Significant Epicardial Coronary Artery Disease Research Articles

Diagnostic Ability of Manual Calcification Length Assessment on Non-Electrocardiographically Gated Computed Tomography for Estimating the Presence of Coronary Artery Disease.

Background: Coronary artery calcification score (CACS) on electrocardiography (ECG)-gated computed tomography (CT) is used for risk stratification of atherosclerotic cardiovascular disease, which requires dedicated analytic software. In this study, we evaluated the diagnostic ability of manual calcification length assessment on non-ECG-gated CT for epicardial coronary artery disease (CAD). Methods: A total of 100 patients undergoing both non-ECG-gated plain CT scans with a slice interval of 1.25 mm and invasive coronary angiography were retrospectively included. We manually measured the length of the longest calcified lesions of coronary arteries on each branch. The relationship between the number of coronary arteries with the length of coronary calcium > 5, 10, or 15 mm and the presence of epicardial CAD on invasive angiography was evaluated. Standard CACS was also evaluated using established software. Results: Of 100 patients, 49 (49.0%) had significant epicardial CAD on angiography. The median standard CACS was 346 [7, 1965]. In both manual calcium assessment and standard CACS, the increase in calcium burden was progressively associated with the presence of epicardial CAD on angiography. The receiver operating characteristic curve analysis showed similar diagnostic abilities of the two diagnostic methods. The best cut-off values for CAD were 2, 1, and 1 for the number of vessels with calcium > 5, 10, and 15 mm, respectively. Overall, the diagnostic ability of manual calcium assessment was similar to that of standard CACS > 400. Conclusions: Manual assessment of coronary calcium length on non-ECG-gated plain CT provided similar diagnostic ability for the presence of significant epicardial CAD on invasive angiography, as compared to standard CACS.

Microvascular resistance reserve: diagnostic and prognostic performance in the ILIAS registry.

The microvascular resistance reserve (MRR) was introduced as a means to characterize the vasodilator reserve capacity of the coronary microcirculation while accounting for the influence of concomitant epicardial disease and the impact of administration of potent vasodilators on aortic pressure. This study aimed to evaluate the diagnostic and prognostic performance of MRR. A total of 1481 patients with stable symptoms and a clinical indication for coronary angiography were included from the global ILIAS Registry. MRR was derived as a function of the coronary flow reserve (CFR) divided by the fractional flow reserve (FFR) and corrected for driving pressure. The median MRR was 2.97 [Q1-Q3: 2.32-3.86] and the overall relationship between MRR and CFR was good [correlation coefficient (Rs) = 0.88, P < 0.005]. The difference between CFR and MRR increased with decreasing FFR [coefficient of determination (R2) = 0.34; Coef.-2.88, 95% confidence interval (CI): -3.05--2.73; P < 0.005]. MRR was independently associated with major adverse cardiac events (MACE) at 5-year follow-up [hazard ratio (HR) 0.78; 95% CI 0.63-0.95; P = 0.024] and with target vessel failure (TVF) at 5-year follow-up (HR 0.83; 95% CI 0.76-0.97; P = 0.047). The optimal cut-off value of MRR was 3.0. Based on this cut-off value, only abnormal MRR was significantly associated with MACE and TVF at 5-year follow-up in vessels with functionally significant epicardial disease (FFR <0.75). MRR seems a robust indicator of the microvascular vasodilator reserve capacity. Moreover, in line with its theoretical background, this study suggests a diagnostic advantage of MRR over other indices of vasodilatory capacity in patients with hemodynamically significant epicardial coronary artery disease.

