Significant Coronary Stenosis Research Articles

Introducing the original web score calculator GARDENIA risk score for severe coronary artery (re)stenosis

Abstract Background/Introduction There are a large number of scores that are used for cardiovascular risk assessment and different online calculators are used to perform it. Risk prediction models provide risk estimates that can assist our decision making and improve guiding for individual clinical outcomes and personalized preventive care. Purpose GARDENIA score is designed to predict highly suspicious probability of significant coronary stenosis in patients without proven CAD or those who have already been revascularized. Methods GAR²DE²NIA is an acronym that incorporates following parameters : Gender, Age, Renal impairment, Respiratory disease, Diabetes Melittus, Echo abnormalities, ECG abnormalities, New symptoms, Ischaemia, Atrial fibrillation. The pointing scale was formed (-1 to 2) on the personal interpretation of evidence based data and is applied and designed as web calculator. The established cut-off values for the risk of significant coronary stenosis is 4. For values below 4, the probability of significant CAD is low, below 0 is very low, equal or greater than 4 significant CAD is high and above 8 is very high. Results Standard statistical formulas for sensitivity, specificity, PPN and NPV were used ( sensitivity 91,43%, specificity 73,33%, PPV 88,89, NPV 78,57). Estimated pilot sample size of 100 patients, was tested on patients cohort treated at the Institute for Cardiovascular Disease Dedinje in the year of 2022. Conclusion This original score is to be checked throughout everyday clinical practice. It is easy to use. It can help in decision making in risk stratification and further treatment of the patients who has never been to cardiologist before, those who has already been revascularized and are symptomatic again or need any kind of non cardiac surgery and the patients we have doubts about what to do next.GARDENIA score calculator

Diagnostic accuracy of a novel optical coherence tomography-based fractional flow reserve algorithm for assessment of coronary stenosis significance.

This study aimed to introduce a novel optical coherence tomography-derived fractional flow reserve (FFR) computational approach and assess the diagnostic performance of the algorithm for assessing physiological function. The fusion of coronary optical coherence tomography and angiography was used to generate a novel FFR algorithm (AccuFFRoct) to evaluate functional ischemia of coronary stenosis. In the current study, a total of 34 consecutive patients were included, and AccuFFRoct was used to calculate the FFR for these patients. With the wire-measured FFR as the reference standard, we evaluated the performance of our approach by accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Per vessel accuracy, sensitivity, specificity, PPV, and NPV for AccuFFRoct in identifying hemodynamically significant coronary stenosis were 93.8%, 94.7%, 92.3%, 94.7%, and 92.3%, respectively, were found. Good correlation (Pearson's correlation coefficient r = 0.80, p < 0.001) between AccuFFRoct and FFR was observed. The Bland-Altman analysis showed a mean difference value of -0.037 (limits of agreement: -0.189 to 0.115). The area under the receiver-operating characteristic curve (AUC) of AccuFFRoct in identifying physiologically significant stenosis was 0.94, which was higher than the minimum lumen area (MLA, AUC = 0.91) and significantly higher than the diameter stenosis (%DS, AUC = 0.78). This clinical study shows the efficiency and accuracy of AccuFFRoct for clinical implementation when using invasive FFR measurement as a reference. It could provide important insights into coronary imaging superior to current methods based on the degree of coronary artery stenosis.

Abstract 16552: Coronary Vasomotor Response to Intracoronary Ergonovine Provocation Test According to the Severity of an Insignificant Coronary Artery Fixed Stenosis

BACKGROUND: Coronary artery spasm (CAS) is a major cause of variant angina in patients with chest pain without significant coronary stenosis. However, whether there are differences in the incidence of CAS according to the severity of underlying coronary artery fixed stenosis is limited. Methods: A total of 608 patients without significant coronary artery disease (CAD) who underwent the ergonovine (ERG) provocation test between January 2018 and December 2021 were enrolled. Significant CAS was defined as having≥70% of temporary narrowing by ERG test. Patients were divided into three groups, based on the presence of coronary artery stenosis: None group (n=456), mild group (30-49%,n=114) and moderate group (50-69%,n=38). Results: In patients with chest pain without significant coronary artery stenosis, mild stenosis was 18.8%, and moderate stenosis was 6.3% in the population. The baseline characteristics of the patients were worse in the mild and moderate group than in the None group, including age, hypertension, diabetes, and smoking habit. In the ERG test, CAS occurred in 44.4% (270/608) of the overall population. The incidence of CAS of the mild (55.3%) and moderate (52.6%) groups were higher than the None group (41.0%). Also, in the case of CAS occurrence, focal CAS (Length&lt;20mm) was more frequent in the mild (14.3%) and moderate (30%) groups than in the no group (8.6%). CONCLUSIONS: In patients with resting chest pain without severe coronary artery stenosis, CAS was observed in a high proportion of nearly half by ergonovine provocation test. Moreover, the mild to moderate coronary artery fixed stenosis showed higher incidence of CAS and focal CAS than patients without fixed stenosis.

