Significant Epicardial Stenosis Research Articles

The Effect of Sleep Quality on Coronary Lesion Severity and Prognosis in the Young Acute Coronary Syndrome Population.

This study aimed to explore the effect of long-term (≥1 year) sleep quality on coronary lesion complexity and cardiovascular prognosis in young acute coronary syndrome (ACS) patients. We consecutively recruited young patients aged from 18 to 44 years old with first-episode ACS and significant epicardial stenosis on coronary angiography from January 2016 to January 2017. Coronary lesion complexity was evaluated based on SYNTAX scores. Long-term sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) (PSQI ≤ 5 and PSQI > 5 groups). The primary endpoints were major adverse cardiovascular events (MACEs). A total of 466 young ACS patients (93.13% male; median age, 41 years) were included. Poor sleepers (PSQI > 5) had higher SYNTAX scores. After adjusting for confounders, PSQI scores (continuous variables, OR: 1.264; 95%CI: 1.166-1.371; p < 0.001) and PSQI grade (binary variable, OR: 3.864; 95%CI: 2.313-6.394; p = 0.001) were significantly associated with an increased risk of complex coronary lesions. During a median follow-up of 74 months, long-term poor sleep quality (PSQI > 5) was significantly associated with an increased risk of MACEs (HR: 4.266; 95%CI: 2.274-8.001; p < 0.001). Long-term poor sleep quality was a risk factor for complex coronary lesions and has adverse effects on cardiovascular prognosis in the young ACS population.

Predictive role of monocyte count for significant coronary artery disease identification in patients with stable coronary artery disease.

The coronary artery disease (CAD) remains the leading cause of morbidity that is characterized by broad spectrum of symptoms. Up to 30% of performed angiographies reveal normal coronary arteries. The aim of the study was to find simple predictor for significant epicardial artery stenosis among patients with chronic coronary syndrome. There were 187 patients (131 (709%) men and 56 (30%) women) in the median (Q1-Q3) age of 67 [58-72] presenting with stable CAD symptoms enrolled into the present retrospective analysis. The demographical, clinical and laboratory characteristics between patients with normal and significant coronary artery stenosis were compared. The multivariable analysis revealed coexistence of hypercholesterolemia as significant differentiation factor (odds ratio [OR]: 4.38, 95% confidence interval [CI]: 1.78-10.80, p = 0.001) for significant CAD and inverse relation to serum high density lipoprotein (OR: 0.19, 95% CI: 0.05-0.72, p = 0.015) and relation to creatinine concentration (OR: 1.03, 95% CI: 1.00-1.05, p = 0.012). Among whole peripheral blood count analysis, the significant relation was noticed to be hemoglobin concentration (OR: 1.09, 95% CI: 1.10-1.18, p = 0.022) and monocyte count (OR: 32.3, 95% CI: 1.09-653.6, p = 0.017). Receiver operator curve revealed (AUC: 0.641, p = 0.001) with the optimal cut-off value above 0.45 K/uL for monocyte, yelding sensitivity of 81.82% and specificity of 58.06%. The peripheral monocyte count above 0.45 k/uL may be considered as a predictor of significant coronary artery disease in symptomatic patients with chronic coronary syndrome.

Microvascular resistance reserve in the presence of functionally significant epicardial stenosis and changes after revascularization.

In the presence of functionally significant epicardial lesions, microvascular resistance reserve (MRR) calculation needs incorporation of collateral flow. Coronary fractional flow reserve (FFRcor ) requiring coronary wedge pressure (Pw ), which is an essential part of the true MRR calculation, is reportedly estimated by myocardial FFR (FFRmyo ) not requiring Pw measurement. We sought to find an equation to calculate MRR without the need for Pw . Furthermore, we assessed changes in MRR after percutaneous coronary intervention (PCI). An equation to estimate FFRcor was developed from a cohort of 230 patients who underwent physiological measurements and PCI. Corrected MRR was calculated using this equation and compared with true MRR in 115 patients of the different set of the validation cohort. True MRR was calculated using FFRcor . FFRcor and FFRmyo showed a strong linear relationship (r2 =0.86) and an equation was FFRcor =1.36 × FFRmyo - 0.34. This equation provided no significant difference between corrected MRR and true MRR in the validation cohort. Pre-PCI lower coronary flow reserve and higher index of microcirculatory resistance were independent predictors of pre-PCI decreased true MRR. True MRR significantly decreased after PCI. In conclusion, MRR can be accurately corrected using an equation for FFRcor estimation without Pw .