Serial ECG in suspected ACS

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

Three, dynamic variants of ST segment elevations in a patient with osteosarcoma and cardiac metastasis

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

169 CARDIAC AMYLOIDOSIS AND CORONARY ARTERY DISEASE: INSIGHTS FROM A RETROSPECTIVE OBSERVATIONAL STUDY

Abstract Introduction Patients with cardiac amyloidosis (CA) frequently present with heart failure with various extra-cardiac red flags. However, some patients can present with typical or atypical chest pain or even mimicking an acute coronary syndrome. Significant epicardial coronary artery disease (CAD) and CA can coexist, but microvascular dysfunction might also play a role. The aims of this study were to systematically investigate clinical indications for invasive coronary angiography (ICA) in patients with CA, to verify the prevalence of significant epicardial CAD and its relation to the symptoms at presentation, and to start investigating the role cardiac troponin (cTn) in this setting of patients with multiple possible causes of myocardial injury. Methods Retrospective observational study of patients with CA, both transthyretin (ATTR-CA) and light chain (AL-CA) evaluated in our Cardiac Amyloidosis Outpatient Clinic and undergoing ICA for clinical indication. Significant epicardial CAD was defined as stenosis ≥ 50% of the left main coronary artery and/or ≥ 70% of the other epicardial vessels. Results Of the 161 patients initially evaluated, 67 (42%) underwent ICA; after exclusion of those with ICA older than 5 years than CA diagnosis, the final cohort was of 61 patients, 12 (20%) AL-CA and 49 (80%) ATTR-CA. Patients with significant epicardial CAD at the index ICA had ATTR-CA and were more frequently affected by systemic hypertension and dyslipidemia. In 42 (69%) patients ICA was performed during an urgent hospitalization and in 38 (62%) patients CA diagnosis was already established/suspected at the time of the index ICA. The most common indication for ICA was chest pain (n=24, 39%), followed by dyspnea (n=21, 34%); electrocardiographic alterations/arrhythmias were the main indication for 4 patients (6.6%) while imaging for 6 (9.8%). In the remaining 6 patients (9.8%), there were other indications. Prevalence of significant epicardial CAD at the index ICA was 28% (n=17), up to 36% (n=22) if patients with previous coronary revascularization but without actual critical stenoses at index ICA were included. Among those presenting with chest pain (n=24), 9 (38%) had significant epicardial CAD at the index ICA whereas 15 (62%) did not. Considering those presenting with an acute event, the most frequent indication for ICA was chest pain (n=20, 48%); among these patients with chest pain, 55% did not have evidence of significant epicardial CAD whilst 45% did. Regarding cardiac troponin (cTn) values, concentrations at all timepoints were similar between patients with and without significant epicardial CAD at index ICA, also considering those presenting acutely and for chest pain. Conclusion In our cohort of CA patients undergoing ICA, the main clinical indication was chest pain; however, the majority of those presenting with chest pain did not have evidence of significant epicardial CAD. Significant epicardial CAD was present in around one third of patient, which is slightly less than what reported in non-amyloidotic HFpEF patients. The role of cTn in this setting is controversial, due to the possible concomitant causes of chronic and acute myocardial injury in these patients.

Abnormal epicardial coronary vasomotor reactivity is associated with altered outcomes

The prevalence and significance of abnormal epicardial coronary vasomotor reactivity (ACVR) in patients with symptoms compatible with myocardial ischaemia remains ill-defined. Our diagnostic strategy is to perform a provocative test (PT) in every patient presenting with chest pain at rest, for whom coronary angiography does not reveal significant epicardial coronary artery disease (≥70% stenosis by visual assessment). To evaluate such a strategy in terms of incidence of ACVR, PT safety and patient outcomes. The present study was a retrospective observational study with a median clinical follow-up of 5years. The primary outcome was incidence of ACVR in patients with PT. Risk factors for ACVR and clinical follow-up were obtained, and the rate of major adverse cardiovascular and cerebrovascular events (MACCE; death, cardiovascular mortality, myocardial infarction, stroke and coronary revascularization) was reported. ACVR was documented in 294 (12.4%) of the 2379 patients with PT, out of the 13,654 patients undergoing angiography. Patients with ACVR were more often female (43.9% vs. 30.0%; P<0.0001), current smokers (37.4% vs. 8.7%; P<0.0001) and had a suspected acute coronary syndrome (36.7% vs. 29.1%; P=0.005) at admittance compared with patients without ACVR. During clinical follow-up, MACCE occurred more frequently in patients with (9.8%) than in those without (3.7%) ACVR (hazard ratio [HR] 4.15, 95% confidence interval [CI] 2.62-6.57; P<0.0001), including more myocardial infarctions (4.0% vs. 0.4%; HR 17.8, 95% CI 6.41-49.5; P<0.0001) and more myocardial revascularizations (6.1% vs. 1.1%; HR 9.36, 95% CI 4.67-18.74; P<0.0001) compared with patients with normal PT at baseline. ACVR is frequent in patients with symptoms compatible with myocardial ischaemia at rest, with no significant coronary stenosis. PT is a safe strategy to identify a population at high risk of recurrent ischaemic events.

