Significant Coronary Artery Disease Research Articles

Combined single-photon emission computed tomography-myocardial perfusion imaging with coronary calcium score for assessing coronary disease.

Coronary artery disease (CAD) underestimation represents a major pitfall of single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI). Coronary artery calcium score (CACS) has emerged as a sensitive tool for the assessment of suspect CAD; however, the integration of SPECT-MPI with CACS has been seldom evaluated, so far, and was therefore the aim of the present study. Patients undergoing SPECT-MPI with CACS and subsequent coronary angiography were included. ROC curves were used to identify the CACS values best predictive for CAD. In SPECT-MPI negative patients, the formula: defined the optimal CACS cut-points. The Systematic Coronary Risk Evaluation 2 was applied for 10-year cardiovascular risk estimation. Significant CAD was defined for an epicardial coronary stenosis >70 or 50% for the left main. Among 124 patients, 61 (49.19%) displayed positive SPECT-MPI, whereas 69 (56%) had significant CAD at angiography. Sensitivity, specificity, and positive predictive value (PPV) for SPECT-MPI were, respectively, 74, 82, and 84%. Considering 63 SPECT-MPI negative cases, the index values for CACS at the optimal cutoff value of 1949 were: sensitivity 28%, specificity 89%, and PPV 50%, allowing to further detect five (8%) of the patients with significant CAD. The increased discriminative power of the combined SPECT-MPI with CACS was not conditioned by the pretest cardiovascular risk. Among patients with suspect CAD undergoing SPECT-MPI, the addition of CACS in negative cases allows to detect a consistent further 8% of patients with significant CAD, thus limiting the risk of disease underestimation and offering potential prognostic benefits.

Diagnostic Accuracy of Low-Dose Myocardial Perfusion Imaging in a Real-World Setting.

This large-scale study analyzes factors affecting diagnostic accuracy of low-dose myocardial perfusion imaging and correlation with coronary angiography in a real-world practice. We compared data extracted from routine reports of (i) low-dose [99mTc]sestamibi stress-MPI performed with no attenuation correction and predominantly exercise stress testing and (ii) the corresponding coronary angiography. We considered 1070 pairs of coronary angiography/stress-MPI results reported by 11 physicians. Mean MPI effective dose was 4.5±2.1 mSv. The extent of MPI-ischemia was predictive of > 70% but not 50-70% coronary stenoses. A positive test was associated with a sensitivity of 74.7% (413/553) and a specificity of 53.2% (275/517) for > 70% stenosis detection. Positive predictive values were lower in patients with left bundle branch block or pacemakers (LBBB/PM) (45.6% vs. 64.7%, p=0.006) and markedly higher for patients with MPI-ischemia ≥ 3 segments or associated with ST-segment depression (75.0% (165/220)) as compared to those with < 3 segments MPI-ischemia, MPI-infarction or isolated ST-segment depression (57% (248.0/435), p<0.001). Negative predictive values were lower for patients with previous CAD history (58.3%), male (61.0%) and elderly patients (59.6%) (vs. 72.1%, 79.2% and 72.4%, respectively, all p < 0.05). Routine results from low-dose stress-MPI, predominantly associated with exercise stress testing and uncorrected for attenuation, correlate with real-world coronary angiography results. However, this correlation is lower than that achieved with conventional study designs and affected by the definition of significant CAD and context variables (LBBB/PM, CAD history, sex and age). Better consideration of these interacting factors could improve patient monitoring.

Coronary artery profile on coronary angiography in TMT positive female patients presenting in BPKIHS, Nepal

BACKGROUND Diagnosis of Coronary artery disease by Coronary artery angiography is limited by its availability, cost and as an invasive procedure. Treadmill test is a noninvasive and easily available test for diagnosing as well as prognosis of coronary artery disease and is most commonly performed stress test for diagnosis of coronary artery disease. Women tend to have a greater release of catecholamines during exercise, which could potentiate coronary vasospasm and augment the incidence of abnormal exercise results. TMT in women have a relatively low diagnostic yield for CAD compared to men, especially when symptoms are atypical or non-specific. AIM AND OBJECTIVE To analyze the coronary artery profile on Coronary Angiography (CAG) in TMT positive female patients. METHODS This was a cross sectional observational study carried out over a period from 15th July 2024 to 15th October 2024 in Department of Cardiology. A total of 64 female patients with positive Treadmill test and underwent CAG after pre-test probability Results: A total of 64 patients were enrolled in the study. The mean age of the patient was 53.38±16.7 years. Hypertension was present in (43.8%) study female as must common risk factors. DM female patient was 35.9% study patients. Dyslipidemia was seen in 34.4% patients. CAD was seen in 29.7% of cases with significant CAD in 18.97% study patients. The most common coronary artery involved having significant disease during coronary angiogram was LAD in 38.89% of cases with CAD. Two third of patient who had CAD was at high pre-test probability categories. CONCLUSIONS TMT has a low predictive value of CAD in female patients except those female TMT positive patients with a high pre-test probability score.

