Significant Coronary Stenosis Research Articles

Role of myocardial strain imaging in diagnosing inducible myocardial ischemia with treadmill contrast-enhanced stress echocardiography

IntroductionThe aim of this study is to analyze the diagnostic value of global longitudinal strain (GLS) in detecting inducible myocardial ischemia in patients with chest pain undergoing treadmill contrast-enhanced stress echocardiography (SE).MethodsWe retrospectively enrolled all patients who underwent invasive coronary angiography after treadmill contrast-enhanced SE. Rest and peak-stress myocardial GLS, segmental LS, and LS of 4-chamber (CH), 2-CH, and 3-CH views were reported. Luminal stenosis of more than 70% or fractional flow reserve (FFR) of < 0.8 was considered significant.ResultsIn total 33 patients were included in the final analysis, among whom sixteen patients (48.4%) had significant coronary artery stenosis. Averaged GLS, 3-CH, and 4-CH LS were significantly lower in patients with critical coronary artery stenosis compared to those without significant stenosis (-17.1 ± 7.1 vs. -24.2 ± 7.2, p = 0.041), (-18.2 ± 8.9 vs. -24.6 ± 8.2, p = 0.045) and (-14.8 ± 6.2 vs. -22.8 ± 7.8, p = 0.009), respectively. Receiver operating characteristic (ROC) analysis of ischemic and non-ischemic segments demonstrated that a cut-off value of -20% of stress LS had 71% sensitivity and 60% specificity for ruling out inducible myocardial ischemia (Area under the curve was AUC = 0.72, P < 0.0001).ConclusionMyocardial LS measured with treadmill contrast-enhanced stress echocardiography demonstrates potential value in identifying patients with inducible myocardial ischemia.

ANOMALY OF ORIGIN AND COURSE OF THE CIRCUMFLEX ARTERY: AN ECHOCARDIOGRAPHIC DIAGNOSIS

Abstract Coronary artery anomalies are often incidental findings. Most anomalies are benign, but some can cause sudden death. It is important to identify them especially before invasive procedures and cardiac surgery. The echocardiogram, as in this case report, provides a high diagnostic accuracy. We describe three typical echocardiographic signs that we find when the circumflex artery originates from the right coronary cusp and has a retroaortic course. A 42–year–old man presented to the emergency department with oppressive chest pain at rest lasting 1 h. In his medical history, the patient reported the following cardiovascular risk factors: smoking, family history of coronary heart disease, hypertension, type 2 diabetes mellitus for 10 years and hypercholesterolemia. Electrocardiogram showed sinus rhythm at 70 bpm without signs of myocardial ischemia. Troponin, D–dimer, C–reactive protein were normal in consecutive blood samples. The echocardiogram documented a left ventricle with normal size and wall thickness, preserved systolic function and absence of significant valvular disease and pericardial effusion. Apical 4–chamber view showed a tubular structure on the atrial side of the mitral valve (Figure 1A, RAC sign). The same structure was identified in parasternal short–axis view just below the noncoronary aortic cusp (Figure 1B, crossed aorta). The tubular shape suggested a vascular structure in an anomalous position. In the parasternal long–axis view, a transverse section of this vessel was visible near aortic valve (Figure 1C, bleb sign). Patient underwent coronary angiography due to persistence of symptoms. Angiography did not reveal significant coronary stenoses, but documented anomalies in the origin and course of the coronary arteries. The circumflex artery shared its origin from the right coronary cusp with the right coronary artery and had a retroaortic course while the only anterior descending artery originated from the left coronary cusp. Anomalies of origin and/or course of the coronary arteries can be detected in 1.3% of the population undergoing coronary angiography. On echocardiogram “RAC sign”, “crossed aorta” and “bleb sign” are often misdiagnosed as artefacts, calcifications or catheter. In case of suspected coronary anomalies, CT is the reference diagnostic test. The abnormal origin and course found in our patient are considered benign and not associated with an increased risk of sudden death and myocardial ischemia.

Four-dimensional computed tomography is useful for detection of apical sparing of cardiac amyloidosis.