Coronary flow abnormalities in chronic kidney disease: A systematic review and meta-analysis.

Coronary vasomotion abnormalities have been described in small studies but not studied systematically. We aimed to review the present literature and analyze it to improve our understanding of chronic kidney disease (CKD) related-coronary microvascular dysfunction. Coronary flow reserve (CFR) is a well-known measure of coronary vasomotion. We aimed to assess the difference in CFR among participants with and without CKD. PubMed, Embase, and Cochrane CENTRALwere systematically reviewed to identify studies that compared CFR in participants with and without CKD. We estimated standardized mean differences in mean CFR reported in these studies. We performed subgroup analyses according to imaging modality, and the presence of significant epicardial coronary artery disease. In 14 observational studies with 5966 and 1410 patients with and without CKD, the mean estimated glomerular filtration rate (eGFR) was 29±04 and 87±25ml/min/1.73m2 , respectively. Mean CFR was consistently lower in patients with CKD in all studies and the cumulative mean difference was statistically significant (2.1±.3vs. 2.7±.5, standardized mean difference -.8, 95% CI -1.1, -.6, p<.05). The lower mean CFR was driven by both significantly higher mean resting flow velocity (.58cm/s, 95% CI .17, .98) and lower mean stress flow velocity (-.94cm/s, 95% CI -1.75, -.13) in studies with CKD. This difference remained significant across diagnostic modalities and even in absence of epicardial coronary artery disease. In meta-regression, there was a significant positive relationship between mean eGFR and mean CFR (p<.05). Patients with CKD have a significantly lower CFR versus those without CKD, even in absence of epicardial coronary artery disease. There is a linear association between eGFR and CFR. Future studies are required to understand the mechanisms and therapeutic implications of these findings. In this meta-analysis of observational studies, there was a significant reduction in coronary flow reserve in studies with chronic kidney disease versus those without. This difference was seen even in absence of epicardial coronary artery disease. In meta-regression, a lower estimate glomerular filtration rate was a significant predictor of lower coronary flow reserve. Coronary microvascular dysfunction, rather than atherosclerosis-related epicardial disease may underly increase cardiovascular risk in a patient with chronic kidney disease.

QFR vs. perfusion imaging to predict abnormal FFR in patients with prior coronary artery disease