Resting coronary flow drives the daily pattern in coronary flow reserve in patients with chest pain without obstructive epicardial stenosis.

Ischemia with no obstructive coronary artery disease (INOCA) is a risk factor for major adverse cardiovascular events and is characterized by abnormal coronary microvascular tone. In patients with INOCA, adverse cardiovascular events most commonly occur in the morning compared to other times of the day and night. We tested whether coronary microvascular function varies diurnally with attenuation in the morning in patients with symptomatic coronary artery disease without significant (>50%) epicardial stenosis. We evaluated data from 17 patients studied in the AM (700-1159 h) and 11 patients in the PM (1200-1800 h). Coronary microvascular function was measured using perfusion contrast imaging at rest and after infusion of intravenous regadenoson. We calculated microvascular flow reserve as the ratio of hyperemic to resting flow. Along with independent sample t-tests, we performed bootstrapping procedures to test mean differences between AM and PM groups, using the bias-corrected and accelerated method with 5,000 bootstrapped samples. The AM and PM groups were matched for demographic and existing risk factors. Coronary microvascular flow reserve was ∼33% higher in the AM compared to the PM (P = 0.025, BCa 95% CI [0.25, 1.64]; Hedge's g = 0.89, 95% CI [0.11, 1.66]) as a result of significantly lower resting flow (∼50%) in the AM compared to the PM (P = 0.03, M Diff = -56.65, BCa 95% CI [-118.59, -2.12]; Hedge's g = -0.86, 95% CI [-1.60, -0.06]). Our observations are of clinical value and can influence diagnosis and treatment in the clinic based on the time of day of measurements.

6 EVALUATION OF ECHOCARDIOGRAPHIC PARAMETERS IN PATIENTS WITH MICROVASCULAR DYSFUNCTION: A PROSPECTIVE STUDY.

Abstract Background The prevalence of microvascular angina is underestimated in the general population because it is often difficult to detect. Microvascular dysfunction is defined by parameters of reduced coronary flow reserve (CFR &amp;lt;2) without epicardial stenosis and/or increased index of microvascular resistance (IMR&amp;gt; 25). Purpose The aim of this study was to evaluate the echocardiographic parameters in patients with symptoms of myocardial ischemia without evident coronary epicardial obstruction. Primary endpoint was to analyze the global longitudinal strain of the left ventricle and the left atria strain in patients with microvascular angina. Secondary endpoint was to analyze echocardiographic parameters to evaluate the diastolic function of the left ventricle, the prevalence of cardiovascular risk factors and the blood tests values. Methods Between 1st February 2019 and 1st May 2022, subjects with angina and not functionally significant epicardial stenosis (Resting Full-cycle Ratio &amp;gt; 0.91, Fractional flow reserve &amp;gt;0.80), underwent assessment of microvascular function and were divided into 2 cohorts. All patients had sinus rhythm, preserved left ventricular ejection fraction (LVEF&amp;gt; 55%), no severe left ventricular hypertrophy (interventricular septum &amp;lt;13 mm) or structural heart disease. For each patient we analyzed the left ventricular global longitudinal strain in the three apical views (4 chamber, 2 chamber and 3 chamber) and the left atria strain, PALS (peak atrial longitudinal strain) and PACS (peak atrial contraction strain), in two apical views (4 chamber and 2 chamber). We also measured the diastolic function indices (E/e’, isovolumic relaxation time, deceleration time), the left atrial area and pulmonary artery systolic pressure (PASP) evaluated on echocardiography. Results A total of 132 patients were enrolled. Of those, 47 had evidence of microvascular dysfunction and 85 had normal CFR/IMR. Primary Endpoint: patients with microvascular dysfunction had reduced values of left ventricular global longitudinal strain and reduced values of left atrial strain compared to controls (p&amp;lt;0,001). Secondary Endpoint: a higher prevalence of diabetic and obese women was associated with microvascular dysfunction. However, there were no significant differences in age, prevalence of hypertension, dyslipidemia, smoking and dysthyroidism. Numerically higher values of NTproB-type Natriuretic Peptide (NTproBNP) and C-reactive protein were seen in patients with microvascular dysfunction, while there were no significant differences in hemoglobin, white bold cells, platelets, cholesterol, creatinine and troponin values. Left ventricular isovolumic relaxation time, left atrium area, and pulmonary artery systolic pressure as well as E/e' values were significantly increased in patients with microvascular dysfunction. Furthermore, there was a significant reduction in deceleration time values. Conclusion Patient with microvascular dysfunction are frequently diabetic and obese women. Echocardiographic parameters show left ventricular diastolic dysfunction and possibly subsequent left atrial remodeling. Furthermore, the analysis of the global longitudinal strain of the left ventricle could reveal alterations in cardiac contractile mechanics that are difficult to identify with conventional echocardiography. NTproBNP values were not significantly higher, demonstrating that patients with microvascular dysfunction have an early diastolic dysfunction that is not clinically evident.