A 73-year-old male was admitted because of recurrent syncope. He was diagnosed with transient bradycardia caused by a 2:1 atrioventricular block, and he underwent cardiac computed tomography (CT) using 320 detector-row CT to screen for coronary artery disease. Significant coronary artery stenosis was not detected, but diffuse late iodinate enhancement was found on the epi-myocardium and endo-myocardium of the interventricular septum, and endo-myocardium of the anterior and lateral left ventricular (LV) myocardium (LVM) on CT. The ejection fraction and global longitudinal strain (LS) of LVM were 53.97% and - 9.87% on CT. Apical sparing was present, meaning the LS of LV apical segments were preserved compared with basal segments on CT. Pathological findings of LVM demonstrated loss of myocardial cells and extra-cellular amyloid deposition on the direct fast scarlet staining. He was finally diagnosed with transthyretin amyloidosis.

Renal functional reserve assessment in patients with coronary microvascular dysfuntion and preserved renal function

Abstract Funding Acknowledgements None. Introduction Renal Functional Reserve (RFR) is a field of scientific debate and may be a valuable diagnostic tool for the early detection of subclinical renal disease. According to literature, chronic kidney disease is related to cardiovascular disease (CVD), however the available data on the association of early renal dysfunction and CVD are sparse. Aim The aim of the present study is to evaluate RFR in patients with coronary microvascular dysfunction (CMD) and preserved renal function [eGFR≥ 60 ml/min/1.73m2 (CKD-EPI) and proteinuria&amp;lt; 400mg/24h]. Methods This is a single-center, prospective study enrolling patients with CMD. We are presenting preliminary resuts. In the absence of significant coronary artery stenosis, functional coronary circulation assessment was performed for all patients. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured invasively. In all participants, RFR was estimated by endogenous creatinine clearance after oral protein load (cooked meal, 1.2gr/kg). Normal RFR was defined as ≥30 ml/min/1.73m2. Also, patients with CMD were offered 24-hour Ambulatory Blood Pressure Monitoring (ABPM). Results A total of 25 participants have been enrolled so far in study: 11 without CMD - non-CMD group [7 female, 64%, mean age: 52.9±8.8 years) and 14 with INOCA – CMD group (11 female, 79%, mean age : 53.5±10.3 years). CMD patients were classified into 2 groups, structural and functional endotype (CFR&amp;lt;2.5 and IMR≥25 were considered abnormal). The RFR value for CMD group is 7.4±6.3 ml/min/1.73m2, while for control group 36.3±5.8 ml/min/1.73m2 (p&amp;lt;0.005), This difference between groups was found to be statistically significant after controlling for confounding factors. It was found that RFR value for functional CMD endotype was 3.8±2.6 ml/min/1.73m2, while for patients with structural endotype 9.6±7,2 ml/min/1.73m2 (p=0.06). Furthermore, no statistical significance was found between RFR and IMR, CFR indices (p =0.35, p =0.23 respectively). According to data from 24hr ABPM , there were no significant differences in ambulatory blood pressure (systolic and diastolic) between the two endotypes of CMD (p=NS for all), as well as no relationship with RFR (p=0.6, p=0.6 respectively) was observed. However, the proportion of non-dippers (for both SBP and DBP) was significantly higher in functional CMD endotype (p&amp;lt;0.05). It was not found correlation between RFR and non-dipping phenotype, for both SBP and DBP (p=NS). Conclusion Abnormal RFR has been observed in all patients with microvascular dysfunction. In addition, patients with functional CMD show a lower RFR value compared to those with structural. RFR is not related to levels of BP or the non-dipping pattern. Given the hypothesis that the assessment of renal functional reserve is an early diagnostic tool for subclinical renal disease, the early identification of patients with specific phenotypes could contribute to the individualization of therapeutic interventions.

[15O]H2O myocardial perfusion PET: Added value of relative stress perfusion deficit in the prediction of significant coronary artery stenosis in a mixed population