Acute Anterior Wall Myocardial Infarction in a Gallbladder Cancer Patient: A Case of Sudden Coronary Thrombosis Post-normal Angiogram

Cancer patients face a heightened risk for thromboembolic events, including arterial thromboembolism such as myocardial infarction (MI). Thrombosis is a major cause of mortality in these patients due to the hypercoagulable state induced by malignancy and its treatments. Pro-inflammatory cytokines and pro-coagulants secreted by tumor cells lead to endothelial damage and an increased risk of thrombus formation. Despite extensive research on venous thromboembolism in cancer, arterial thromboembolism remains less studied. This case report highlights an acute anterior wall MI in a patient with metastatic gallbladder cancer, who developed a sudden thrombotic event despite having a normal coronary angiogram shortly before. A 52-year-old female with metastatic gallbladder cancer presented to the emergency department with acute chest pain. Her cancer, diagnosed 6 months earlier, had been managed with cholecystectomy and subsequent chemotherapy. Fifteen days before her current admission, she had undergone a coronary angiogram due to atypical chest pain, which showed no significant coronary artery disease. At presentation, the patient reported, sudden chest pain radiating to the left arm. She was hemodynamically stable with normal blood pressure and heart rate. The physical examination was unremarkable. Electrocardiogram segment elevation (ST)-segment elevation in anterior leads (V2-V6) and limb leads (II, II, and augmented vector foot [aVF]), indicative of an acute anterior wall MI. Elevated cardiac biomarkers confirmed myocardial injury. A two-dimensional echocardiogram showed mild hypokinesia of the distal interventricular septum and the apex. A repeat coronary angiogram identified a thrombus in the left anterior descending artery, which was not present in the previous angiogram. The rapid appearance of the thrombus pointed to an acute thrombotic event. This case illustrates the aggressive nature of thrombotic events in cancer patients. Despite a normal angiogram 2 weeks prior, the patient developed a sudden coronary thrombus, reflecting the hypercoagulable state associated with malignancy. The management involved thrombus aspiration and tirofiban, which effectively resolved the acute event. This aligns with existing literature, emphasizing the need for vigilant monitoring and proactive management in cancer patients to address the risk of rapid-onset thrombotic events. Cancer patients can experience sudden and severe thrombotic events, even with recent normal coronary evaluations. This case highlights the importance of ongoing cardiovascular assessment and tailored therapeutic strategies in managing cancer-associated thrombosis, underscoring the need for a collaborative approach between oncologists and cardiologists.

The Utility of Coronary Revascularization to Reduce Ventricular Arrhythmias in Coronary Artery Disease Patients: A Systematic Review.

Ventricular arrhythmias (VA) are a major cause of morbidity and mortality in patients with coronary artery disease (CAD). Current guidelines recommend revascularization of significant CAD to improve survival in patients with ventricular fibrillation (VF), polymorphic ventricular tachycardia (VT), or those who are post-cardiac arrest. However, revascularization is not recommended for CAD patients with suspected scar-mediated monomorphic VT. There is a paucity of data detailing the utility of revascularization in reducing VA in CAD patients who do not present with acute coronary syndrome (ACS) and are not immediately post-cardiac arrest, which is the focus of this review. Medline, Scopus, and the Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies addressing this question. Studies that included patients presenting with ACS or those who were immediately post-cardiac arrest at the time of revascularization were excluded. In total, five studies comprising 2663 patients were reviewed.

Assessment of bystander coronary artery disease in transcatheter aortic valve replacement (TAVR) patients using noncoronary-dedicated planning computed tomography angiography (CTA): diagnostic accuracy in a retrospective real-world cohort.