Diagnostic value of myocardial perfusion CT to detect coexisting microvascular dysfunction in patients with obstructive epicardial coronary disease

Abstract Background The usefulness of computed tomography myocardial perfusion (CTP) to assess hemodynamically significant coronary artery lesions has been previously reported. However, the diagnostic value of quantitative evaluation of regional absolute coronary flow by CTP to detect microvascular dysfunction remains unknown. Purpose The aim of study is to assess the diagnostic value of preprocedural CTP to detect coexisting microvascular dysfunction with functionally significant epicardial stenosis in patients with chronic coronary syndromes. Methods and results Thirty-three chronic coronary syndrome patients with de novo single functionally significant stenosis (Fractional flow reserve [FFR]&amp;lt;0.80) who underwent noncomplicated PCI were investigated. In CTP analysis, regional myocardial blood flow (MBF) at rest (rest-MBF) and hyperemia (hyperemic-MBF) were evaluated semi-automatically. Clinical characteristics, pressure-temperature sensor-chipped wire-based information and CTP findings were compared between groups with and without microvascular dysfunction defined by the index of microcirculatory resistance (IMR) (IMR≥25, n=17, IMR&amp;lt;25, n=16, respectively). The determinants of coexistence of microvascular dysfunction and functional epicardial stenosis were determined. In invasive wire-based analysis, FFR, coronary flow reserve (CFRwire) and IMR were 0.68 (0.57–0.72), 1.61 (1.00–1.98), and 26.7 (19.3–39.4) respectively. In CTP analysis, rest and hyperemic-MBF and CFR derived from CTP (CFRCTP; calculated as hyperemic-MBF/rest-MBF) were 2.00 (1.31–2.35) ml/min/g, 4.03 (2.11–5.44) ml/min/g, and 2.09 (1.49–2.09) respectively. In the lesions with IMR&amp;gt;25, hyperemic-MBF was significantly lower than that in IMR&amp;lt;25 (3.42 [1.89–4.34] vs 4.50 [3.44–5.99], p=0.031), although there was no significant difference in regional rest-MBF and CFRCTP (1.75 [1.31–2.24] vs 2.05 [1.35–2.46], p=0.439, and 1.83 [1.21–2.11] vs 2.61 [1.91–2.91], p=0.101 respectively). Receiver operating characteristic curve analysis of hyperemic-MBF detecting IMR&amp;gt;25 showed area under the curve of 0.72 (0.54–0.90), sensitivity of 47% and specificity of 94%. Conclusion Quantitative assessment of absolute coronary flow by CTP may help detect coexisting microvascular dysfunction in patients with significant epicardial stenotic lesions. Funding Acknowledgement Type of funding source: None

(Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance.