BackgroundIt remains unknown whether estimation of the relative stress perfusion deficit offers added value in the prediction of significant coronary artery stenosis in myocardial perfusion imaging with [15O]H2O PET in a population with high prevalence of established cardiac disease. MethodsDuring eight months, we consecutively included all patients undergoing [15O]H2O PET and subsequent invasive coronary angiography (ICA). Significant stenosis was defined from ICA as fractional flow reserve ≤0.8 or coronary artery narrowing of ≥70%. We calculated absolute and relative total perfusion deficits (aTPD and rTPD, respectively) as semiquantitative measures of the extent and severity of reduced stress perfusion. A multivariate logistic regression analysis was performed to test the adjusted associations (odds ratio (OR) with 95% CI) with significant coronary artery stenosis. ResultsOf 800 patients undergoing [15O]H2O PET, 144 underwent ICA, where 142 patients had an aTPD ≥3% and 79 (55%) of these had at least one significant stenosis. In an adjusted analysis rTPD (OR10% increase = 2.12 (1.44-3.12), P<0.001), previous coronary artery bypass grafting (CABG) (OR = 0.11 (0.03-0.36), P<0.001) and reduced left ventricular ejection fraction (LVEF) (OR = 0.25 (0.08-0.84), P=0.02) were independently associated with significant stenosis, whereas the association with aTPD (OR10% increase = 1.14 (0.98-1.32), P=0.08) was modest. ConclusionsIn the presence of an absolute perfusion deficit (aTPD ≥3%), rTPD may improve the prediction of significant stenosis in a heterogeneous population of patients examined with [15O]H2O PET. Furthermore, previous CABG and reduced LVEF are associated with non-stenotic perfusion deficiencies suggesting caution when interpreting myocardial perfusion imaging in such patients.

Association of postsystolic shortening on stress echocardiography and significant coronary artery stenosis:A single-centre retrospective cohort study.

Postsystolic shortening (PSS) is one of the proposed quantitative measures to predict myocardial ischaemia in the stress echocardiographic (SE) evaluation. It is previously known that hypo-/akinesia (HA) correlates well with coronary stenosis. However, some patients undergoing SE only present with PSS, and their risk of significant coronary stenosis is less clear. This study aimed to evaluate the association between PSS and significant coronary stenosis compared with HA. This was a retrospective cohort study at the hospital of S:t Görans, Stockholm, Sweden. All patients who underwent SE to investigate inducible ischaemia between 1 January2018 and 15 October 2021were eligible for inclusion. Exclusion criteria were normal SE and inconclusive test. Pathological SE were divided into two groups, patients with HAand those with PSS. Outcome was significant coronary artery stenosis visualized by invasive coronary angiography. The final study population consisted of 108 patients (73 PSS, 35 HA). The presence of HA was associated with a higher risk of significant stenosis compared to those with PSS (63% vs. 23%, p < 0.001). This relationship was observed among males (p < 0.001), but not among females (p = 0.133). Nonsignificant stenosis trended to be more common among patients with PSS (21% vs. 6%, p = 0.053) CONCLUSIONS: The finding of PSS without HA was associated with a lower risk of significant coronary stenosis than HA. However, patients with PSS still often had nonsignificant coronary stenosis and PSS in the evaluation for nonobstructive coronary artery disease (CAD) should be further investigated.

Ten questions about myocardial infarction with non-obstructed coronary arteries

The term "MINOCA" refers to myocardial infarction with non-obstructed coronary arteries and has been used to define acute myocardial infarction with no angiographic evidence of significant epicardial coronary artery stenosis. Patients with MINOCA represent a rather heterogeneous group of acute coronary syndrome, and this may account for the wide variation in the incidence of MINOCA in different studies. Several pathogenic mechanisms have been suggested to underlie MINOCA, but the condition continues to represent a diagnostic and therapeutic challenge for the cardiologist. Therefore, an adequate diagnostic assessment, carefully characterizing the pathogenic mechanisms, and a selection of more targeted treatments are needed to improve clinical outcomes. In this focused review, we will try to provide answers to the most common questions on the causes, diagnosis, treatment, and outcomes of MINOCA.

Coronary Artery Tree Description and Lesion Evaluation (CatLet) score for functional evaluation of coronary stenosis: a comparison study with pressure wire fractional flow reserve.