Abstract Background In patients with suspected obstructive coronary artery disease (CAD) and a high pre-test probability, myocardial perfusion imaging (MPI) or referral for invasive coronary angiography (ICA) are viable diagnostic strategies. The present study compared the diagnostic performance of quantitative flow ratio (QFR) and MPI by single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR). Methods In this PACIFIC-II substudy, 189 patients with prior MI/PCI who were suspected of having symptoms related to myocardial ischemia and underwent SPECT, PET, and CMR before ICA were evaluated for inclusion. ICA was obtained with (109 patients) and without (80 patients) adherence to a QFR acquisition protocol. All major coronary arteries were interrogated by FFR, except for vessels with a subtotal/total occlusion. An FFR ≤0.80 was used to define significant epicardial CAD. QFR analyses (v2.0) were performed based on ICA by a corelab in vascular territories (N=487) in which FFR was obtained. MPI modalities were assessed for presence of ischemia by corelabs, uninterpretable scans were omitted from the diagnostic comparison analyses. Results QFR analysis success rate was higher (81%) among vessels acquired using the QFR acquisition protocol compared to vessels obtained without the protocol (52%, p&amp;lt;0.001). Overall, a QFR result was available in 334 (69%) vessels. Among these vessels, QFR had a higher sensitivity (72%) and accuracy (84%) compared to SPECT (46%, p=0.001 and 66%, p&amp;lt;0.001), PET (58%, p=0.032 and 65%, p&amp;lt;0.001), and CMR (33%, p&amp;lt;0.001 and 72%, p&amp;lt;0.001). Whereas specificity of QFR (87%) was similar to CMR (83%, p=0.123) but higher than that of SPECT (71%, p&amp;lt;0.001) and PET (67%, p&amp;lt;0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, p&amp;lt;0.001), PET (0.66, p&amp;lt;0.001), and CMR (0.60, p&amp;lt;0.001). Conclusions Provided QFR was analyzable (69% of the vessels), QFR correlated better with FFR (both as measures of epicardial CAD) than MPI as reflected in the diagnostic performance measures for detecting vessels-specific significant epicardial CAD as defined by FFR. Funding Acknowledgement Type of funding sources: None.

Myocardial Infarction with Nonobstructive Coronary Artery Disease—Definition, Etiopathogenesis, Diagnosis, and Management

AbstractMyocardial infarction with nonobstructive coronary arteries (MINOCA) is a complex clinical syndrome that is characterized by evidence of acute myocardial infarction in the absence of significant epicardial coronary artery disease on angiography. The term “MINOCA” encompasses a group of heterogeneous diseases with varying underlying mechanisms and each with its own pathophysiology. Overlooked plaque rupture or erosion and coronary vasospasm are the most common causes of MINOCA and can be diagnosed by routine intracoronary imaging and vasoreactivity testing, respectively. Coronary microvascular dysfunction is a less recognized, albeit an important cause of morbidity in patients presenting with MINOCA. Although MINOCA is a rare presentation of acute coronary syndrome, it is not a benign disorder and can have adverse consequences if untreated. In this article, we aim to review the pathogenesis, clinical characteristics, and finally propose a systematic approach in the diagnosis and management of patients with MINOCA.

Moment of truth for aspirin use in variant angina: a meta-analysis

Abstract Background Aspirin has been a mainstay of antiplatelet therapy for coronary artery disease (CAD). However, in the context of variant angina (VA), high-dose aspirin was reported to exacerbate coronary spasms. Consequently, the value of traditional low-dose aspirin in VA, especially if not associated with atherosclerotic CAD, may be disputed. Purpose To perform a meta-analysis aimed at evaluating the extent to which low-dose aspirin therapy influences cardiovascular (CV) prognosis in VA. Methods We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for studies addressing the long-term impact of low-dose aspirin on main CV outcomes of VA patients, published up until February 1, 2020. The primary endpoint was all-cause mortality, whereas secondary endpoints included CV mortality, acute coronary syndrome (ACS) events, revascularization procedures and hospital admissions for angina. The subgroup of patients with no significant epicardial CAD was further investigated separately, underneath similar outcomes. Study-specific odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random-effects model. Results One prospective multicenter and two retrospective single-center studies, encompassing 1652 and 1164 patients, respectively, were regarded as eligible for quantitative evaluation. Median follow-up ranged between 12 and 52.1 months. 1284 patients were allocated to the aspirin arm and 2770 had no epicardial CAD. Absolute number of events for each endpoint may be reported as follows: all-cause mortality, 33; CV mortality, 11; ACS, 57; revascularization, 14; hospital admission for angina, 218. Aspirin was not found to reduce neither all-cause mortality (OR 0.78, 95% CI 0.38–1.58, p=0.49, i2=0%), nor CV mortality (OR 0.98, 95% CI 0.30–3.25, p=0.98, i2=0%), nor ACS events (OR 1.44, 95% CI 0.51–4.10, p=0.49, i2=47%), nor revascularization procedures (OR 2.06, 95% CI 0.63–6.75, p=0.23, i2=0%), nor hospital admissions for angina (OR 1.60, 95% CI 0.67–3.80, p=0.29, i2=86%). Likewise, this comprehensively neutral effect held true in those with VA and no significant atherosclerotic CAD (OR 1.04, 95% CI 0.28–3.92, p=0.95, i2=0%, for CV mortality; OR 1.29, 95% CI 0.19–8.94, p=0.79, i2=33%, for revascularization; OR 1.73, 95% CI 0.81–3.73, p=0.16, i2=75%, for hospital admission for angina). Conclusion Even though scarce, currently available evidence suggests that low-dose aspirin is not effective in shrinking major adverse cardiovascular events in VA patients, particularly in those with no epicardial CAD. On the other hand, lower doses of aspirin may avoid the menace of clinically significant coronary spasms. Funding Acknowledgement Type of funding source: None

