Silent Coronary Artery Disease Research Articles

Atherogenic Effect of Homocysteine, a Biomarker of Inflammation and Its Treatment

AbstractHyperhomocysteinemia (HHcy) is an independent risk factor for atherosclerosis. Ischemic stroke and heart disease, coronary heart disease, and cardiovascular disease are events resulting from long-lasting and silent atherosclerosis. This paper deals with the synthesis of homocysteine (Hcy), causes of HHcy, mechanism of HHcy-induced atherosclerosis, and treatment of HHcy. Synthesis and metabolism of Hcy involves demethylation, transmethylation, and transsulfuration, and these processes require vitamin B6 and vitamin B12 folic acid (vitamin B9). Causes of HHcy include deficiency of vitamins B6, B9, and B12, genetic defects, use of smokeless tobacco, cigarette smoking, alcohol consumption, diabetes, rheumatoid arthritis, low thyroid hormone, consumption of caffeine, folic acid antagonist, cholesterol-lowering drugs (niacin), folic acid antagonist (phenytoin), prolonged use of proton pump inhibitors, metformin, and hypertension. HHcy-induced atherosclerosis may be mediated through oxidative stress, decreased availability of nitric oxide (NO), increased expression of monocyte chemoattractant protein-1, smooth muscle cell proliferation, increased thrombogenicity, and induction of arterial connective tissue. HHcy increases the generation of atherogenic biomolecules such as nuclear factor-kappa B, proinflammatory cytokines (IL-1β, IL-6, and IL-8), cell adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selection), growth factors (IGF-1 and TGF-β), and monocyte colony-stimulating factor which lead to the development of atherosclerosis. NO which is protective against the development of atherosclerosis is reduced by HHcy. Therapy with folic acid, vitamin B6, and vitamin B12 lowers the levels of Hcy, with folic acid being the most effective. Dietary sources of folic acid, vitamin B6, vitamin B12, omega-3 fatty acid, and green coffee extract reduce Hcy. Abstaining from drinking coffee and alcohol, and smoking also reduces blood levels of Hcy. In conclusion, HHcy induces atherosclerosis by generating atherogenic biomolecules, and treatment of atherosclerosis-induced diseases may be by reducing the levels of Hcy.

Atherogenic Effect of Homocysteine, a Biomarker of Inflammation and Its Treatment

AbstractHyperhomocysteinemia (HHcy) is an independent risk factor for atherosclerosis. Ischemic stroke and heart disease, coronary heart disease, and cardiovascular disease are events resulting from long-lasting and silent atherosclerosis. This paper deals with the synthesis of homocysteine (Hcy), causes of HHcy, mechanism of HHcy-induced atherosclerosis, and treatment of HHcy. Synthesis and metabolism of Hcy involves demethylation, transmethylation, and transsulfuration, and these processes require vitamin B6 and vitamin B12 folic acid (vitamin B9). Causes of HHcy include deficiency of vitamins B6, B9, and B12, genetic defects, use of smokeless tobacco, cigarette smoking, alcohol consumption, diabetes, rheumatoid arthritis, low thyroid hormone, consumption of caffeine, folic acid antagonist, cholesterol-lowering drugs (niacin), folic acid antagonist (phenytoin), prolonged use of proton pump inhibitors, metformin, and hypertension. HHcy-induced atherosclerosis may be mediated through oxidative stress, decreased availability of nitric oxide (NO), increased expression of monocyte chemoattractant protein-1, smooth muscle cell proliferation, increased thrombogenicity, and induction of arterial connective tissue. HHcy increases the generation of atherogenic biomolecules such as nuclear factor-kappa B, proinflammatory cytokines (IL-1β, IL-6, and IL-8), cell adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selection), growth factors (IGF-1 and TGF-β), and monocyte colony-stimulating factor which lead to the development of atherosclerosis. NO which is protective against the development of atherosclerosis is reduced by HHcy. Therapy with folic acid, vitamin B6, and vitamin B12 lowers the levels of Hcy, with folic acid being the most effective. Dietary sources of folic acid, vitamin B6, vitamin B12, omega-3 fatty acid, and green coffee extract reduce Hcy. Abstaining from drinking coffee and alcohol, and smoking also reduces blood levels of Hcy. In conclusion, HHcy induces atherosclerosis by generating atherogenic biomolecules, and treatment of atherosclerosis-induced diseases may be by reducing the levels of Hcy.