Pressure wire fractional flow reserve (FFR) and its derivatives, such as quantitative flow ratio (QFR), computational pressure flow-derived FFR (caFFR), coronary angiography-derived FFR (FFRangio), and computed tomography-derived FFR (FFRCT), have been validated for identifying functionally significant stenosis and guiding revascularization strategy. The limitations of using these methods include the side effects of hyperemia-induced agents, additional costs, and vulnerability to microvascular resistance. FFR is related both to the degree of a stenotic coronary artery and to its subtended myocardial territory. Coronary Artery Tree Description and Lesion Evaluation (CatLet) score (also known as Hexu) is a product of the degree of a stenosis and the weighting of the affected coronary artery (myocardial territory). Hence, we hypothesized that the CatLet score could predict hemodynamically significant coronary stenosis. We retrospectively enrolled consecutive patients with stable coronary artery disease. They attended Sichuan Science City Hospital with at least one lesion of 50-90% diameter stenosis in a coronary artery of 2 mm or larger. FFR measurement was obtained during invasive coronary angiography. The CatLet score was obtained by multiplying a fixed value of 2.0 (for non-occlusive lesions) and the weight of the affected coronary artery. The primary endpoint was the CatLet score's diagnostic accuracy in identifying hemodynamically significant coronary stenosis, with a pressure wire FFR of ≤0.80 being used as reference. We analyzed the FFR and CatLet scores from 206 vessels in 175 patients with stable coronary disease and intermediate coronary lesions. The per-vessel analysis revealed an overall good correlation between the CatLet score and the FFR [r=-0.61; 95% confidence interval (95% CI): -0.69 to -0.52; P<0.01]. We also noted a significant CatLet score-FFR correlation for each of the left anterior descending artery (LAD), left circumflex (LCX), and right coronary artery (RCA). With a CatLet score ≥10 as a predictor of FFR ≤0.80, the overall diagnostic accuracy included a sensitivity of 78.80% (95% CI: 67.00-87.90%), a specificity of 85.00% (95% CI: 78.00-90.50%), a positive likelihood ratio of 5.25, a negative likelihood ratio of 0.25, and an area under the curve of 0.90 (95% CI: 0.85-0.94). Equivalent vessel-specific results were also achieved for each of the LAD, LCX, and RCA. The CatLet score, solely based on visual estimation of the results of coronary angiography, demonstrated good diagnostic performance with respect to myocardial ischemia. Its clinical values in guiding revascularization warrant further investigation.

Improvement of quality of life indicators in patients with metabolic syndrome after correction of hemodynamically significant coronary stenoses and dyslipidemia

It is known that metabolic syndrome is currently the leading cause of the development of cardiovascular pathology, which occupies a leading position in the structure of mortality not only in the Russian population, but also in the world. The prevalence of MS is growing, which is associated with stressful professions, eating disorders. The presence of MS is associated with arterial hypertension and atherosclerosis of the arteries of any localization. In this regard, the purpose of our study was to study the quality of life in patients with MS, depending on the severity of coronary atherosclerosis. Materials and methods: The study included 239 patients (142 men, 97 women) with MS with atherosclerosis of the coronary and carotid arteries. The number of subjects in group 1 (n=141), of which 101 were men and 40 were women. The second group consisted of 84 male and 14 female patients (n=98). The control group consisted of 70 people (27 men, 43 women) with grade 1-3 hypertension. The age of the subjects was 31-56 years. All patients underwent: collection of complaints and anamnesis, assessment of body mass index (BMI); determination of the lipid spectrum, blood glucose, glycated hemoglobin. Microalbuminuria and glomerular filtration rate were determined. Instrumental studies were carried out: ultrasound examination of brachiocephalic vessels with determination of the thickness of the intima-media complex and the percentage of carotid artery stenosis; coronary angiography on the General Electric Innova 3100 angiographic complex. Based on the results of coronary angiography, the patients were divided into two subgroups: group 1 - with coronary artery stenosis of less than 50% (n=141), group 2 - with stenosis of 50% or more (n=98), group 3 (control) without stenotic lesions of the coronary arteries. A non-specific questionnaire “SF-36 Health Status Survey” was used to assess the quality of life. Results: assessing physical functioning and mental health, there was a significant decrease in these indicators in patients of group 2, in whom, according to coronary angiography, hemodynamically significant coronary artery stenoses were diagnosed, a strong correlation (r=0.730; p=0.005) was revealed between deterioration in quality of life and hemodynamically significant stenosis of the carotid and coronary arteries. Restriction of physical activity and reduction of daily activities were more significant in group 2 compared to groups 1 and 3. The feeling of uncertainty with restless expectation and fears, as well as a feeling of depression prevailed in men. However, patients after percutaneous coronary intervention, as well as with lipidogram correction, assessed the quality of life with some restriction of physical activity, but with significant social functioning. Conclusions: hemodynamically significant atherosclerosis of the carotid and coronary arteries is a predictor of deterioration in the quality of life, especially in men. The use of the international questionnaire “SF-36 Health Status Survey” is appropriate for assessing the health and vital activity in patients with MS and hypertension, with signs of atherosclerosis. The interaction of a cardiologist, an endocrinologist and a psychotherapist are justified for the most optimal management of patients with comorbid pathology.