Even "WISE-R?"-an Update on the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation.

For over 20years, the Women's Ischemia Syndrome Evaluation (WISE), a program sponsored by the National Heart, Lung, and Blood Institute, has explored diverse and important aspects of ischemic heart disease in women. Women with symptoms and signs of ischemia but no significant epicardial obstructive coronary artery disease (INOCA) were documented to be at elevated risk for recurrent angina hospitalization, major adverse cardiac events, death, and health resource consumption rivaling those with obstructive coronary disease. WISE investigators have advanced our understanding of cardiovascular outcomes, systemic manifestations, psychological variables, socioeconomic factors, genetic contributions, hormonal status, advanced imaging, coronary functional findings, biomarkers, patient-reported outcomes, and treatments pertaining to women with this disease entity. This review delves into the WISE findings subsequent to a prior review1, postulates directions for future research, and asks are we "Even 'WISE-R?'".

Ischaemic cardiomyopathy. Pathophysiological insights, diagnostic management and the roles of revascularisation and device treatment. Gaps and dilemmas in the era of advanced technology.

Ischaemic cardiomyopathy (ICM) represents an important cardiovascular condition associated with substantially increased morbidity and mortality. It is characterised from a broad spectrum of clinical manifestations and pathophysiological substrates and its diagnosis is based on the demonstration of significant left ventricular dysfunction in the context of significant epicardial coronary artery disease. Contemporary management aims at improving prognosis through evidence-based pharmacotherapy and device therapy, where indicated. Whilst the beneficial role of revascularisation remains clear in patients with strong indications such as those with symptoms and/or acute coronary syndromes, for those patients that are asymptomatic and suffer from stable ischaemic heart disease the impact of revascularisation on hard outcomes remains less well defined and currently its adoption is hampered by the lack of robust randomised data. The aim of this review is therefore to provide a constructive appraisal on the pathophysiology of ICM, the role of the various non-invasive imaging techniques in the diagnosis of ICM and the differentiation between viable and non-viable myocardium and finally discourse the potential role of revascularisation and contemporary device therapy in the management of patients with ICM.

P6262Coronary microphysiology in relation to low endogenous testosterone and dietary habits in andropause men with erectile dysfunction