To assess the diagnostic potential of a noncoronary-dedicated pre-TAVR CT angiography (CTA) conducted as a prospective ECG-gated scan without premedication and standard cardiac reconstructionsin evaluating bystander coronary artery disease (CAD) against invasive coronary angiography (ICA) as the gold standard. This retrospective study included 232 patients who underwent both CTA and ICA as part of their pre-TAVR evaluation. Exclusion criteria included prior stent, pacemaker, coronary artery bypass, or valve surgery. Coronary arteries were analysed solely through thin-slice axial reconstructions, with observers blinded to ICA results. Stenosis was categorised as mild (< 50%), moderate (50%-69%), or severe (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for 50% and 70% diameter stenosis (DS) thresholds. At the 50% DS threshold, CTA demonstrated 71% sensitivity, 74% specificity, 92% NPV, and 38% PPV. At the 70% DS threshold, results included 46% sensitivity, 91% specificity, 93% NPV, and 41% PPV. The highest vessel-specific NPV at 50% DS was for the left main (98%) and left anterior descending (LAD) (91%); at 70% DS, left main (LM) (98%) and left circumflex (LCX) (94%) showed the highest NPV. Image quality impacted NPV, with excellent or very good image quality linked to higher diagnostic performance. Noncoronary-dedicated pre-TAVR CTA shows promise for ruling out significant CAD effectively and may act as a gatekeeper for ICA, aligning with typical coronary CT angiography (CCTA) outcomes.

An observational study on global longitudinal strain in acute coronary syndrome and its correlation with coronary angiogram

Background: Coronary angiography (CA) is crucial for diagnosing acute coronary syndrome (ACS) and assessing coronary artery disease (CAD), enabling healthcare providers to determine treatment options and assess the risk of cardiovascular events. Global longitudinal strain (GLS) is a sensitive marker of cardiac function. This study aimed to determine the correlation between GLS in ACS and CA findings. Methods: This prospective observational study was conducted at the cardiology department of the Salem government medical college. The study involved transthoracic echocardiography (TTE) to assess LV volumes, ejection fraction (EF), and LVGLS and strain analysis using 2D echocardiography to measure regional longitudinal peak systolic strain in different LV segments. CA was performed to visualise the coronary vessels and detect significant CAD. Results: The study population consisted predominantly of male patients (n=93, 62%), with notable smoking (n=48, 32%) and alcohol consumption (n=36, 24%). A significant majority of the patients (n=111, 74%) exhibited ECG abnormalities. Obstruction was present in 82% of the patients (n=123), with those showing impaired myocardial function compared to those without obstruction. GLS values below 13.95 were more common in patients with obstruction (n=8 out of 11), indicating reduced myocardial deformation. The GLS demonstrated excellent diagnostic performance for detecting significant coronary artery obstruction, with a high sensitivity of 88.89%, specificity of 90.63%, and overall accuracy of 90.24%. Conclusions: Our study revealed a strong correlation between reduced GLS and CAD, highlighting its importance in CAD assessment and risk stratification in ACS. GLS demonstrated excellent diagnostic performance for detecting significant CAD, showing high sensitivity and specificity.

Accuracy of 2-dimensional speckle tracking echocardiography in diagnosis of coronary artery stenosis in stable angina pectoris

Background It’s difficult to detect the severity of coronary artery disease in the patients who have stable angina pectoris. Echocardiography is a well-validated non-invasive diagnostic tool for detecting myocardial ischaemia, but judging wall motion abnormalities is subjective. Conventional echocardiography can assess radial mechanics only, so it cannot assess the sensitive longitudinal mechanics. 2-Dimensional strain echocardiography is a recent tool that has the ability to solve these drawbacks. Aim of study To detect the accuracy of 2D-STE in prediction of significant coronary artery stenosis in the patients with stable angina pectoris. Methods This study included 70 patients who have stable angina pectoris. Conventional and 2D speckle tracking echocardiography were done to all patients then compared with the coronary angiography results. Patients were classified into three groups according to their coronary arteries affection; patients with normal Coronaries, non-obstructed lesion and patients with significant lesion. Results Our study results show that the mean GLS was (-18.67 ± 0.93) in normal cases, and it was (-15.82 ± 1.11) in non-obstructed lesions but GLS was (-13.19 ± 1.7) in patients with significant CAD. And the best cut-off point of GLS was reported as (-17.35%) with a sensitivity of 97.6% and specificity of 93.3%. Also we found that SLS results in significant lesions of LAD, LCX, RCA territory was (-16.3%, −15.95%, −17.45%) with sensitivity and specificity (87.8%, 93.3%), (70.7%, 93.3%), (82.9%, 93.3%) respectively. Conclusion Global longitudinal strain has a good diagnostic significance over visual evaluation during conventional echocardiogram in predicting significant stenosis of the coronary arteries in patients with stable coronary artery disease. Segmental Longitudinal strain is also a sensitive tool to detect the affected Coronary Territory.