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

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

Prognostic Implications of Microvascular Resistance Reserve in Symptomatic Patients With Intermediate Coronary Stenosis

BackgroundMicrovascular resistance reserve (MRR) is a novel index reflecting coronary microcirculatory function, irrespective of epicardial coronary artery stenosis. There is limited evidence regarding whether MRR can be an independent prognostic tool in patients with stable ischemic heart disease (IHD). ObjectivesThe aim of this study was to evaluate clinical outcomes according to MRR in patients with stable IHD accompanied with or without significant epicardial coronary artery stenosis. MethodsThe present study included 547 consecutive patients undergoing systematic echocardiographic and invasive physiological assessment for suspected stable IHD. Significant epicardial coronary artery stenosis was defined as fractional flow reserve (FFR) ≤0.80. Coronary microvascular dysfunction (CMD) was defined as MRR ≤3.0. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure. ResultsAmong the study group, 172 patients (31.4%) had FFR ≤0.80, and 200 patients (36.6%) had CMD defined by MRR ≤3.0. MRR showed no significant correlation with FFR (R = −0.031; P = 0.469), but it was significantly correlated with the index of microcirculatory resistance (R = −0.353; P < 0.001), N-terminal pro–B-type natriuretic peptide (R = −0.296; P < 0.001), left ventricular filling pressure (E/e′ ratio) (R = −0.224; P < 0.001), and diastolic dysfunction grade (P < 0.001). During a median follow-up period of 3.3 years (Q1-Q3: 2.0-4.5 years), MRR was significantly associated with MACE risk (HR: 1.23 per 1-U decrease; 95% CI: 1.12-1.36; P < 0.001). CMD defined by MRR ≤3.0 was associated with an increased MACE risk for both FFR >0.80 (41.0% vs 26.0%; adjusted HR: 1.59; 95% CI: 1.07-2.35; P = 0.021) and FFR ≤0.80 (34.7% vs 14.8%; adjusted HR: 2.32; 95% CI: 1.12-4.82; P = 0.024). ConclusionsDecreased MRR was associated with the presence of cardiac diastolic dysfunction as well as increased left ventricular filling pressure. The presence of CMD defined by MRR was independently associated with the risk for a composite of cardiovascular death, myocardial infarction, repeat revascularization, and admission for heart failure in patients with stable IHD, irrespective of significant epicardial coronary artery stenosis. (Prognostic Impact of Cardiac Diastolic Function and Coronary Microvascular Function [DIAST-CMD]; NCT05058833)

Diagnostic value of clinical-instrumental and hematological indicators in predicting complications of the hospital period of STEMI in conditions of chronic stress caused by wartime