Abstract 16620: Long-Term Prognostic Factors for Cardiovascular Events in Patients With Chest Pain Without Diabetes Mellitus and Significant Coronary Stenosis

Background: 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 and 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. Methods: 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 cardiovascular events (MACE) were defined as the composite of total death, myocardial infarction (MI), and revascularization. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of MACE, 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 5 years. Results: 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 anti-anginal medication therapy. However, a recurrent chest pain remains a problem even with continuous anti-anginal medication therapy. Up to 5-year, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia, ICS, the use of aspirin and nitrates were associated with long-term MACCE. Conclusions: 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 anti-anginal medications.

Abstract 18374: Effective Atomic Number and Electron Density Number Acquired Using Latest Spectral CT Enable the Differentiation of Infarcted Myocardium and Hypertrophied Myocardium From Normal Myocardium

Introduction: Spectral CT can acquire effective atomic (EAN) and electron density number (EDN). Hypothesis: EAN and EDN using spectral CT enable the differentiation of infarcted myocardium and hypertrophied myocardium from normal myocardium. Methods: We analyzed 146 patients (73 males; mean age 55 ± 14 years old) who had no significant coronary stenosis on CT (7500; Philips) and normal ECG (normal group), 20 patients with previous myocardial infarction (MI) (12 males; mean age 73 ± 7 years old) (MI group), and 10 patients with hypertrophic cardiomyopathy (HCM) (5 males; mean age 66 ± 15 years old) (HCM group). On CT, we measured EAN and EDN in the interventricular septum (IVS), left ventricular (LV) anterior wall (LVAW), and lateral wall (LVLW) within a 1.0 mm2 circle at LV inflow level in the non-contrast and early contrast phase. In MI and HCM groups, EAN and EDN were also measured in the infarcted and hypertrophied myocardium, respectively. Results: In the non-contrast and early contrast phase, the EAN was significantly lower in the infarcted myocardium group than in the normal group (p &lt; 0.01), in the non-infarcted myocardium than in the MI group (p &lt; 0.05) and non-hypertrophied myocardium in the HCM group (p &lt; 0.05), and in the hypertrophic myocardium in the HCM group than in the normal group (p &lt; 0.05) and non-hypertrophic myocardium in the HCM group (p &lt; 0.05). In the non-contrast and early contrast phase, the EDN was also lower in the infarcted myocardium than in the normal group (p &lt; 0.01), non-infarcted myocardium in the MI group (p &lt; 0.05), hypertrophied and non-hypertrophied myocardium in the HCM group (p &lt; 0.05). Conclusion: The use of EAN and EDN enables the differentiation of infarcted myocardium (EAN and EDN) and hypertrophied myocardium (EAN) from normal myocardium even on non-contrast CT alone. The use of EAN and EDN enables the detection of abnormal myocardial characteristics (blood flow decrement, fibrotic change, hypertrophy, and inflammation) on non-contrast CT alone.

The importance of baseline fractional flow reserve to detect significant coronary artery stenosis in different patient populations.

Fractional flow reserve (FFR) assessment compares the blood flow on either side of a blockage in the coronary artery and indicates how severe the stenosis is in the artery. Intravenous adenosine is widely used to achieve conditions of stable hyperaemia for the measurement of FR. However, intravenous adenosine affects both systemic and coronary vascular beds differentially. Therefore, FFR has some limitations, such as the side effects of adenosine and the long procedure time. In addition, there are not enough studies on the evaluation of the baseline ratio of distal coronary pressure to aortic pressure (Pd/Pa) according to standard cut-off values in coronary stenosis under special clinical conditions. This study aimed to assess the diagnostic power of the baseline FFR value for critical coronary stenosis and to determine its predictive value in special patient groups. This retrospective study included 158 patients, who were stratified as Q1 (< 0.89), Q2 (0.89-0.92), Q3 (0.93-0.95) and Q4 (> 0.95) based on baseline FFR values. The baseline Pd/Pa value, the change in adenosine FFR and the raw FFR change were recorded. Its predictive value was also calculated for specific patient groups. The threshold value of baseline FFR level for predicting critical stenosis was ≤ 0.92 with a sensitivity of 92.8% and a specificity of 82% (upper limit of Q2 cartilage). Patients with a baseline FFR value ≤ 0.92 had a 58.4-fold greater likelihood of a critical outcome compared with patients with a baseline FFR value > 0.92 (OR: 58.4; 95% CI: 20.3-124.6). In patients with a baseline FFR ≤ 0.92, the Q1 group had a 10.23-fold higher odds of critical stenosis compared with the Q2 group (OR: 10.23; 95% CI: 2.14-48.84). The same values had similar diagnostic power for all specific patient groups. The baseline FFR value could be used to predict critical coronary stenosis in our patients and had similar value for predicting lesion severity in all the subgroups.