Accuracy of dynamic stress CT myocardial perfusion in patients with suspected non-ST elevation myocardial infarction.

Coronary CT angiography (CCTA) and dynamic stress CT myocardial perfusion (CT-MPI) are established modalities in the analysis of patients with chronic coronary syndromes. Their role in patients with suspected non-ST elevation myocardial infarction (NSTEMI) is unknown. CCTA with CT-MPI might assist in the triage of NSTEMI patients to the Cath lab. We investigated the correlation of significant epicardial lesions by CT-MPI in addition to CCTA compared to invasive coronary angiography (ICA) with fractional flow reserve (FFR) in patients with NSTEMI. Twenty NSTEMI patients scheduled for ICA were enrolled in this study with planned ICA. CCTA and CT-MPI was performed pre-ICA. For each coronary artery, the presence or absence of significant lesions was interpreted by CCTA with CT-MPI, using an FFR of ≤ 0.8 or angiographic culprit (stenosis > 90%, suspected plaque rupture) as reference. The main outcome was the per-vessel correlation. Sixteen out of 20 patients had a culprit lesion that required immediate revascularization. CCTA with ≥ 50% stenosis demonstrated a per vessel sensitivity and specificity for the detection of significant stenosis of respectively 100% (95% CI: 86-100%) and 75% (95% CI: 58-88%). CCTA with CT-MPI showed a lower sensitivity 90% (95% CI: 70-99%) but higher specificity of 100% (95% CI: 90-100%). CCTA with CT-MPI exhibits a strong correlation for identifying significant CAD in patients with NSTEMI. Thereby, it might assist in the triage of ICA in NSTEMI patients.

Quantitative Coronary Angiography Guidance for Drug-Eluting Stent Implantation: A Narrative Review.

Percutaneous coronary intervention (PCI) using drug-eluting stents is an established strategy for the treatment of significant obstructive coronary artery disease. Evidence supports that intravascular imaging-guided PCI offers advantages over conventional angiography-guided PCI, though its use is limited, likely due to high costs. Angiography-guided PCI relies on visual estimation, leading to inter- and intra-observer variability and suboptimal outcomes. Quantitative coronary angiography (QCA) provides reliable information about vascular dimensions, overcoming these limitations. Poststenting postdilation with appropriately sized noncompliant balloons improves outcomes by increasing lumen area and reducing stent malapposition. We investigated the procedural details of each modality used to guide PCI and assessed the utility of QCA-guided PCI with routine postdilation when intravascular imaging is unavailable. A systematic search was conducted from inception to May 31, 2024, identifying nine randomized controlled trials (with over 500 patients) that compared outcomes of PCI guided by intravascular imaging versus conventional angiography or QCA. The findings indicate that intravascular imaging guidance significantly improves clinical outcomes compared to angiography guidance. Notably, QCA-guided PCI with routine postdilation yielded outcomes comparable to those achieved with intravascular imaging-guided PCI. QCA-guided PCI with routine postdilation may be a viable alternative for improving PCI outcomes, especially in settings where intravascular imaging is unavailable.

Target-triggered catalytic hairpin assembly of miR-21/155/1 coupled with dsDNA-reporter amplified detection for prediction of clinically significant coronary artery disease

Multiple microRNAs (miRNAs) have demonstrated potential as early biomarkers of coronary artery disease (CAD), but diagnosis outcome is challenging because of the limitations of clinical application. In this study, we reported a general and machine learning-enhanced diagnostic strategy for miRNA analysis: catalytic hairpin assembly (CHA) and dsDNA-reporter-assisted cascade reaction for isothermal amplification. The sensor achieved high sensitivity and rapid turnaround time (<30min) using micro samples of patient serum in a one-pot assay without extraction and enrichment. Additionally, the system demonstrated robust multiplex capability in simultaneously detecting three miRNA targets. By training a machine learning model on a large dataset of miR-21/155/1, the assay was superior in differentiating CAD patients (n=115) from non-CAD individuals (n=30) achieving an enhanced accuracy of 87.5%, surpassing the individual performance of miR-1 (18.9%), miR-21 (75.6%), and miR-155 (51.1%). This reliable and user-friendly approach provides a powerful tool for multiple miRNA analysis, holding significant promise for point-of-care CAD diagnosis.

Impact of Smoking on MicroRNAs in Significant Coronary Artery Disease.