The aim – to develop a diagnostic system that takes into account the peculiarities of clinical, instrumental and laboratory indicators in patients with STEMI against the background of wartime and will allow to objectify a tendency to a more difficult hospital course of ACS.Materials and methods. We studied a cohort of patients (n=133 individuals, 77.4 % men, average age 61.8±0.9 years) with STEMI, part of which (group 1) was hospitalized from February to May 2019 (n=87), while another part of which (group 2) was hospitalized in the period from February 24, 2022 to March 2023 (n=46) within the first 24 hours from the development of symptoms of the disease (average time of admission 5.2±0.4 hours). The groups were compared according to the clinical and anamnestic and laboratory parameters of the first day.Results and discussion. It was found that in the Ukrainian population during wartime, patients with STEMI are admitted to the hospital later, have a more burdensome history of cerebrovascular diseases, a greater number of significant coronary stenoses, a higher percentage of smokers, and also have higher heart rate levels upon admission, ESR, triglycerides, leukocytes (at the expense of lymphocytes and monocytes), as well as platelets (with lower indicators of their size inhomogeneity). Also, invasive treatment of these lesions leads to slightly worse results on the TIMI and MBG scales. Informativeness of hematology analysis indicators and other markers of inflammation/stress on the first day of STEMI in wartime was evaluated for predicting the risk of an complicated course of the hospital period (development of cardiac death, signs of LVEF, ventricular tachyarrhythmias, stent thrombosis, acute renal dysfunction, recurrence of ACS/angina). It was found that predictors of the undesirable course of STEMI during wartime are: heart rate &gt; 70/min, ESR &gt; 10 mm/h, glucose level &gt; 8.5 mmol/l, leukocytes &gt; 13 · 109/l, lymphocytes &gt; 2 · 109/l, platelets &gt; 270 · 109/l, large (&gt;12 fl) platelets &lt; 27 %, triglycerides &gt; 1.3 mmol/l, as well as combined criteria made up of these indicators. Thus, the 6-component score (heart rate, ESR, glucose, levels of leukocytes, lymphocytes, and platelets) had an area under the ROC curve of 0.87 (for values ​​&gt; 30 units – BP 6.39 (2.16–18.9), p&lt;0.0001) when determining the risk of an undesirable course of ACS in patients during wartime. These predictors are specific to the stress-induced effects of war and are not informative in peacetime STEMI patients.Conclusions. The coexistence of acute stress caused by STEMI with chronic exposure to stress-associated wartime factors can worsen the course of the hospital period of STEMI, which is associated with an increase in heart rate, ESR, glucose level, leukocytes, lymphocytes, triglycerides, platelets with a decrease in their inhomogeneity in size. Taking into account these features allows predicting the risk of a complicated course of the hospital period of the STEMI in wartime.

Comparison of machine learning-based CT fractional flow reserve with cardiac MR perfusion mapping for ischemia diagnosis in stable coronary artery disease.

To compare the diagnostic performance of machine learning (ML)-based computed tomography-derived fractional flow reserve (CT-FFR) and cardiac magnetic resonance (MR) perfusion mapping for functional assessment of coronary stenosis. Between October 2020 and March 2022, consecutive participants with stable coronary artery disease (CAD) were prospectively enrolled and underwent coronary CTA, cardiac MR, and invasive fractional flow reserve (FFR) within 2weeks. Cardiac MR perfusion analysis was quantified by stress myocardial blood flow (MBF) and myocardial perfusion reserve (MPR). Hemodynamically significant stenosis was defined as FFR ≤ 0.8 or > 90% stenosis on invasive coronary angiography (ICA). The diagnostic performance of CT-FFR, MBF, and MPR was compared, using invasive FFR as a reference. The study protocol was completed in 110 participants (mean age, 62years ± 8; 73 men), and hemodynamically significant stenosis was detected in 36 (33%). Among the quantitative perfusion indices, MPR had the largest area under receiver operating characteristic curve (AUC) (0.90) for identifying hemodynamically significant stenosis, which is in comparison with ML-based CT-FFR on the vessel level (AUC 0.89, p = 0.71), with comparable sensitivity (89% vs 79%, p = 0.20), specificity (87% vs 84%, p = 0.48), and accuracy (88% vs 83%, p = 0.24). However, MPR outperformed ML-based CT-FFR on the patient level (AUC 0.96 vs 0.86, p = 0.03), with improved specificity (95% vs 82%, p = 0.01) and accuracy (95% vs 81%, p < 0.01). ML-based CT-FFR and quantitative cardiac MR showed comparable diagnostic performance in detecting vessel-specific hemodynamically significant stenosis, whereas quantitative perfusion mapping had a favorable performance in per-patient analysis. ML-based CT-FFR and MPR derived from cardiac MR performed well in diagnosing vessel-specific hemodynamically significant stenosis, both of which showed no statistical discrepancy with each other. • Both machine learning (ML)-based computed tomography-derived fractional flow reserve (CT-FFR) and quantitative perfusion cardiac MR performed well in the detection of hemodynamically significant stenosis. • Compared with stress myocardial blood flow (MBF) from quantitative perfusion cardiac MR, myocardial perfusion reserve (MPR) provided higher diagnostic performance for detecting hemodynamically significant coronary artery stenosis. • ML-based CT-FFR and MPR from quantitative cardiac MR perfusion yielded similar diagnostic performance in assessing vessel-specific hemodynamically significant stenosis, whereas MPR had a favorable performance in per-patient analysis.

Predictors of Revascularization in Patients with Unstable Angina.