Abstract 16473: Validation of the Artificial Intelligence-Based 5-Lead 3D Vectorcardiography in Comparison to the 12-Lead ECG in a Mixed Population

Introduction: Artificial Intelligence-based 5-lead 3D-vectorcardiography (5L3DVCG-AI) offers additional information over 12-lead electrocardiography (ECG) in the detection of significant coronary stenoses. 5L3DVCG-AI is under investigation as a new screening tool for coronary vascular disease (CVD). Hypothesis: We tested the hypothesis of variables from the reconstructed “12-lead ECG” (5L12L-ECG, modified Dower transformation) corresponding with the standard 12-lead ECG (ECG). Methods: In this monocentric exploratory retrospective study, raw data of 331 patients with 5L3DVCG-AI and ECG were included. Cardiac pathology (CP) was categorised as exclusion of any CP (control), mild CP or overt CP by 2 independent cardiologists. The following variables were compared: RR-interval, P, PQ, QRS, QT, QTcB, QTcF, QRS-morphology, and ST-morphology. Cardiovascular risk factors (CVRF) were quantified with the modified PROCAM score. Results: From 331 patients (m:w 60:40%, 50.0 ± 19.8 years) of mixed ethnicity and moderate CVRF (2.1 ± 1.2), 70% were controls, 21% had mild CP and 9% overt CP. All variables from reconstructed 5L12L-ECG correlated to the corresponding individual variables from ECG (r= 0.49 to 0.7, p&lt;0.001). With identical RR-intervals in both methods, all defined variables were significantly, but irrelevantly or mildly (Cohen’s d) different in 5L12L-ECG compared to ECG (P 106 ± 12 vs. 109 ±20 ( d =0.3), PQ 152 ± 24 vs. 159 ± 26 ( d =0.3), QRS 105 ± 16 vs. 97 ± 14 ( d =0.7), QT 380 ± 33 vs. 396 ± 27 ( d =0.46), QTcB 432 ± 31 vs. 426 ± 25 ( d =0.57), QTcF 414 ± 26 vs. 416 ± 19 ( d =0.53). 5L3DVCG-AI was able to distinguish between controls and patients with CVD (Sensitivity 78%, Specificity 66%, p=0.01). Comparing heart axis, there was a small, but significant difference with a significant correlation between methods (r=0.30, p&lt;0.01). Conclusions: The easy to use 5-lead ECG may thus be used in clinical practice to reconstruct valid 12-lead ECG curves without major training or expertise. Additionally, 5L3DVCG-AI can identify persons at risk for CVD. Shorter values for the defined variable will have to be considered when interpreting 5L12L-ECG and separate “normal” value ranges will be given and validated in the ongoing prospective large-scale performance clinical trials.

Abstract 17002: Platelet-Derived Purified Exosome Product to Treat In-Stent Restenosis Porcine Model