Angina pectoris is a chest discomfort caused by myocardial ischaemia, and it is classified as ‘typical’ or ‘atypical’ if specific features are present. Unfortunately, there is a heterogeneous list of cardiac diseases characterized by this symptom as onset sign. Mostly, angina is due to significant epicardial coronary artery stenosis, which causes inadequate oxygen supply increase after raised myocardial oxygen demand. In the absence of significant epicardial stenoses, another potential cause of angina is microvascular dysfunction, related to inadequate response of resistance coronary vessels to vasodilator stimuli. The unique capability of cardiovascular magnetic resonance (CMR) in providing extremely detailed morphological and functional information, along with precise stress perfusion defects and wall motion abnormalities depiction, translates it into the test with one of the best diagnostic performance and prognostic stratification among non-invasive cardiac imaging modality. Moreover, CMR is also extremely accurate in detecting non-ischaemic cardiac causes of chest pain (such as myocardial and pericardial inflammation, or stress-related cardiomyopathy), and is very useful in helping physicians to correctly approach patients affected by chest pain.

Effect of Hyperglycemia on Myocardial Perfusion in Diabetic Porcine Models and Humans.

BackgroundDiabetes mellitus (DM) causes macro- and microvasculopathy, but data on cardiac microvascular changes in large animals are scarce. We sought to determine the effect of DM on macro- and microvascular changes in diabetic pigs and humans.MethodsEight domestic pigs (4 with type I diabetes and 4 controls) underwent coronary angiography with optical coherence tomography (OCT; at baseline and 1 and 2 months), coronary computed tomography angiography, cardiac magnet resonance (CMR) imaging, and histologic examination.ResultsThe diabetic pigs had more irregular capillaries with acellular capillaries and a smaller capillary diameter (11.7 ± 0.33 μm vs. 13.5 ± 0.53 μm; P < 0.001) than those of the control pigs. The OCT showed no significant epicardial stenosis in either group; however diabetic pigs had a greater intima-media thickness. CMR results showed that diabetic pigs had a lower relative upslope at rest (31.3 ± 5.9 vs. 37.9 ± 8.1; P = 0.011) and during stress (18.0 ± 3.0 vs. 21.6 ± 2.8; P = 0.007) than the control pigs, implying decreased myocardial perfusion. Among the 79 patients with ST elevation myocardial infarction, 25 had diabetes and they had lower myocardial perfusion on CMR as well.ConclusionDM causes microvascular remodeling and a decrease in myocardial perfusion in large animals at a very early stage of the disease course. Early and effective interventions are necessary to interrupt the progression of vascular complications in diabetic patients.

113 Novel diagnostic criterion for microvascular ischaemia using cmr perfusion imaging: validation against invasive index of microvascular resistance

BackgroundIn over 50% of patients with angina, the underlying ischaemia is related to microvascular dysfunction (MVD), rather than epicardial coronary artery disease (CAD). Clinically, MVD remains a major diagnostic challenge,...

112 Evaluation of patients with left ventricular thrombus using intra-cardiac blood visualisation with 4d flow

IntroductionVentricular thrombus is a serious complication in a subgroup of left ventricular dysfunction (LVD) patients because of the risk of embolisation. Thrombus occurs as a consequence of stasis, hypercoagulability and...

Značaj relativne koronarne reserve protoka kod pacijenata sa mikrovaskulrnom disfunkcijom u proceni značajne koronarne stenoze

Introduction: Coronary flow reserve (CFR) is defined as a ratio of hyperemic-to-basal coronary flow velocity and it can be measured by a variety of methods. Transthoracic Doppler echocardiography (TTE) CFR became useful method to assess functional significance of coronary artery stenosis in both left anterior descending (LAD) and posterior descending coronary artery (PD). CFR is combined measure of the capacity of epicardial coronary artery and microcirculation to achieve maximal blood flow in response to hyperemic stimulation. Thus in patients with already impaired microcirculation and accordingly CFR, differentiation from presence of significant coronary stenosis is difficult without known coronary angiography. Case report: We present a case of patient with hypertrophic cardiomyopathy and diabetes, where relative CFR as the ratio of the CFRs of two coronary arteries helped us in decision making to do coronarography because of atypical chest pain and fatigue. Conclusion: In patients with known microvascular dysfunction and already impaired CFR, relative CFR might be helpful to differentiate presence of significant epicardial stenosis. Future studies are needed to obtain appropriate clinical implications of relative CFR in everyday practice.