Abstract Background Coronary flow reserve (CFR) in the presence of non-obstructive coronary artery disease displays the ability of microcirculation to augment flow to the myocardium. Endogenous total testosterone (TT) exhibits vasodilator effects and the Mediterranean diet (Med-diet) promotes cardiovascular health. Erectile dysfunction (ED) in a milieu of subclinical microvascular damage often coexists with the decline of endogenous testosterone of the aging male population. Purpose To investigate the effects of male hypogonadism in CFR and the relation between the Med-diet and the TT of the andropause middle aged men with ED. Methods 190 non-diabetic male patients with ED (mean age: 56yo) enrolled the study. Significant epicardial coronary artery disease was excluded after a negative for ischemia dobutamine stress echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140μg/kg/min over 6 minutes). Measurements by the pulse wave Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was estimated as ratio between peak diastolic flow velocity following drug infusion and rest. CFR ratio ≥2 is considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am and hypogonadism was considered when TT &lt;3,5 ng/ml. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Finally, carotid – femoral pulse wave velocity (PWV) was assessed as index of central vascular stiffness (sphygmocor device). Results In bivariate analysis CFR ratio (mean value: 2,35) was positively related to TT (p&lt;0,001, r=0,9), the SHIM-5 and the Med-diet score (p&lt;0,05 for both r=0,45 and r=0,5 respectively).On the contrary, it was negatively related to the PWV (p&lt;0,05, r=−0,35). Med-diet was related to the SHIM-5 score (p=0,01, r=0,363) and to TT (p=0,02, r=0,46). In multiple linear regression analysis relation of CFR to TT remain significant (p&lt;0,01) after adjustment for age, body mass index (BMI), LDL, PWV, smoking habits and systolic blood pressure. We further stratified our population in to hypogonadics (HYPO, n=38, 20%) and patients with normal TT levels. Poor adherence to the Med-diet was the only factor related to hypogonadism (independent sample t-test p=0,005) as compared with age, BMI and smoking. Conclusion In middle aged men with ED endogenous testosterone enhances coronary microcirculation. Moreover the Med-diet regime may blunt the fall of androgens during andropause independently of other life-style parameters. We emphasize on this culinary preference to assist coronary microvascular physiology and maintain hormonal balance.

Coronary Steal Phenomenon and Altered Myocardial Microcirculation Demonstrated by Contrast Enhanced Echocardiography in Apical Hypertrophic Cardiomyopathy Presenting as an Acute Coronary Syndrome

A 55 year-old female was admitted for central chest pain on a background of hypertension and morbid obesity. 12-lead electrocardiogram revealed sinus rhythm and T-wave inversion inferolaterally. Coronary angiography revealed no significant atherosclerotic epicardial coronary artery disease. Contrast blush was noted in the left ventricular (LV) cavity. Left ventriculography “spade-like” morphology was suggestive of apical hypertrophic cardiomyopathy (ApHCM) (Fig. 1). Cardiac MRI confirmed increased apical wall thickness (17 mm), mid-chamber obliteration during systole and contrast enhancement in thickened apical segments (Fig. 2). Transthoracic echocardiography (TTE) confirmed normal LV size and function (LVEF = 65%) with increased LV apical wall thickness (Fig. 3). Figure 2cMRI. View Large Image Figure Viewer Download Hi-res image Figure 3TTE. View Large Image Figure Viewer Download Hi-res image

Histologic Sequelae of Apical Hypertrophic Cardiomyopathy: Dystrophic Calcification.

We present cardiac computed tomography (CT) findings demonstrating apical hypertrophic cardiomyopathy with dystrophic calcification of the left ventricular apex. The absence of significant epicardial coronary artery disease demonstrated by coronary CT angiography suggests that increased wall tension and decreased microvascular perfusion over time account for the dyskinetic apical myocardium, rather than myocardial infarction secondary to atherosclerotic plaque rupture. These observations support CT as the imaging modality of choice to visualize the deposition of calcium in injured myocardial tissue, a recognized occurrence in chronically infarcted myocardium.

Abnormal stress echocardiography findings in cardiac amyloidosis

Background: Cardiac involvement in immunoglobulin light chain (amyloid light chain, AL) amyloidosis is characterized by myocardial interstitial deposition but can also cause obstructive deposits in the coronary microvasculature.Methods: We retrospectively identified 20 patients who underwent stress echocardiography within 1 year prior to the histologic diagnosis of AL amyloidosis. Only patients with cardiac amyloidosis and no known obstructive coronary disease were included.Results: Stress echocardiograms (13 exercise; 7 dobutamine) were performed for evaluation of dyspnea and/or chest pain. Stress-induced wall motion abnormalities (WMAs) occurred in 11 patients (55%), 4 of whom had normal left ventricular wall thickness. Coronary angiogram was performed in 9 of 11 patients and demonstrated no or mild epicardial coronary artery disease. Seven (54%) patients had an abnormal exercise blood pressure which occurred with similar likelihood between those with and without stress-induced WMAs.Conclusions: Stress-induced WMAs and abnormal exercise blood pressure may occur in patients with cardiac AL amyloidosis despite the absence of significant epicardial coronary artery disease. This finding should raise the possibility of cardiac amyloidosis even in the absence of significant myocardial thickening.