Introduction: Patients with coronary artery disease (CAD) not amenable to revascularization are reported to have a 3-year mortality &gt;14%. Advances in treatment modalities including medical management, rotational atherectomy, balloon lithotripsy, and drug-eluting stents work for focal disease but poorly treat diffuse CAD. In a porcine model of in-stent restenosis, we here evaluated whether a pro-angiogenic platelet-derived exosome product (PEP) could be delivered into the perivascular space to foster collateral vessel formation. Methods/Results: Cobalt chromium stents were placed and were oversized by 1 mm in the left anterior descending (LAD) and posterior descending arteries (PDA) of sus scrofa domesticus pigs. In-stent restenosis was angiographically visualized at the 2-month timepoint, with hemodynamic significance documented with fractional flow reserve (FFR) of &lt;0.8. To document feasibility of PEP delivery into the perivascular space, exosomes were labeled with a far-red fluorescent tag and delivered into the perivascular bed. Here, the Bullfrog® micro-infusion catheter was positioned either in the great cardiac vein or the middle cardiac vein and PEP was delivered with the microneedle pointed towards the LAD or the PDA. Biodistribution demonstrated exosome retention and uptake around cardiac veins. Using the Bullfrog® technique, PEP was delivered in the perivascular space adjacent to areas of significant coronary stenosis. Initial results 1-month post-treatment demonstrated improved FFR of treated stenotic vessels (from 0.68 to 0.85), while untreated vessels demonstrate no change from previous FFR measurement (from 0.79 to 0.78). Conclusions: Here, exosome-mediated angiogenesis in the perivascular space improved coronary blood flow, distal to areas of stenosis. In patients with diffuse CAD, delivery of biotherapy in cardiac veins running anatomically parallel to stenosed epicardial arteries provides a novel therapeutic opportunity to supplement the existing armamentarium of therapies available for in-stent restenosis.

Diseases of the Coronary Microcirculation: Diagnosis and Treatment.

Coronary microvascular dysfunction (CMD) comprises a variety of pathogenic mechanisms that impair the microcirculation of the heart. Clinical studies have shown that 30-50% of patients suffering from myocardial ischemia without significant coronary artery stenosis have CMD. The disease is associated with elevated mortality and poor quality of life. Whenever a patient presents with symptoms of angina pectoris and no underlying disease is detected by the usual methods, CMD should be considered a possible cause. This review is based on publications retrieved by a selective search in PubMed and on current international guidelines and recommendations of specialty societies. The diagnosis of CMD is based on objective evidence of a microvascular origin of symptoms. The guidelines contain a class IIa recommendation for invasive coronary flow reserve and microvascular resistance measurements. Noninvasive tests such as positron emission tomography and cardiac magnetic resonance imaging are less accurate and are given a class IIb recommendation. No high-quality therapeutic trials are available to date, and the treatment of CMD is thus based on that of chronic coronary syndrome. Lifestyle modification is performed to reduce risk factors. Patients with an abnormal coronary flow reserve or elevated microvascular resistance can be treated with an ACE inhibitor or angiotensin receptor blocker. Beta-blockers and calcium channel antagonists can relieve angina pectoris. Statins lower the LDL level and have positive pleiotropic effects. First-line treatment can be supplemented with further medications. Approximately 25% of patients with CMD have symptoms that do not respond to intensive treatment with the currently available modalities. New treatments, including interventional therapies, are being studied. Their long-term benefit remains to be assessed and compared to that of the existing methods.

Peripheral blood mononuclear cells expression of miR-200c, miR-125b, miR-27b, miR-203, and miR-155 in patients with significant or insignificant coronary artery stenosis

Coronary artery disease (CAD) is one of the principal causes of death worldwide. Among several predisposing factors, inflammation and inflammatory genes play a significant role in disease pathogenesis. Inflammatory microRNAs, small noncoding RNAs involved in regulating inflammation, are promising candidates for understanding pathogenesis of CAD and developing diagnostic biomarkers. The aim of the study was to evaluate the alteration of miR-200c, miR-125b, miR-27b, miR-203 and, miR-155 in patients suffering from coronary artery stenosis and insignificant coronary artery stenosis compared to healthy subjects. In this study we compared expressions of five inflammatory miRNAs in peripheral blood mononuclear cells (PBMCs) of 72 patients suffering significant coronary artery stenosis (CAD), 74 individuals without coronary artery disease and 30 individuals with insignificant coronary artery stenosis (ICAD). After blood collection, PBMCs were isolated and RNA was extracted. Gene expression levels were assessed by SYBR green based real-time PCR. Statistical analysis was performed using R program. Expression levels of miR-200c, miR-203, and miR-155 were lower in subjects with ICAD than that in CAD patients and subjects of the control group. MiR-125b was downregulated in CAD and ICAD groups compared to the control group. PBMC miR-27b was upregulated in the CAD group as compared to the ICAD and control groups. Receiver operating characteristic curve analysis verified potential of three miRNAs in separating subjects with ICAD from CAD patients and healthy individuals. In conclusion, this original investigation suggested that altered expression of these five miRNAs may serve as a novel diagnostic biomarker discriminating clinical presentations of coronary artery diseases.