Immersion Pulmonary Edema in the setting of Takotsubo Cardiomyopathy

&lt;p&gt;Immersion Pulmonary Edema (IPE) is a unique medical condition being increasingly described in the medical literature as sudden-onset pulmonary edema in the setting of scuba diving and/or swimming. We report on three patients with unique presentations of IPE with associated development of Takotsubo cardiomyopathy (TTC). All three cases occurred in Oahu, Hawaii and were seen by the same cardiologist within a span of seven years. Each patient was scuba diving with sudden onset dyspnea with pulmonary edema on chest x-ray. Cardiac catheterization revealed no significant epicardial stenosis or thrombosis. EKGs showed typical evolution of symmetric T wave inversion. Wall motion abnormalities resolved. IPE and TTC may occur together and may be more common than initially thought. Physical and emotional stressors are known to trigger TTC. TTC should be considered as a possible complication of IPE. Initial workup should include EKGs, cardiac enzymes, echocardiogram and, in the appropriate situation, cardiac catheterization. &lt;/p&gt;

Diagnosis of ischemia in hypertrophic cardiomyopathy: role of computed tomography and nuclear stress testing.

Chest pain and myocardial ischemia are common features in patients with hypertrophic cardiomyopathy (HCM). This review addresses diagnostic roles of computed tomography and nuclear stress testing (NST) in patients with HCM. Current evidence showed the limitation of NST in the diagnosis of epicardial coronary artery stenosis due to the prevalent microvascular dysfunction. In this context, the excellent negative predictive value of coronary computed tomography angiography (CCTA) makes it very attractive to serve as a gatekeeper to invasive angiography in low-risk symptomatic patients, either as the first noninvasive imaging test of choice or after the presence of perfusion defect seen in NST. Furthermore, the identification of coronary atherosclerosis process in the absence of obstructive lesion could have impacts on the management of risk factors for coronary artery disease. We also propose an algorithm for evaluation of ischemia in HCM patients based on the recent evidence. In low-intermediate-risk symptomatic patients with HCM, both NST and CCTA are acceptable diagnostic tools for the evaluation of myocardial ischemia. In the presence of nuclear perfusion defect, CCTA can be used to rule out significant epicardial stenosis. Presence of significant major epicardial artery stenosis on CCTA or high-risk patients could be considered for invasive angiography.

Abstract 17658: The Impact of Elective Percutaneous Coronary Intervention on Coronary Microvascular Resistance

Background: The influence of elective percutaneous coronary intervention (PCI) in patients with stable angina pectoris on coronary microvascular function has not been fully elucidated. We performed a prospective study to investigate serial changes of microvascular function in patients undergoing elective PCI. Methods and Results: The index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) was measured before, after PCI, and at follow-up (10 months) in 52 patients treated with single vessel uncomplicated elective PCI (male 80.8%, age 66.5 ± 8.3). IMR was calculated by taking collateral flow into account. The median IMR values before, after PCI, and at follow-up were 24.2 (interquartile range (IQR) 13.1-31.3), 15.8 (IQR 11.8-21.6), and 14.7 (IQR 11.3-20.9), respectively. IMR values significantly decreased after PCI (P=0.006), and showed no further significant change at follow-up. There was no significant relationship between delta IMR (post-pre IMR) values and PCI-related cardiac troponin elevations that distributed in the range of (median: 0.50 ng/dL, IQR 0.22-1.02 ng/dL). Pre-PCI IMR was not correlated with pre-PCI FFR values. Post-PCI IMR was significantly correlated with pre-PCI IMR values (P=0.005). Periprocedural IMR decrease (Pre-Post) was inversely associated with pre-PCI FFR (P=0.008) and greater improvement of FFR values by PCI was significantly associated with greater reduction of IMR values at follow-up (P=0.03). Decrease in FFR values from immediately after PCI to follow-up was greater in patients with DM (P=0.01). Furthermore, IMR at follow-up was worse in patients with DM than those without (P=0.009). Conclusions: Removal of physiologically significant epicardial stenosis leads to a decrease in microvascular resistance in patients with stable angina undergoing electively performed uncomplicated PCI. The periprocedural decrease in microvascular resistance was influenced by the hemodynamic significance of the epicardial stenosis before PCI. The baseline status of microvascular function is a significant determinant of post-PCI and follow-up microvascular function in these patients, and diabetes has an impact on the serial changes in microvascular function after successful PCI.