Given the importance of coronary artery disease (CAD) and the range of cardiovascular disease phenotypes in smokers, as well as the potential genetic and epigenetic factors, we were motivated to explore the impact of smoking on some selected microRNAs associated with significant CAD. A total of 60 individuals were selected in four groups including non-smoker without significant CAD (S-A-), non-smokers with significant CAD (S-A+), smokers without significant CAD (S+A-) and smokers with significant CAD (S+A+). Micro-RNA expression was investigated using real-time PCR. General linear model was used to calculate fold change (FC) considering SA- as the reference group. For mir-34a, down-regulation was observed in S+A- (FC =0.13, P =0.007) and S+A+ (FC =0.23, P =0.036) groups. For mir-126-3p, down-regulation was observed in S-A+ group (FC =0.05, P =0.024). For mir-199, up-regulation was observed for S+A- group (FC =9.38, P =0.007). The only significant interaction between pack-years of smoking and number of significantly narrowed vessels (≥75% stenosis) was for mir-199 which was in favor of down-regulation (P =0.006), while the main effects were in favor of up-regulation (P <0.05). Mir-34a expression may be affected by smoking, whereas mir-126-3p expression may be affected by atherosclerosis, the most common reason of CAD. The significant down-regulation of mir-199 for the interaction of smoking dose and severity of CAD was a notable finding showing the harmful consequence of this interaction. Further studies are needed for this micro-RNA.

Dynamic CT myocardial perfusion combined with coronary CT angiography for detecting hemodynamical significance of coronary artery stenosis: a comparative study

This study aimed to evaluate the diagnostic performance of combined dynamic stress CT myocardial perfusion imaging (CTP) and coronary CT angiography (CTA) alongside CT-derived fractional flow reserve (CT-FFR) in detecting hemodynamically significant coronary artery disease (CAD). A total of 33 patients (86 vessels) who underwent coronary CTA, dynamic stress CTP, and coronary angiography were included. Vessels exhibiting 30–90% stenosis were subjected to FFR analysis based on coronary angiography (Angio-FFR). Hemodynamic significance, determined by Angio-FFR ≤ 0.80, and imaging findings were evaluated. The evaluation involved a comparison between the combined use of coronary CTA, CTP and CT-FFR, versus the sole use of coronary CTA. Out of 86 coronary vessels, 17 (19.8%) exhibited hemodynamically significant stenosis. The sensitivity, specificity, and accuracy of coronary CTA for detecting ischemia were 94.12%, 34.78%, and 46.51%, respectively. Adding CTP to CTA improved specificity to 88.41%, and accuracy to 87.21%, respectively. The area under the curve (AUC) for the discrimination of functional significant stenosis was 0.798 when using CTA alone, and for CTA plus CTP, it reached 0.910. Furthermore, the combination of CTA, CTP and CT-FFR, showed accuracy of 88.37%, sensitivity of 88.24% and specificity of 88.41% with the AUC of 0.946. The integration of dynamic CTP with CTA significantly enhances the diagnostic accuracy for identifying patients with hemodynamically significant CAD, compared to the use of CTA alone. This study underscores the value of combining CTP, CT-FFR, and CTA in improving diagnostic precision for CAD. The combination of CTP, CT-FFR and CTA offers a multifaceted assessment for patients with CAD by simultaneously providing anatomical detail, functional analysis, and physiological quantification, which facilitating rapid, accurate, and optimal clinical decision-making and significantly enhances patient management.

Lymphocyte-based inflammatory markers: Novel predictors of significant coronary artery disease✰,✰✰

BackgroundLymphocyte-based inflammatory indices such as monocyte-to-lymphocyte ratio (MLR) have long been recognized as reliable coronary artery disease (CAD) predictors. More recently, novel indices like the Systemic Inflammatory Index (SII), Systemic Inflammatory Response Index (SIRI), and Systemic Immune-Inflammation Index (SIIRI) have emerged. These newer markers offer a more comprehensive assessment of inflammation by integrating multiple immune cell types, potentially enhancing the prediction of cardiovascular outcomes. ObjectivesWe evaluated the predictive value of novel inflammatory markers in estimating the pretest probability of severe CAD in high-risk patients. MethodsWe enrolled consecutive patients undergoing diagnostic coronary angiography in a single tertiary care hospital. Inflammatory markers were calculated based on pre-procedural complete blood count laboratory measurements. Severe CAD was defined as critical (>70 %) and actionable narrowing of a primary coronary artery. Classification performance was assessed using multivariate logistic regression. ResultsThe study sample included 363 patients (age 58.9± 11 years, 44.9 % females, 30 % severe CAD). In univariate analysis, MLR, SIRI, and SIIRI were significant predictors of severe CAD, with age- and sex-adjusted OR of 1.98 [1.25–3.14], 1.79 [1.24–2.59], and 1.63 [1.11–2.38], respectively. In multivariate analysis, SIRI remained an independent predictor of severe CAD (OR = 1.98, 95 % CI 1.13–3.46, p = 0.02). ConclusionOur results suggest that novel inflammatory markers derived from routine blood tests are predictive of severe CAD in high-risk patients. Such simple, practical, and cost-effective inflammatory markers may enhance cardiac risk stratification and prediction of severe CAD.

