centile upper reference limit) will be randomised 1:1 to outpatient CTCA plus standard of care or standard of care alone. The primary endpoint is myocardial infarction or cardiac death. Secondary endpoints include clinical, patient-centred, process and cost-effectiveness. Recruitment of 2270 patients will give 90% power with a two-sided P value of 0.05 to detect a 40% relative risk reduction in the primary endpoint. Follow-up will continue until 97 primary outcome events have been accrued in the standard care arm with an estimated median follow-up of 36 months.DiscussionThis randomised controlled trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction.Trial registrationClinicalTrials.gov Identifier: NCT03952351. Registered on May 16, 2019.

Improved Performance of PET Myocardial Perfusion Imaging Compared to SPECT in the Evaluation of Suspected CAD.

Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) has played a central role in the non-invasive evaluation of patients with obstructive coronary artery disease (CAD) for decades. In this review, we discuss the key differences and advantages of positron emission tomography (PET) MPI over SPECT MPI as it relates to the diagnosis, prognosis, as well as clinical decision-making in patients with suspected CAD. Stress-induced perfusion abnormalities on SPECT help estimate presence, extent, and location of ischemia and flow-limiting obstructive CAD, help with risk stratification, and serve as a gatekeeper to identify patients who will benefit from downstream revascularization versus medical management. Some of the major limitations of SPECT include soft-tissue attenuation artifacts, underestimation of ischemia due to reliance on relative perfusion assessment, and longer protocols with higher radiation dose when performed with traditional equipment. PET MPI addresses most of these limitations and offers better quality images, higher diagnostic accuracy along with shorter protocols and lower radiation dose to the patient. A special advantage of PET scanning lies in the ability to quantify absolute myocardial blood flow and assess true extent of epicardial involvement along with identifying non-obstructive phenotypes of CAD such as diffuse atherosclerosis and microvascular dysfunction. In addition, stress acquisition at/near peak stress with PET allows us to measure left ventricular ejection fraction reserve and myocardial blood flow reserve, which help with identifying patients at a higher risk of future cardiac events and optimally select candidates for revascularization. The several technical advantages of PET MPI position as a superior method to diagnose obstructive and non-obstructive phenotypes of ischemic heart disease affecting the entirety of the coronary circulation offer incremental value for risk stratification and guide post-test management strategy for patients with suspected CAD.

The prevalence of left ventricular hypertrophy associated with type-2 diabetes in Shiraz, Iran: a cross-sectional study

BackgroundLeft ventricular hypertrophy (LVH) is a common diagnosis in patients with cardiovascular disease (CVD). The prevalence of LVH among patients with Type-2 Diabetes Mellitus (T2DM), high blood pressure and aging is higher than the healthy population and has been independently associated with an increased risk for future cardiac event, including stroke. The aim of this study is to identify the prevalence of LVH among T2DM subjects and evaluate its association with related risk factors of CVD patients in the metropolis of Shiraz, Iran. The novelty of this study is that there has been no known published epidemiological study related to the relationship of LVH and T2DM on this unique population.Materials and methodThis cross-sectional study was designed based on collected data of 7715 free dwelling subjects in the community-based Shiraz Cohort Heart Study (SCHS) from 2015 to 2021, ages 40–70 years. Overall, 1118 subjects with T2DM were identified in the SCHS and after exclusion criteria, 595 subjects remained eligible for study. Subjects with electrocardiography (ECG) results, which are appropriate and diagnostics tools, were evaluated for the presence of LVH. Thus, the variables related to LVH and non-LVH in subjects with diabetes were analyzed using version-22 statistical package for social sciences software program to ensure consistency, accuracy, reliability, and validity for final analysis. Based upon related variables and identifying LVH and non-LVH subjects, the relevant statistical analysis was implemented to ensure its consistency, accuracy, reliability, and validity for final analysis.ResultsOverall, the prevalence of diabetic subjects was 14.5% in the SCHS study. Furthermore, the prevalence of hypertension in the study subjects aged 40–70 years was 37.8%. The prevalence of hypertension history in T2DM study subjects for LVH compared to non-LVH was (53.7% vs. 33.7%). The prevalence of LVH among patients with T2DM as the primary target of this study was 20.7%. Analytical findings comparing both LVH and non-LVH subjects who have T2DM identified significance for variables in the older (≥ 60) mean and categorical age group (P < 0.0001), history of hypertension (P < 0.0001), mean and categorical duration of hypertension in years (P < 0.0160), status of controlled versus uncontrolled hypertension level (P < 0.0120), the mean systolic blood pressure (P < 0.0001) as well as mean duration years of T2DM and categorical duration of diabetes in years (< 0.0001 and P < 0.0060), mean fasting blood sugar (< 0.0307) and categorical status of FBS Level (mg/dl): controlled and uncontrolled FBS status of controlled vs. uncontrolled FBS levels P < 0.0020). However, there were no significant findings for gender (P = 0.3112), diastolic blood pressure mean (P = 0.7722) and body mass index (BMI) mean and categorical BMI (P = 0.2888 and P = 0.4080, respectively).ConclusionThe prevalence of LVH in the study increases significantly among T2DM patients with hypertension, older age, years of hypertension, years of diabetes, and higher FBS. Thus, given the significant risk of diabetes and CVD, evaluation of LVH through reasonable diagnostic testing with ECG can help reduce the risk of future complications through the development of risk factor modifications and treatments guidelines.