Diagnostic value of coronary flow acceleration measured by transesophageal echocardiography in coronary artery bypass graft surgery

Background: Transesophageal echocardiography as a method of intraoperative coronary flow assessment is largely unstudied.Objective: To evaluate the potential of intraoperative transesophageal echocardiography in diagnosing proximal coronary artery stenoses, to reveal the correlation between stenoses found on coronary angiography and coronary flow velocity in the corresponding area measured by intraoperative transesophageal echocardiography, and to study how coronary flow velocity changes before and after coronary artery bypass graft surgery and how it is related to postoperative myocardial injury.Methods: Our prospective cohort study included 186 patients scheduled for coronary artery bypass graft surgery. All the patients underwent intraoperative transesophageal echocardiography: coronary flow velocity was measured in the area of its acceleration (proximal parts of the left coronary artery) before and after the surgery. Troponin I was measured on the first postoperative day.Results: The areas of accelerated coronary flow before the procedure were detected in the left main coronary artery (88 patients, 47.3%), left anterior descending artery (146 patients, 78.5%), and left circumflex artery (28 patients, 15.1%). ROC analysis showed that coronary flow velocity of &gt;73 cm/s in the left main coronary artery and of &gt;91 cm/s in the left circumflex artery was associated with a stenosis of 50% and 70% in the respective arteries measured by coronary angiography. Furthermore, an increase in coronary flow velocity in the left anterior descending artery or its decrease by 4 cm/s after coronary artery bypass graft surgery are predictors of a 10-fold increase in troponin I concentration in the postoperative period.Conclusion: Coronary flow velocity assessment during intraoperative transesophageal echocardiography can offer added value in detecting clinically significant coronary artery stenoses, while assessment of changes in velocity may predict perioperative myocardial injury. Received 16 January 2023. Revised 16 May 2023. Accepted 31 August 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: S.M. Efremov, M.A. Novikov, A.V. ZagatinaData collection and analysis: S.M. Efremov, M.A. Novikov, A.A. Trofimov, A.V. ZagatinaStatistical analysis: S.M. Efremov, A.A. TrofimovDrafting the article: S.M. Efremov, A.A. TrofimovCritical revision of the article: S.M. Efremov, M.A. Novikov, A.A. Trofimov, D.V. Shmatov, M.S. Kamenskih, A.V. ZagatinaFinal approval of the version to be published: S.M. Efremov, M.A. Novikov, A.A. Trofimov, D.V. Shmatov, M.S. Kamenskih, A.V. Zagatina

Capabilities of the Treadmill Test in Modern Cardiological Practice

Many publications in recent years have been dedicated to the search for the best preliminary method of diagnosing coronary artery disease (CAD), where the availability of technology and staff experience are the determining factors. According to the National Cardiovascular Data Registry of the American College of Cardiology, 58.4% of patients referred for coronary angiography after functional testing do not have significant coronary artery stenoses. European guidelines for the diagnosis and management of patients with chronic coronary syndrome recommend the use of imaging diagnostic tests instead of exercise electrocardiography for the diagnosis of obstructive CAD.&#x0D; The aim. To analyze the capabilities of the exercise electrocardiography test for patients in modern cardiological practice.&#x0D; Materials and methods. A treadmill test was performed on 406 patients, among whom 317 (78.07%) were men, 89 (21.9%) were women, the mean age was 44.7±17.3 years. The test was carried out according to the Bruce protocol on the Valiant Ergometric Treadmill.&#x0D; Results. The patients were divided into groups depending on the area of diagnostic search: verification of CAD in cardiac pain (n=184); evaluation of the long-term results of cardiac surgery (n=74); visualization of myocardial ischemia in borderline stenoses of coronary arteries (n=4); screening in the presence of additional CAD risk factors (n=49); in the case of heart rhythm disorders in order to decide on further treatment tactics and evaluation of the effectiveness of the antiarrhythmic treatment (n=34); evaluation of the coronary artery in patients with congenital heart defects (n=7); determination of tolerance to physical exertion (n=54). Among the examined patients, there were 48 (11.8%) with positive, 246 (60.5%) with negative, and 112 (27.5%) with doubtful treadmill test. Among 48 patients with a positive treadmill test, myocardial revascularization was performed in 41 (85.4%) cases.&#x0D; Conclusions. Exercise electrocardiography is an affordable tool for diagnostic research which, with its high-quality performance and interpretation, can be an alternative to modern imaging techniques.