Abstract 4138602: Effect of Left Ventricular Ejection Fraction On Computed Tomography-Derived Fractional Flow Reserve Diagnostic Accuracy For Significant Coronary Artery Disease

Background: Coronary Computed Tomography Angiography (CCTA) and CT-derived fractional flow reserve (CT-FFR) accurately assess the severity of coronary artery disease. However, the diagnostic accuracy of CT-FFR in patients with low left ventricular ejection fraction (LVEF) is unknown. Goal: Describe the per-vessel diagnostic performance of CT-FFR to detect significant coronary disease in patients with normal and reduced LVEF by echocardiogram. Methods: This was a retrospective study of 441 patients who underwent CCTA and CT-FFR at the UMass Memorial Health System between 2020 and 2023. Those with echocardiogram and invasive coronary angiography were analyzed and divided in two groups based on two-dimensional LVEF: those with LVEF &lt; 55%, and with LVEF ≥ 55%. We excluded those with prior coronary stents, incomplete CCTA, CT-FFR data due to artifacts, or poor-quality echocardiographic images. CT-FFR ≤ 0.8 was considered abnormal. Significant coronary disease by invasive angiography (reference standard) was defined as lumen stenosis ≥ 70% (left main ≥ 50%), or abnormal physiologic characteristics by FFR, resting full-cycle ratio, or instantaneous wave-free ratio. Results: 222 coronary vessels (102 patients) were analyzed. Of 102 vessels (44%) with significant coronary artery disease, 55 (53.9%) were treated with percutaneous coronary intervention, and 25 (24.5%) with coronary artery bypass grafting. Overall, CT-FFR sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 86.7% (95%CI 78.3-92.7), 75.0% (95%CI 66.4-82.3), 73.2% (95%CI 66.6-78.9), 87.7% (95%CI 81.0-92.3), and 80.1% (95%CI 74.3-85.2), respectively. 37 vessels corresponded to patients with LVEF &lt; 55%, and 185 to those with LVEF ≥ 55%. Diagnostic accuracy in both groups is seen in table 1. Conclusions: Low-normal and reduced LVEF adversely affects the diagnostic performance of CT-FFR, by reducing sensitivity, and slightly increasing specificity.

Abstract 4138546: From Nature’s Remedy to Cardiac Emergency: A Case of Takotsubo Cardiomyopathy Induced by High-Dose Berberine Supplementation

Introduction: Takotsubo cardiomyopathy (TCM) is a reversible cardiac condition often precipitated by emotional or physical stress. Certain medications have also been implicated. While prognosis is generally favorable, associated QTc prolongation and ventricular arrhythmias can be life threatening, necessitating identification of potential triggers. This report highlights TCM in a patient using high-dose berberine, a plant alkaloid known for its hypoglycemic properties. Case description: A 69-year-old female with a history of type 2 diabetes mellitus, and hyperlipidemia presented after a syncopal event. It was preceded by sudden onset of dizziness, nausea, and vomiting. She had been using berberine for a year to lower her blood sugar and had recently switched to a higher dose of a more potent formulation. Vitals were unremarkable. Initial evaluation revealed a prolonged QTc interval of 659 ms (Figure 1A) and elevated troponin-I levels. She was treated with intravenous magnesium, which improved her QTc to 540 ms and revealed new T-wave inversions in the precordial leads. Echocardiogram showed an ejection fraction (EF) of 35%, with LV apical akinesia and hypercontractile basal segments. Cardiac catheterization ruled out significant coronary artery disease, leading to a diagnosis of TCM. Berberine was discontinued, and guideline-directed medical therapy was initiated. Given the presentation with syncope and high suspicion of aborted sudden cardiac death (SCD), she was discharged with a wearable cardioverter-defibrillator (WCD) as a precaution due to the risk of ventricular arrhythmias during recovery. At her 8-week follow-up, QTc and EF had normalized (Figure 1B), prompting WCD removal. Conclusion: The pathophysiology of berberine-induced cardiomyopathy remains uncertain and requires further research. This case underscores the importance of recognizing the potential cardiotoxic effects of berberine, particularly when used in high doses. A thorough medication and supplement history is crucial in patients presenting with unexplained cardiac symptoms. The reversible nature of TCM, when promptly recognized and treated, highlights the need for comprehensive follow-up to ensure recovery of cardiac function.