Coronary Microvascular Dysfunction Assessed by Intracoronary Acetylcholine Provocation Testing Is a Frequent Cause of Ischemia and Angina in Patients With Exercise‐Induced Electrocardiographic Changes and Unobstructed Coronary Arteries

The exercise electrocardiogram (ECG) is a standard examination in patients with suspected coronary artery disease. However, despite a pathologic result, many patients undergoing diagnostic coronary angiography do not have any significant epicardial stenosis. In this study, we assessed the relation between a pathologic exercise ECG and coronary microvascular dysfunction in response to intracoronary acetylcholine (ACh) provocation in patients without any relevant epicardial stenosis. Coronary microvascular dysfunction is significantly more often in patients with angina, unobstructed coronary arteries and a pathologic exercise stress test compared to those without pathologic stress test. This study recruited 137 consecutive patients with exertional angina pectoris who underwent diagnostic coronary angiography between September 2008 and April 2011 (68% women; mean age, 63 ± 10 years). In none of the patients was there a stenosis of >50%. All patients underwent an exercise ECG before angiography and intracoronary ACh provocation testing for assessment of coronary vasomotor responses directly after angiography. The exercise ECG showed an abnormal result in 69 patients (50%; ST-segment depression ≥0.1 mV and/or reproduction of the patient's usual symptoms). The ACh test revealed a coronary vasomotor abnormality (reproduction of the patient's symptoms, ischemic ECG shifts ± diffuse distal vasoconstriction) in 87 patients (64%). Such a result was significantly more often found in patients with a pathologic exercise ECG (50/69 [72%] vs 19/69 [28%], P = 0.034). There were no other statistically significant differences between patients with and those without pathologic exercise ECG. Coronary microvascular dysfunction is frequently found in patients with exertional angina pectoris and unobstructed coronary arteries. Such a finding is found significantly more often in presence of a pathologic exercise ECG.

Preserved Coronary Flow Reserve Effectively Excludes High-Risk Coronary Artery Disease on Angiography

Myocardial perfusion imaging has limited sensitivity for the detection of high-risk coronary artery disease (CAD). We tested the hypothesis that a normal coronary flow reserve (CFR) would be helpful for excluding the presence of high-risk CAD on angiography. We studied 290 consecutive patients undergoing (82)Rb PET within 180 d of invasive coronary angiography. High-risk CAD on angiography was defined as 2-vessel disease (≥ 70% stenosis), including the proximal left anterior descending artery; 3-vessel disease; or left main CAD (≥ 50% stenosis). Patients with prior Q wave myocardial infarction, elevated troponin levels between studies, prior coronary artery bypass grafting, a left ventricular ejection fraction of less than 40%, or severe valvular heart disease were excluded. Fifty-five patients (19%) had high-risk CAD on angiography. As expected, the trade-off between the sensitivity and the specificity of the CFR for identifying high-risk CAD varied substantially depending on the cutoff selected. In multivariable analysis, a binary CFR of less than or equal to 1.93 provided incremental diagnostic information for the identification of high-risk CAD beyond the model with the Duke clinical risk score (>25%), percentage of left ventricular ischemia (>10%), transient ischemic dilation index (>1.07), and change in the left ventricular ejection fraction during stress (<2) (P = 0.0009). In patients with normal or slightly to moderately abnormal results on perfusion scans (<10% of left ventricular mass) during stress (n = 136), a preserved CFR (>1.93) excluded high-risk CAD with a high sensitivity (86%) and a high negative predictive value (97%). A normal CFR has a high negative predictive value for excluding high-risk CAD on angiography. Although an abnormal CFR increases the probability of significant obstructive CAD, it cannot reliably distinguish significant epicardial stenosis from nonobstructive, diffuse atherosclerosis or microvascular dysfunction.