Diagnostic value of exercise stress echocardiography on a horizontal cycle ergometer in patients with low-risk non-ST elevation acute coronary syndrome

Aim. To evaluate the diagnostic accuracy of exercise stress echocardiography on a horizontal cycle ergometer for the detection of obstructive coronary artery disease (CAD) in patients with low-risk non-ST-elevation acute coronary syndrome (NSTE-ACS).Material and methods. The study included 95 patients aged 53 (46;63) years (men, 58%), hospitalized in the regional vascular center with low-risk NSTE-ACS. Patients with known CAD, impaired resting left ventricular contractility were not included. During hospitalization, standard stress echocardiography on a horizontal cycle ergometer and invasive or non-invasive coronary angiography (CAG) were performed. All values of coronary obstruction ≥70% were verified by invasive CAG. The assessment of myocardial revascularization was observational.Results. All patients had normal structural and functional cardiac parameters at rest. No adverse events were recorded during the tests. The result of stress echocardiography according to impaired local contractility (ILC) criterion was positive in 9 (16%), negative in 28 (49%), incomplete symptom-limited in 20 (35%) patients. Coronary artery stenosis ≥50%/≥70% was detected in 78/78% of cases in the subgroup with a positive result, in 29/11% — with a negative result, 30/10% — with a non-diagnostic result. The association of ILC with stenosis ≥70% was higher, with an odds ratio of 30,1 (4,9; 186,5) vs 8,5 (1,6; 46,1) for stenosis ≥50%. There were following diagnostic accuracy for stenosis ≥70%: sensitivity — 70%, specificity — 93%, positive predictive value — 78%, negative predictive value — 89%, overall accuracy — 86%.Conclusion. Exercise stress echocardiography on a horizontal cycle ergometer in patients with low-risk NSTE-ACS patients is safe and feasible. The method has moderate sensitivity and positive predictive value and high specificity, negative predictive value and overall accuracy for the detection of anatomically significant coronary artery stenosis. In the structure of results, there is a significant proportion (35%) of symptom-limited tests incomplete due to heart rate, characterized by the lowest incidence of obstructive atherosclerosis.

Global and regional myocardial function assessment in symptomatic patients with chronic coronary syndrome using longitudinal strain and noninvasive myocardial work.

Speckle tracking echocardiography (STE) derived longitudinal strain (LS) and noninvasive pressure-strain loop (PSL) derived myocardial work (MW) are more sensitive than conventional echocardiographic parameters in quantitative assessment of early myocardial dysfunction. The aim of this study was to assess left ventricular (LV) global and regional myocardial function in symptomatic chronic coronary syndrome (CCS) patients using the two promising methods.Transthoracic echocardiography was performed on patients with angina or equivalent symptoms before coronary angiography. STE-based LS and PSL-based MW analysis were carried out on each patient for global and regional myocardial function assessment.A total of 102 patients were classified into significant and nonsignificant coronary artery stenosis (CAS) groups. Among global myocardial function parameters, LS had the biggest area under the curve (AUC) of 0.735, with cutoff value of 18.4% (sensitivity, 79.6%; specificity, 72.9%), but remained statistically alike with all MW indices in predicting significant CAS (P>0.05 for all). Among regional myocardial function parameters, both LS and MW indices had predictive value for significant left anterior descending artery (LAD) or left circumflex artery (LCX) stenosis, while only myocardial work efficiency (MWE) for right coronary artery (RCA) stenosis.Both global and regional LS and MW have predictive value for significant CAS, but their value of regionalized assessment varies with specific coronary artery involvement.

Exploring the ECG "6+2" Phenomenon in Coronary Artery Disease and Coronary Artery Spasm: A Case Report Analysis and Treatment Implications.

BACKGROUND Although coronary artery disease and coronary artery spasm (CAS) can lead to acute myocardial infarction, there are clear differences in treatment between coronary heart disease and CAS, and the therapeutic schedule should not be confused. Furthermore, electrocardiogram (ECG) "6+2" phenomenon is recommend as a specific ECG indicator for lesions in the left main coronary artery or multiple vessels. Currently, no reports of this phenomenon in CAS exist. CASE REPORT A 72-year-old man had history of recurrent chest pain for over 6 years, with episodes lasting about 10 min and resolving with rest. He experienced symptom recurrence and exacerbation due to substance abuse. He was admitted to our Emergency Department for chest pain at rest. His emergency ECG revealed a 6+2 phenomenon, accompanied by troponin levels exceeding 18 times the reference value. Promptly, we conducted coronary angiography, with unexpected normal findings. Following thorough assessment, we postulated the patient could have CAS. Subsequent to medical team intervention, the patient's ECG normalized, leading to his discharge upon condition stabilization. CONCLUSIONS We report a case of CAS in a patient with ECG 6+2 phenomenon, without significant coronary artery stenosis. This differs from transient ST-segment elevation on ECG, a well-recognized hallmark of CAS; however, such a presentation has not been documented before. Additionally, treatment strategies for myocardial ischemic conditions stemming from coronary atherosclerosis diverge from those employed for CAS. Therefore, clinicians should advocate for coronary angiography whenever feasible. This approach serves to elucidate the underlying disease etiology and facilitates the administration of precision-targeted interventions for patients.