The factors that determine the necessity of coronary artery revascularization in patients with unstable angina (UA) have been supported by limited data. Therefore, this study aimed to identify the predictors of revascularization in patients with UA. The study included the recorded data of 3668 patients with UA who underwent cardiac catheterization (age 66 ± 9.2, men 70%); 2615 of them (71%) underwent revascularization (percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), or hybrid revascularization. The remaining 1053 patients (29%) had no significant coronary stenosis and were regarded as controls. Multivariable logistic regression analysis was performed to separate the predictors of revascularization. It was found that severe angina (OR 2.7, 95%CI 1.9-3.7), male gender (OR 1.4, 95%CI 1.1-1.7), and hyperlipidemia were the predictors of revascularization. It was also noted that intraventricular conduction disorders including left and right bundle branch blocks and a history of previous revascularization and myocardial infarction were associated with lower odds of revascularization. Overall, however, the predictive value of the studied factors proved to be poor and may still point to the multifactorial nature of significant coronary artery stenosis and the need for revascularization in patients with UA.

Long-term prognostic factors for cardiovascular events in patients with chest pain without diabetes mellitus nor significant coronary stenosis.

Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.

Polymorphic Variants of SCN5A Gene (rs41312433 and rs1805124) Associated with Coronary Artery Affliction in Patients with Severe Arrhythmias.

A group of 32 unrelated individuals, aged 63 ± 12 years, was included in the study. All the patients were examined, diagnosed and treated with an implantable cardioverter defibrillator at the Department of Internal Cardiology Medicine, Faculty Hospital Brno. The control group included 87 persons of similar age without afflicted coronary circulation, which was confirmed coronagraphically. Genomic DNA was extracted from samples of peripheral blood according to the standard protocol. Two SCN5A polymorphisms-IVS9-3C/A (rs41312433) and A1673G (rs1805124, H558R)-were examined in association with coronary artery stenosis in the patients. In the case-control study, no significant differences in genotype distribution/allelic frequencies were observed for IVS9-3c>a and A1673G gene polymorphisms between patients with severe arrhythmias and healthy persons. The distribution of SCN5A double genotypes was not significantly different among different types of arrhythmias according to their ejection fraction in arrhythmic patients (p = 0.396). The ventricular arrhythmias with an ejection fraction below 40% were found to be 10.67 times more frequent in patients with multiple coronary stenosis with clinically valid sensitivity, specificity and power tests. In the genotype-phenotype study, we observed a significant association of both SCN5A polymorphisms with the stenosis of coronary vessels in the patients with severe arrhythmia. The double genotype of polymorphisms IVS9-3C/A together with A1673G (CCAA) as well as their simple genotypes were associated with significant multiple stenosis of coronary arteries (MVS) with high sensitivity and specificity (p = 0.05; OR = 5 (95% CI 0.99-23.34); sensitivity 0.70; specificity 0.682; power test 0.359) Moreover, when a concrete stenotic coronary artery was associated with SCN5A genotypes, the CCAA double genotype was observed to be five times more frequent in patients with significant stenosis in the right coronary artery (RCA) compared to those without affliction of this coronary artery (p = 0.05; OR = 5 (95% CI 0.99-23.34); sensitivity 0.682; specificity 0.700; power test 0.359). The CCAA genotype was also more frequent in patients without RCA affliction with MVS (p = 0.008); in patients with ACD affliction but without MVS (p = 0.008); and in patients with both ACD affliction and MVS compared to those without ACD affliction and MVS (p = 0.005). Our study presents a highly sensitive and specific association of two polymorphisms in SCN5A with significant coronary artery stenoses in patients with potentially fatal ventricular arrhythmias. At the same time, these polymorphisms were not associated with arrhythmias themselves. Thus, SCN5A gene polymorphic variants may form a part of germ cell gene predisposition to ischemia.