The role of epicardial and pericoronary adipose tissue in cardiometabolic disease

Epicardial adipose tissue (EAT) is a metabolically active fat depot which modulates coronary arterial function. The measurement of EAT volume and attenuation from non-contrast cardiac computed tomography (CT) provides valuable information on cardiometabolic risk. Pericoronary adipose tissue (PCAT), a subset of EAT which directly surrounds the coronary vessels, may function as a sensor of coronary inflammation. PCAT attenuation on coronary CT angiography associates with coronary plaque morphology, stages of coronary artery disease, and risk of future cardiac events. Quantification of EAT and PCAT has incremental and complementary prognostic value over and above current risk assessment tools. This review covers the biological role of EAT in healthy and dysfunctional states, and CT-based assessment of EAT and PCAT towards the development of clinically meaningful imaging biomarkers.

High-Risk Culprit Plaque Predicts Cardiovascular Outcomes Independently of Plaque Rupture in ST-Segment Elevation Myocardial Infarction: Insight From Optical Coherence Tomography.

The present study explored the predictive value of culprit high-risk plaque (HRP) detected by optical coherence tomography (OCT) for predicting major adverse cardiovascular events (MACEs) in patients with ST-segment elevation myocardial infarction (STEMI). HRP was defined as the simultaneous presence of four criteria: minimum lumen area <3.5mm2, fibrous cap thickness <75μm, lipid plaque with lipid arc extension >180°, and presence of macrophages. Patients (n = 274) were divided into non-HRP group (n = 206) and HRP group (n = 68). MACEs were defined as a composite of all-cause death, myocardial infarction, stroke, and revascularization. During a mean follow-up of 2.2years, 47 (17.5%) MACEs were observed: 28 (13.6%) in the non-HRP group and 19 (27.9%) in the HRP group (log-rank P = .005). Patients with HRP were 2.05 times more likely to suffer from a MACE than those without HRP (hazards ratio: 2.05, 95% confidence interval: 1.04-4.02, P = .038); MACE risk was comparable between plaque rupture and plaque erosion. In conclusion, HRP was present in 24.8% of STEMI patients and associated with higher cardiovascular risk independent of plaque rupture, suggesting that HRP detected by OCT may help identify patients at high risk of future cardiac events.

SERUM BIOMARKERS OF LIPID, ATHEROGENIC INDEX OF PLASMA, ELECTROCARDIOGRAM AND FUNDUS CHANGES IN HYPERTENSIVE PATIENTS OF CENTRAL NEPAL

Background: Hypertensive retinopathy, its ocular complication, is characterized by progressive metabolic disorders and structural damage to the retina. Lipids play an essential role in retinal hemostasis. The study was aimed to assess the prevalence of hypertensive retinopathy, the association between traditional lipid biomarkers and hypertensive retinopathy, and the predictive risk for future cardiac events using the atherogenic index of plasma in hypertensive patients of central Nepal. Methods: A hospital-based cross-sectional study was conducted in the Department of Ophthalmology, Chitwan Medical College, from 15 August 2021 to 30 October 2021. Ethical clearance was taken from the Institutional Review Committee (Ref: CMC-IRC/078/079-025). Convenience sampling was done to reach the sample size. Relevant data was entered in a proforma specified for the study. Data analysis was done using Statistical Package for the Social Sciences version 26, point estimate at 95% Confidence Interval (CI) was calculated along with frequency and proportion for binary data, p-value &lt;0.05 was considered statistically significant. Results: The prevalence of hypertensive retinopathy was 34 (10.7%) (7.5-14.6 at 95% CI) in the study subjects. Gender wise females 167 (52.7%) outnumbered the males 150 (47.3%). Serum cholesterol level was the only biomarker significantly associated with the development of hypertensive retinopathy (p = 0.01). The mean atherogenic index of plasma in the study subjects was high (0.52). Conclusions: The prevalence of hypertensive retinopathy was lower in this study than similar studies done elsewhere. The atherogenic index of plasma was higher in the study subjects.

Exploring the experiences of the cardiac rehabilitation journey among South Asian patients

Background/AimsIndividuals from South Asian backgrounds are at greater risk of developing coronary heart disease. Cardiac rehabilitation reduces the risk of future cardiac events, yet uptake is low among South Asian populations. This study explored South Asian patients' understanding and experiences of cardiac rehabilitation.MethodsThis qualitative, semi-structured study identified a purposeful sample of 36 eligible patients, of whom six participated in an interview that explored their experiences and perceptions of cardiac rehabilitation. Data were analysed using inductive analysis.ResultsThree themes were identified: starting the conversation; expectation vs reality; and meeting patient needs. Patients perceived cardiac rehabilitation as additional support rather than a fundamental part of care. Moreover, they considered the content of cardiac rehabilitation programmes to lack cultural sensitivity, which influenced both attendance and perceived relevance.Conclusions:Nurses must promote cardiac rehabilitation during the acute phase of recovery, while considering South Asian patients' beliefs, perceptions and cultural acceptance of cardiac rehabilitation. Invitations to attend and cardiac rehabilitation delivery must be personalised, accounting for cultural influences on lifestyle.