Artificial intelligence-based opportunistic detection of coronary artery stenosis on aortic computed tomography angiography in emergency department patients with acute chest pain.

To evaluate a deep-learning model (DLM) for detecting coronary stenoses in emergency room patients with acute chest pain (ACP) explored with electrocardiogram-gated aortic computed tomography angiography (CTA) to rule out aortic dissection. This retrospective study included 217 emergency room patients (41% female, mean age 67.2 years) presenting with ACP and evaluated by aortic CTA at our institution. Computed tomography angiography was assessed by two readers, who rated the coronary arteries as 1 (no stenosis), 2 (<50% stenosis), or 3 (≥50% stenosis). Computed tomography angiography was categorized as high quality (HQ), if all three main coronary arteries were analysable and low quality (LQ) otherwise. Curvilinear coronary images were rated by a DLM using the same system. Per-patient and per-vessel analyses were conducted. One hundred and twenty-one patients had HQ and 96 LQ CTA. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of the DLM in patients with high-quality image for detecting ≥50% stenoses were 100, 62, 59, 100, and 75% at the patient level and 98, 79, 57, 99, and 84% at the vessel level, respectively. Sensitivity was lower (79%) for detecting ≥50% stenoses at the vessel level in patients with low-quality image. Diagnostic accuracy was 84% in both groups. All 12 patients with acute coronary syndrome (ACS) and stenoses by invasive coronary angiography (ICA) were rated 3 by the DLM. A DLM demonstrated high NPV for significant coronary artery stenosis in patients with ACP. All patients with ACS and stenoses by ICA were identified by the DLM.

Diagnostic Performance of Intracoronary Optical Coherence Tomography-Modulated Quantitative Flow Ratio for Assessing Coronary Stenosis.

A novel method for fast computation of Murray law-based quantitative flow ratio (μQFR) from coregistered angiography and optical coherence tomography (OCT) was recently developed. This study aimed to evaluate the diagnostic performance of this OCT-modulated μQFR (OCT-μFR). Patients who underwent coronary angiography, OCT, and fractional flow reserve (FFR) were retrospectively enrolled. μQFR was computed from a single angiographic projection. Subsequently, OCT image pullback was coregistered with the angiogram, and OCT-μFR was calculated based on the coregistered data. The same cut-off value of 0.80 was used for OCT-μFR, μQFR, and FFR to define ischemia. A paired comparison of OCT-μFR and μQFR was performed in 269 vessels from 218 patients. The mean FFR was 0.81 ± 0.11, and 45.0% of vessels had an FFR ≤0.80. OCT-μFR showed a better correlation with FFR than μQFR (r = 0.83 vs 0.76, P = .018) and numerically higher diagnostic performance (area under the curve [AUC] = 0.95 vs 0.92, P = .057). Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for OCT-μFR to identify ischemia-causing stenosis were 89.3%, 93.2%, 91.5%, 91.4%, 13.2, and 0.1, respectively. In addition, OCT-μFR showed significantly higher diagnostic performance compared with μQFR in vessels with suboptimal angiographic image quality (AUC = 0.93 vs 0.87, P = .028) and tandem lesions (AUC = 0.94 vs 0.87, P = .017). Computation of OCT-μFR was feasible and accurately identified physiologically significant coronary stenosis with simultaneous morphological assessment. In vessels with suboptimal angiographic image quality or tandem lesions, OCT-μFR had a higher diagnostic performance than angiography-based μQFR.

Predictors of coronary tortuosity in patients with chronic coronary syndrome.