Patients with Diabetes and Significant Epicardial Coronary Artery Disease Have Increased Systolic Left Ventricular Apical Rotation and Rotation Rate at Rest.

The purpose of this study was to determine whether resting myocardial deformation and rotation may be altered in diabetic patients with significant epicardial coronary artery disease (CAD) with normal left ventricular ejection fraction. A prospective observational study. Diagnosis of epicardial CAD in patients with diabetes. Eighty-four patients with diabetes suspected of epicardial CAD scheduled for cardiac catheterization had a resting echocardiogram performed prior to their procedure. Echocardiographic measurements were compared between patients with and without significant epicardial CAD as determined by cardiac catheterization. Measurement of longitudinal strain, strain rate, apical rotation, and rotation rate, using speckle tracking echocardiography. Eighty-four patients were studied, 39 (46.4%) of whom had significant epicardial CAD. Global peak systolic apical rotation was significantly increased (14.9 ± 5.1 vs. 11.0 ± 4.8 degrees, P < 0.001) in patients with epicardial CAD along with faster peak systolic apical rotation rate (90.4 ± 29 vs. 68.1 ± 22.2 degrees/sec, P < 0.001). These findings were further confirmed through multivariate logistic regression analysis (global peak systolic apical rotation OR = 1.17, P = 0.004 and peak systolic apical rotation rate OR = 1.05, P < 0.001). Patients with diabetes with significant epicardial CAD and normal LVEF exhibit an increase in peak systolic apical counterclockwise rotation and rotation rate detected by echocardiography, suggesting that significant epicardial CAD and its associated myocardial effects in patients with diabetes may be detected noninvasively at rest.

Myocardial perfusion is impaired in asymptomatic renal and liver transplant recipients: a cardiovascular magnetic resonance study.

BackgroundMyocardial ischemia is a major cause of death in chronic kidney disease (CKD) patients, which can be caused by either epicardial or microvascular coronary artery disease (CAD). Although renal transplantation improves survival, cardiovascular disease remains a major cause of mortality in post renal transplant recipients, including those with no significant epicardial CAD pre-transplant. We aim to utilize stress cardiovascular magnetic resonance (CMR) and MR coronary angiography (MRCA) to assess silent myocardial ischemia and epicardial CAD in renal transplant recipients.MethodsForty-five subjects: twenty renal transplant (RT) with no known CAD, fifteen liver transplant (LT) controls without prior CKD and no known CAD, and ten hypertensive (HT) controls underwent stress perfusion CMR and MRCA.ResultsA total of 1308 myocardial segments (576 of RT, 468 of LT, and 264 of HT) were compared using mixed linear modeling. Left ventricular mass index, septal diameter and presence of diabetes mellitus were similar between the groups. The mean transmural MPRI was significantly lower in the RT and LT groups compared to HT controls (1.19 ± 0.50 in RT versus 1.23 ± 0.36 in LT versus 2.04 ± 0.32 in HT controls, p < 0.0001), in the subepicardium (1.33 ± 0.57 in RT versus 1.30 ± 0.33 in LT versus 2.01 ± 0.30 in HT controls, p < 0.001), and in the subendocardium (1.19 ± 0.54 in RT versus 1.11 ± 0.31 in LT versus 1.85 ± 0.34 in HT controls, p < 0.0001). Seven (35 %) RT and five (33 %) LT had significant epicardial CAD compared to none in HT controls, p = 0.12. One RT and one LT had LGE suggesting sub-endocardial infarction.ConclusionsRT recipients have impaired myocardial perfusion independent of LVH or diabetes mellitus. The impaired myocardial perfusion in RT is similar to LT without prior renal disease, thus unlikely related to previous CKD. It is not fully explained by the presence of significant epicardial CAD, and therefore most likely represents microvascular CAD.