Abstract 4137900: Differences in Echocardiographic Findings Between Epicardial Vasospastic Angina Phenotypes Affect Response to Medical Therapy

Background: The phenotype of epicardial vasospasm is classified as focal or diffuse. However, its echocardiographic characteristics are unknown. Furthermore, patients with diffuse vasospasms have poorer responses to medical therapy than patients with focal spasms because of more extensive areas of endothelial dysfunction. We hypothesized that there are differences in echocardiographic findings between the patients with diffuse and focal vasospasm, which might affect response to medical therapy. Methods: The present study was a single-center retrospective cohort study that included 77 consecutive patients diagnosed with vasospastic angina (VSA) undergoing coronary spasm provocation test using acetylcholine from 2014 to 2024. The patients with a history of cardiomyopathy and significant obstructive coronary artery disease were excluded. Diffuse VSA was defined as vasospasm in 2≧ adjacent coronary segments, and focal VSA was defined as vasospasm in one isolated coronary segment. Patients were divided into diffuse VSA group (n=45) and focal VSA group (n=32). Left ventricular function was assessed using 2D speckle tracking echocardiography. After the diagnosis of VSA and the administration of medical treatment for VSA, an emergency room (ER) visit with a chest pain attack was recorded as the event of poor response to medical therapy. Results: There was no significant difference in the follow-up period and baseline characteristics (Table). LVEF was similar between the two groups (63.1±5.8% vs. 62.9±7.6%, p =0.87). In contrast, the left ventricular global longitudinal strain (LV-GLS) was significantly lower in the diffuse VSA group than in the focal VSA group (17.4±2.8% vs. 20.2±2.4% p &lt;0.001). There is no difference in medical therapy for VSA (Table). Observation of ER visits with a chest was more frequent in the diffuse VSA group [diffuse VSA group (20/45, 44.4%) vs. focal VSA group (3/29, 9.3%), p &lt;0.001]. Kaplan-Meier curves showed that the diffuse VSA group had a higher cumulative rate of ER visits with a chest pain attack (Log-rank p &lt;0.001). On multivariable Cox regression analysis, diffuse VSA (HR=4.2, 95% CI: 1.10-16.06, p =0.030) and low LV-GLS (HR =1.16, 95%CI: 1.01-1.34, p =0.031) were an independent risk factor for poor response to medical therapy. Conclusion: Patients with diffuse VSA had lower LV-GLS than patients with focal VSA. Moreover, diffuse VSA and lower LV-GLS were associated with poor response to medical therapy after diagnosis of VSA.

Abstract 4114372: Is Takotsubo syndrome associated with a favorable in-hospital outcome among patients with cardiogenic shock? A propensity score-matched analysis of the National Inpatient Sample Data (2016-2020)

Background: Takotsubo cardiomyopathy (TTC) is characterized by impaired left ventricular function due to typical, regional wall motion abnormalities in the absence of significant obstructive coronary artery disease. Previous small-sized retrospective studies reported favorable outcomes of cardiogenic shock in patients with TTC. We aimed to investigate whether the presence of TTC is associated with a favorable in-hospital outcome among patients admitted for cardiogenic shock using a large nationally representative dataset. Methods: Utilizing data from the National Inpatient Sample (NIS) spanning from 2016 to 2020, we identified patients admitted for cardiogenic shock using ICD-10 codes. Patients with TTC were also identified using ICD-10 codes. Using sociodemographic variables, and comorbid medical conditions, and performed procedures as matching variables, we conducted a 1:1 nearest-neighbor propensity score matching to mitigate potential confounders. The success of matching was evaluated based on standardized mean differences. In-hospital mortality was the primary outcome, while in-hospital complications, length of stay (LOS), and cost of hospitalization were secondary outcomes. We employed the Cochrane-Mantel-Haenszel method to assess the odds ratio (OR) for in-hospital mortality and complications. Simple linear regression models were used to evaluate differences in LOS and cost of hospitalization. Results: The final sample included 22,594 patients, evenly distributed between the groups with and without TTC. The mean age of the cohort was 65.4 years (SD = 15.9), with 74.7% being males. Ethnic composition indicated 75.7% Whites, 9.3% Blacks, and 8.1% Hispanics. The overall in-hospital mortality rate was 32.7%. The TTS group had a lower mortality rate (38.4% Vs 27%, p&lt;0.001). Patients with TTC had lower odds of in-hospital mortality, cardiac arrest, ventricular tachycardia, and acute kidney injury. However, they were noted to have higher odds of deep vein thrombosis, stroke, slightly higher LOS, and cost of hospitalization. Conclusion: In summary, our study suggests that Takotsubo Cardiomyopathy is associated with significantly lower in-hospital mortality rates among patients admitted for cardiogenic shock, indicating a favorable prognosis in this clinical setting.