Aim Coronary artery tortuosity is a common coronary angiographic finding. This tortuosity can cause myocardial ischemia even in the absence of significant coronary artery stenosis. Our aim was to compare the demographic, clinical and echocardiographic features of patients with chronic coronary syndrome (CCS) and with and without coronary artery tortuosity.Material and methods 361 patients who underwent elective coronary angiography (CAG) due to CCS were included in the study. These patients divided into two groups, those with coronary tortuosity (Group 1) and those without (Group 2). Univariable and multivariable logistic regression analysis was performed to identify predictors associated with coronary artery tortuosity.Results The mean age of the 361 CCS patients (44 % female; 56 % male) was 56.7±11.5 years. In the univariable regression analysis, age, female sex, hypertension (HT), PR interval, QTc interval, ST / T segment changes, left ventricle diastolic dysfunction (LVDD), left ventricle hypertrophia (LVH) were identified as predictors of coronary tortuosity. In the multivariable regression analysis, age (OR: 1.059; 95 %CI: 1.032-1.087, p&lt;0.001) and hypertension (OR: 0.484; 95 %CI: 0.278-0.843, p=0.01) were identified as independent predictors of coronary tortuosity.Conclusion Coronary artery tortuosity is an angiographic finding that develops as a result of adaptive mechanisms in the heart and can cause myocardial ischemia. Predictors of coronary artery tortuosity in patients with CCS were long PR and QTc intervals, ST / T segment changes, LVH, LVDD, advanced age, and female gender. Evaluation of these demographic, electrocardiographic, and echocardiographic data may help clinicans to anticipate coronary artery tortuosity in patients with CCS and to be precautious for PCI.

Association of Klotho with Coronary Artery Disease in Subjects with Type 2 Diabetes Mellitus and Preserved Kidney Function: A Case-Control Study.

Circulating Klotho levels are significantly reduced in subjects with type 2 diabetes mellitus (T2DM) and in kidney disease patients. In this work, the relationship between Klotho levels and the coronary artery disease (CAD) burden in subjects with T2DM and preserved kidney function was analyzed. For this, we performed a cross-sectional case-control study involving 133 subjects with T2DM and 200 age-, sex- and CAD-incidence-matched, non-diabetic patients undergoing non-emergency diagnostic coronary angiography. All of them were non-albuminuric and with normal glomerular filtration rates. The concentrations of serum Klotho, fibroblast growth factor 23, and inflammatory markers were also measured. As expected, the serum Klotho concentration was lower in the T2DM group (12.3% lower, p = 0.04). However, within the group of patients with T2DM, those subjects with CAD presented significantly higher Klotho levels than those without significant coronary stenosis (314.5 (6.15-562.81) vs. 458.97 (275.2-667.2) pg/mL; p = 0.02). Multiple regression analysis revealed that serum Klotho was positively related with stenosis values exclusively in subjects with T2DM (adjusted R2 = 0.153, p < 0.01). Moreover, logistic regression analysis showed that Klotho was positively associated with the presence of significant CAD in the group of T2DM patients (OR: 1.001; p = 0.041). Our data suggest that higher levels of circulating Klotho in subjects with T2DM and preserved kidney function are associated with the presence of significant CAD.

Sex-specific associations of cardiovascular risk factors and coronary plaque composition for hemodynamically significant coronary artery stenosis: a coronary computed tomography angiography study

BackgroundIt has been reported that there are sex differences in plaque composition and hemodynamically significant stenosis. This study aimed to explore the impact of sex on cardiovascular risk factors for specific plaque compositions and hemodynamically significant stenosis.MethodsData regarding demographics and cardiovascular risk factors were collected. Hemodynamically significant stenosis was identified by a computed tomography-derived fractional flow reserve of ≤ 0.8. Associations among cardiovascular risk factors, plaque composition, and hemodynamically significant stenosis were assessed using a multivariate binary logistic regression analysis across sexes. The discriminating capacity of diverse plaque components for hemodynamically significant stenosis was assessed by area under the receiver-operating characteristics curve with 95% confidence intervals.ResultsA total of 1164 patients (489 men and 675 women) were included. For men, hyperlipidemia and cigarette smoking were risk factors for each plaque component (all P < 0.05), and diabetes mellitus also predicted fibrotic components (P < 0.05). For women, risk factors for each plaque component were hypertension and diabetes mellitus (all P < 0.01). Nonetheless, hyperlipidemia (P < 0.05) was a specific risk factor for non-calcified components. Calcified components combined with fibrotic components showed superior discrimination of hemodynamically significant stenosis in men and calcified components alone in women (all P < 0.01). Hypertension (P < 0.01) was a risk factor for hemodynamically significant stenosis in women. In contrast, diabetes, hyperlipidemia, and cigarette smoking were risk factors for hemodynamically significant stenosis in men (all P < 0.05).ConclusionsIn men, hemodynamically significant stenosis was predicted by a combination of calcified and fibrotic components with multiple risk factors. In women, hemodynamically significant stenosis was predicted by calcified components caused by a single risk factor. It might be a key point to improve prognosis by more precise risk management between men and women, which needs to be proved by further prospective trials.