Abstract 17488: Effect of Cocaine on Coronary Microvasculature

Background: Presence of coronary microvascular dysfunction despite normal epicardial coronary arteries is known to significantly impact mortality and morbidity. With the increasing number of cocaine users among urban population, it is imperative to assess its effect on the coronary microvasculature. Method: In this blinded, retrospective study, microvascular dysfunction was assessed using corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC) and TIMI perfusion grade (TMPG), in an available consecutive series of 202 cocaine users in the absence of acute or recent MI, significant epicardial coronary artery disease (CAD) or vasospasm, among the 775 cocaine users who underwent coronary angiography at Mount Sinai Hospital, Chicago from 2005 to 2013. Applying the same criteria, the cTFCs and TMPGs were then compared with 210 randomly chosen non-cocaine users. Angiographers were blinded when determining the cTFC and TMPG. Results: The TMPG 0/1 for the left anterior descending (LAD), circumflex (LCx), and right coronary (RCA) arteries were statistically significant among cocaine users (LAD 22% versus 5%, p=&lt;0.0001; LCx 25% versus 6%, p=&lt;0.0001; RCA 42% versus 8%, p=&lt;0.0001). For the cTFC, the LAD and LCx were significantly elevated among cocaine users (27.33 ± 10.9 versus 24.88 ± 10.05, p=0.03 and 41.11 ± 14.28 versus 38.23 ± 12.69, p=0.04; respectively). Additionally, there was a significant percentage of cocaine users with cTFC&lt;14 (i.e. faster flow) observed in the RCA (9% versus 3%; p=0.008). Conclusion: Our study concludes that there is significant coronary microvascular dysfunction associated with cocaine use despite the absence of significant epicardial CAD. Additionally, reduced coronary filling time might be the reason for the observed higher frequency of hyperemic flow in the RCA among cocaine users, which is associated with poorer clinical outcomes, particularly in the context of impaired myocardial perfusion.

Patients ≥ 75 years with acute coronary syndrome but without critical epicardial coronary disease: prevalence, characteristics, and outcome.

ObjectiveAbsence of significant epicardial coronary artery disease (CAD) in patients with acute onset of chest pain and elevation of myocardial necrosis markers is occasionally observed. The aim of this study was to analyse the clinical characteristics and outcome of such patients with advanced age.MethodsWe retrospectively analysed 4,311 patients with acute onset of chest pain plus necrosis marker elevation. Two hundred and seventy two patients without CAD on angiogram (6.3%) were identified. Out of them, 50 (1.2%) patients ≥ 75 years (Group I) were compared with (1) 222 acute coronary syndrome (ACS) patients without CAD on angiogram < 75 years (Group II), and (2) 610 consecutive patients ≥ 75 years with Non-ST-elevation Myocardial Infarction (NSTEMI) undergoing percutaneous coronary intervention (Group III).ResultsGroup I compared to Group III patients made up for more females (64.0% vs. 49.2%; P < 0.0001), and had more severe anginal symptoms on presentation [Canadian Cardiovascular Society (CCS) class I/II, 26.0% vs. 49.8%; P = 0.02]. Group I patients also had lower troponin levels (0.62 ± 0.8 ng/mL vs. 27 ± 74 ng/mL; P < 0.02), lower leukocyte count (9.4 ± 3.13 × 109 vs. 12 ± 5.1 × 109; P = 0.001) and better preserved left ventricular function (56.7% ± 14.3% vs. 45% ± 11%; P < 0.0001). Event-free survival (cardiac death, myocardial infarction, recurrent angina, and re-hospitalisation) was more frequent in Group I and II patients compared to Group III patients (64.9%, 66.7%, and 41.6%, respectively; P < 0.0001).ConclusionsACS in patients ≥ 75 years without CAD is very infrequent, associated with a (1) similar outcome compared to ACS patients < 75 years without CAD, and (2) significant better outcome compared to NSTEMI patients ≥ 75 years.