Clinical outcome in cardiorenal patients related to coronary computed tomography angiography and serum adrenomedullin

Background: Adrenomedullin is present in numerous human body tissues and its powerful vasodilatatory activity is thought to play role in cardiovascular/renal homeostasis and possibly in atherosclerosis. We conducted a prospective 2-year study of one hundred twenty-three patients with chronic kidney disease (CKD). Clinical outcome was analyzed to coronary computed tomography angiography (CCTA) findings and serum adrenomedullin levels. Methods: We determined plasma mid-regional pro-adrenomedullin (MR-proADM) levels using sandwich immunoassay in patients (pts) on stage 2 to 5 CKD (glomerular filtration rate - GFR < 90 ml/min/1.73 m2). Coronary artery calcification (CAC) and noninvasive coronary angiograms were performed by 64-multi-detector computed tomography (Siemens, Germany). The presence of stenosis ≥ 50% during CCTA was considered as significant. The degree of coronary artery calcification was assessed using the Agatston calcium score method. Results: We studied consecutive 123 pts with suspected coronary artery disease (mean age 62.5±10.7 years, 57.7% male, arterial hypertension 89.2%, type 2 diabetes 25.2%, 29.0% had a history of tobacco use and 38.2% were on regular haemodialysis- mean 51.7 months, ranging from 3 to 252 months). On CCTA, 76 pts (65.0%) had no coronary artery disease (CAD),in 29 pts (24.8%) one significant epicardial stenosis and in 12 (10.3%) multivessel disease were documented. The mean MR-proADM plasma levels and CAC score were 1.4 nmol/l and 472.8, respectively. MR-proADM correlated with CAC (r=0.20; p=0.02), GFR (r=-0.75; p<0.001), total cholesterol and LDL-cholesterol (r=-0.36; p=0.02 and r=-0.34; p= 0.001). During follow-up period (18.4±6.2 months) 7 cardiovascular deaths were occurred and 1 patient underwent percutaneous coronary intervention for unstable angina. The main characteristics in pts with cardiac events or eventfree survival were the following: serum MR-proADM (2.5 vs 1.3 nmol/l), CAC (663.7 vs 462.5). When we compared these variables to cardiac events only significant difference was documented in MR-proADM levels (p=0,04). Otherwise, areas under receiver operating characteristic curve (AUC) for prediction of cardiovascular mortality were 0.82 (95% CI 0.67-0.97), 0.75 (95% CI 0.50-0.99) and 0.64 (95% CI 0.29-0.99) for MR-proADM vs duration of hemodialysis and CAC. Conclusions: Coronary computed tomography angiography and serum adrenomedullin represent new alternative diagnostic tools for risk stratification in special group of cardiorenal patients.

Calculation of the Index of Microcirculatory Resistance Without Coronary Wedge Pressure Measurement in the Presence of Epicardial Stenosis

This study sought to investigate a novel method to calculate the index of microcirculatory resistance (IMR) in the presence of significant epicardial stenosis without the need for balloon dilation to measure the coronary wedge pressure (P(w)). The IMR provides a quantitative measure of coronary microvasculature status. However, in the presence of significant epicardial stenosis, IMR calculation requires incorporation of the coronary fractional flow reserve (FFR(cor)), which requires balloon dilation within the coronary artery for P(w) measurement. A method to calculate IMR by estimating FFR(cor) from myocardial FFR (FFR(myo)), which does not require P(w) measurement, was developed from a derivation cohort of 50 patients from a single institution. This method to calculate IMR was then validated in a cohort of 72 patients from 2 other different institutions. Physiology measurements were obtained with a pressure-temperature sensor wire before coronary intervention in both cohorts. From the derivation cohort, a strong linear relationship was found between FFR(cor) and FFR(myo) (FFR(cor) = 1.34 × FFR(myo) - 0.32, r(2) = 0.87, p < 0.001) by regression analysis. With this equation to estimate FFR(cor) in the validation cohort, there was no significant difference between IMR calculated from estimated FFR(cor) and measured FFR(cor) (21.2 ± 12.9 U vs. 20.4 ± 13.6 U, p = 0.161). There was good correlation (r = 0.93, p < 0.001) and agreement by Bland-Altman analysis between calculated and measured IMR. The FFR(cor), and, by extension, microcirculatory resistance can be derived without the need for P(w). This method enables assessment of coronary microcirculatory status before or without balloon inflation, in the presence of epicardial stenosis.