Coronary Artery Disease Is Related to Methylation Disorders Caused by the c.1286A&gt;C MTHFR Polymorphism and to Low Serum 5-MTHF and Folic Acid Concentrations—Preliminary Results

Background: Single nucleotide polymorphisms in gene encoding is the key enzyme in the folates pathway, methyltetrahydrofolate reductase (MTHFR), which causes methylation disorders associated with coronary artery disease (CAD). We evaluated associations between methylation disorders caused by MTHFR gene polymorphisms and the blood folate concentrations (folic acid, 5-MTHF) in CAD patients. Methods: Study group: 34 patients with CAD confirmed by invasive coronary angiography (ICA). Controls: 14 patients without CAD symptoms or significant coronary artery stenosis, based on ICA or multislice computed tomography (MSCT) with coronary artery calcification (CAC) scoring. Real-time PCR genotyping was assessed using TaqMan™ probes. Folic acid and 5-MTHF concentrations in blood serum were determined using Liquid Chromatography-Mass Spectrometry (LC-MS). Results: The c.[1286A&gt;C];[1286A&gt;C] MTHFR polymorphism occurred significantly more often in (CAD+) patients compared to the (CAD−) cohort and to the selected general European “CEU_GENO_PANEL” population sample. The concentration of 5-MTHF and folic acid in subgroups of CAD+ patients with methylation disorders categorized by genotypes and CAD presence (CAD+) was always lower in CAD+ subgroups compared to non-CAD individuals (CAD−). Conclusions: Further studies on a larger scale are needed to implicate the homozygous c.1286A&gt;C MTHFR variant as CAD genetic marker and the 5-MTHF as CAD biomarker. Identification of high CAD risk using genetic and phenotypic tests can contribute to personalized therapy using an active (methylated) form of folic acid (5-MTHF) in CAD patients with MTHFR polymorphisms.

Updates on Prognostication of Takotsubo Cardiomyopathy: A Literature Review

Abstract Takotsubo cardiomyopathy (TTC), commonly known as “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular (LV) systolic dysfunction, usually in the absence of significant obstructive coronary artery stenosis. The pathophysiology of TTC remains elusive; however, the three most common plausible mechanisms include catecholamine surge causing myocardial stunning, multivessel coronary spasm, and microvascular dysfunction. Although initially thought to be a benign, reversible, and transient disorder, newer research data demonstrate that TTC may sometimes have severe short-term complications and some long-term residual effects. Several risk factors have been associated with the outcomes of TTC. In this review, we aim to provide a comprehensive review of the prognostication of TTC in the context of different clinical variables presented in multiple research studies. Various clinical factors, including the types of TTC triggers, the patient’s sex, the presence of cardiogenic shock, atrial arrhythmias, LV tract obstruction, and the presence of certain other clinical comorbidities may significantly impact patient outcomes in TTC patients. A thorough understanding of these factors helps clinicians to better prognosticate the outcome of their patients. Furthermore, early institution of aggressive treatment interventions in the presence of these risk factors may improve the subsequent clinical course.

The diagnostic value of stress echocardiography with limited myocardial ischemia in high-risk patients

BackgroundThe diagnostic value of limited myocardial ischemia in DSE is not well known. ObjectivesWe investigated whether myocardial ischemia during dobutamine stress echocardiography (DSE) in 1 apical segment of any of the ventricular walls of the left ventricle relates to the anatomical and functional stenosis of the suppling coronary artery. MethodsOur observational, prospective study enrolled 212 patients, symptomatic or asymptomatic, with newly diagnosed limited myocardial ischemia on DSE. Almost 25% of them had already known CAD, while the rest were divided into low-risk and high-risk groups, integrating 1-2 and ≥3 classical cardiovascular risk factors, respectively. After DSE, all patients underwent invasive coronary angiography (ICA) and were followed up for one year. In coronary arteries distributing ischemic area, the calculated stenosis ≥50% and FFR<0.8 were considered anatomically and functionally significant, respectively. In the latter cases, the patients underwent coronary revascularization. ResultsSignificant anatomical and functional stenosis of the supplying coronary artery was common among patients with already known CAD (62.5% and 44.5%, respectively) or those without CAD but a high-risk profile (60.2% and 25.6%, respectively). In logistic regression analysis, CAD revascularization was independently determined by an already known CAD, diabetes mellitus, and high-risk profile. During follow-up, 24 patients experienced ACS or new angina episodes, which were associated with diabetes and smoking in univariate analysis. ConclusionLimited myocardial ischemia may implicate significant anatomical and functional coronary stenosis among individuals with a history of CAD or those without known CAD but a high-risk profile. The prognostic value of our findings requires further investigation.

Myocardial perfusion scintigraphy in the prediction of the existence of hemodynamically significant coronary artery stenosis

Myocardial perfusion scintigraphy in the prediction of the existence of hemodynamically significant coronary artery stenosis