Abstract 4137058: Clinical Characteristics and Outcomes of South Asians Presenting with Acute Coronary Syndrome

Background: Patients of South Asian descent have a higher incidence of atherosclerotic cardiovascular disease and are affected by clinically significant coronary artery disease at an earlier age when compared to the general population. As a result, they have been shown to have a higher rate of cardiovascular events. This at-risk population has not been well studied as it pertains to acute coronary syndrome. Methods: Out of 1610 patients who presented to one of two tertiary care centers between 2021-2022 with a diagnosis of acute coronary syndrome and underwent coronary angiography, 240 patients were identified as being South Asian and were included in the study. 480 non-South Asian patients were randomly selected as controls. A retrospective analysis was conducted to study the demographics, risk factors, clinical presentation, diagnostic features, and outcomes of the two groups. Results: South Asian patients who were diagnosed with acute coronary syndrome and underwent coronary angiography were significantly younger than non-South Asian patients (61 vs 65 years, p &lt; 0.001). Though they were less likely to be smokers, they were significantly more likely to have other known risk factors including hypertension, dyslipidemia, and a history of prior myocardial infarction (p &lt; 0.001). South Asians had mean lower HDL (p = 0.02), higher triglycerides (0.006), and higher Hgb A1C (p &lt; 0.001). Surprisingly, rates of multivessel disease (defined as stenosis of 50% or greater in two or three vessels) were similar between the two groups. South Asians were more likely to be referred for CABG after initial coronary angiography most likely due to diffuse disease (p = 0.014). Clinical outcomes including pre-discharge LVEF, and 2-year mortality were similar between the groups. Conclusions: South Asians are a notoriously high-risk group when it comes to early-onset and more severe coronary artery disease. The pathophysiology behind this disproportionate manifestation of cardiovascular disease is not entirely understood, but several efforts to delineate this are ongoing. Our data demonstrate that this is at least in part, due to a higher prevalence of conventional modifiable and nonmodifiable risk factors in South Asian patients.

“Red Flags”: Case Report of Cardiac Amyloidosis with Significant Coronary Artery Disease

BACKGROUND: Cardiac Amyloidosis is a disorder of protein misfolding and metabolism in which insoluble fibrils are deposited in the myocardial extracellular matrix causing organ dysfunction and eventually death. It can exhibit cardiac signs and symptoms, or it can be identified through screening in patients who exhibit extracardiac symptoms of amyloidosis. As there were no clear clinical signs of cardiac amyloidosis and a biopsy is required to show amyloid deposition, the condition has been historically challenging to diagnose. Thus, a high index of suspicion based on the clinical presentation and the outcomes of the preliminary testing arecrucial to determine the approach to diagnosis. CASE SUMMARY: We outline a case of 75-year-old Filipino male who was admitted due to progressive exertional dyspnea. Cardiac Amyloidosis was considered due to evaluation findings of heart failure with preserved ejection fraction with restrictive type of cardiomyopathy. This was subsequently confirmed through extracardiac fat pad biopsy, echocardiographic strain analysis and Technetium (99mTc) Pyrophosphate (PYP) single photon emission computed tomography scan (SPECT). CONCLUSION: This case report discussed the red flags of clinical manifestations of cardiac amyloidosis and highlighted the use of non-invasive diagnostic modalities to diagnose the disease. Cardiac amyloidosis remains a rare entity and with emerging therapies that have the potential to improve patient outcomes, early diagnosis is really important. Having high index of suspicion based on signs and symptoms can lead to early detection and an increased number of patients being referred for treatment.