Adenosine stress perfusion CMR accurately identifies the culprit vessel

Background The diagnostic evaluation of patients with suspected ischaemic heart disease (IHD) frequently involves a functional assessment of ischaemia. Adenosine stress perfusion CMR is a non-invasive test with high sensitivity for the detection of IHD, however rarely is its accuracy for culprit vessel identification assessed. We sought to determine the accuracy of stress perfusion CMR for identifying the culprit vessel. Furthermore, we sought to affirm the specificity of a positive CMR against an angiographic gold standard. Methods Retrospective study of patients with a positive stress perfusion CMR and subsequent coronary angiography. Perfusion imaging was obtained at stress (adenosine 140 µg/kg/min) and rest on a 1.5T scanner. Late enhancement was assessed with dual pass gadolinium (0.2mmol/kg total dose). Angiographic stenosis ≥ 50% was defined as significant. The presence or absence of a significant lesion together with the correlation between ischaemic territory on CMR and angiographic culprit vessel was evaluated. Results Thirty seven patients (60% male, age 65.1 years ± 11.3; mean ± SD) had a positive CMR with subsequent angiography, with follow up data for a median 24 months (IQR 21-27 months). Thirtee np atients (35%) had previous myocardial infarction or revascularisation. Of the cohort of 37, six (16%) had normal angiograms and 31 (84%) had a significant epicardial stenosis. Of the six false positives, three had localised septal hypoperfusion, while a further three had circumferential defects. Of the 31 patients correctly identified, CMR accurately established the territory of the culprit vessel in 29 (94%). The vessels confirmed as ischaemic were left anterior descending 12 (39%), circumflex 6 (19%) and right coronary artery 13 (42%). Conclusions Adenosine stress perfusion CMR reliably identifies the territory supplied by the culprit vessel (29 out of 31 94%). Furthermore, we reaffirm the high specificity (84%) of stress perfusion CMR.

Long-term prognostic value of coronary flow reserve in patients without significant left anterior descending coronary artery stenosis: results from the SZEGED Study

Coronary flow reserve (CFR) measured by pulsed Doppler echocardiography is a useful hemodynamic index to evaluate coronary microcirculatory (dys)function in the left anterior descending coronary artery (LAD), in the absence of macrovascular lesions. The present study was designed to evaluate long-term prognostic value of CFR in patients without significant epicardial LAD stenosis. A total of 166 patients without significant LAD stenosis were enrolled in this prospective follow-up study. Coronary angiography demonstrated absence of significant LAD disease in all cases. All patients underwent transthoracic and stress transesophageal echocardiography (CFR measurement) and coronary angiography. The success rate of follow-up was 124 out of 166 (75%). During a mean follow-up of 93+/-34 months 27 patients died, including 16 sudden cardiac deaths, 3 acute heart failures, 2 strokes, while 6 patients had pulmonary or gastrointestinal malignancies. Using ROC analysis, the best cut-off value for CFR was 2.13 to predict survival (sensitivity 67%, specificity 60%, area, under the curve 62%, p = 0.046). Patients with CFR < 2.13 had significantly more events (32% vs. 13%, p<0.05). The logistic regression model identified CFR (hazard ratio (HR) 2.43, p = 0.04) and left ventricular end-systolic volume (HR 1.09, p = 0.03) as independent predictors of survival. Long-term prognostic significance of CFR for prediction of survival has been demonstrated during a long-term follow-up in patients without significant LAD stenosis.