The role of preparticipation screening in detecting silent coronary artery disease in master athletes: a way to prevent exercise-related adverse cardiovascular events

Abstract Introduction Regular exercise reduces morbidity and mortality from cardiovascular diseases through cardiac and systemic adaptations including the increased coronary blood flow, an improved endothelial function, a slower progression of atherosclerotic processes as well as the stabilization of pre-existing lesions. However, long-term exercise is frequently associated with adverse cardiovascular events in 35-year older subjects because of a cardiac remodeling that predisposes to malignant arrhythmias and to an earlier atherosclerosis. Moreover, in athletes, ischemia is often silent with a higher risk of sudden cardiac death. Purpose The aim of our observational study was to evaluate the efficacy of preparticipation screening in identifying the presence of coronary artery disease (CAD) in a population of asymptomatic master athletes. Methods Between 2018 and 2019, 420 35-year older athletes (mean age: 55 + 17) underwent a preparticipation screening at the University of Pisa. None of them reported cardiovascular risk factors or previous cardiovascular diseases. After a physical examination, all subjects were submitted to spirometry and ECG stress test. Results The ECG stress test demonstrated signs of myocardial ischemia (ST depression > 1 mm) in 41 subjects; 3 athletes showed a frequency-dependent left bundle-branch block; 24 subjects had exercise-induced premature ventricular complexes during the ECG stress test. These subjects underwent further evaluations (Tc-99 myocardial perfusion SPECT and coronary angio-CT) to detect the presence of perfusion defects or coronary abnormalities: 26 athletes had an important coronary atherosclerosis with significant stenosis in one or more vessels and later subjected to Percutaneous transluminal coronary angioplasty (PTCA) or to coronary artery bypass grafting (CABG). 5 athletes presented a coronary myocardial bridge and 1 subject was demonstrated to have an anomalous origin of the left coronary. Conclusions Preparticipation screening in 35-year-older athletes was able to detect the presence of obstructive coronary artery disease (CAD) in the 38% of suspected cases and anomalous origin or intramural coronary course in 8,8% of cases that showed electric abnormalities during the stress test. Despite recent conflicting opinions about the scientific value of the preparticipation screening in young athletes, the present study demonstrated that it was fundamental to early detect silent conditions that could predispose master athletes to adverse cardiovascular events.

Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications.

Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.

THU-487 - Assessment of silent coronary artery disease with functional and anatomic tests in liver transplantation: analysis of the diagnostic and prognostic capacity of a risk-adapted protocol

THU-487 - Assessment of silent coronary artery disease with functional and anatomic tests in liver transplantation: analysis of the diagnostic and prognostic capacity of a risk-adapted protocol

Silent Coronary Artery Disease in Patients with Rheumatoid Arthritis in Kurdistan, Iraq: A cross-sectional study

Objectives: This study attempts to determine the silent coronary artery disease (CAD) in a sample of Iraqi Kurdish patients diagnosed with rheumatoid arthritis (RA).
 Methods: A total of 50 such patients from Duhok, Kurdistan region of Iraq, underwent multi slices computed tomography (MSCT) coronary angiography 64 slices to determine coronary artery calcium (CAC) scores and coronary stenoses.
 Results: 62% of cases had a (CAC) score > zero on non-contrast MSCT scans. Coronary angiograms showed that 26 (52%) of the cases had variable coronary artery stenosis; 17(34%) of them were obstructive (>50% luminal narrowing). The study demonstrated that Inflammatory markers (rheumatoid factor, Anti- cyclic citrullinated peptides, and some cardiovascular risk factors, namely (hypertension and type 2 diabetes mellitus) were significantly related to the presence of CAD in these patients.
 Conclusions: Patients with rheumatoid arthritis are at increased risk of CAD. This risk is higher in the presence of inflammatory and cardiovascular risk factors.

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BackgroundThe 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.MethodsIn this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.ResultsCAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.ConclusionThe ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study

BackgroundMyocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention.MethodsProspective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48–72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality.ResultsWe included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%).ConclusionThis study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes.Trial registration Clinicaltrials.gov identifier: NCT03438448 (19/02/2018).

Prevalence of Coronary Artery Disease in Asymptomatic type 2 Diabetes Mellitus Patients with Invasive Correlation in North India.

Type 2 diabetes mellitus (T2DM) is the risk factor for coronary artery disease (CAD). In this study, we assessed the prevalence of CAD in asymptomatic T2DM patients and its correlation with invasive testing in treadmill testing (TMT)-positive cases. A total of 90 patients with asymptomatic T2DM were recruited and subjected to TMT TMT-positive patients were subjected to coronary angiography (CAG). At baseline, the mean duration of T2DM (years) was 4.87 ± 4.04 with mean levels of HbA1c (%) of 7.96 ± 1.02. TMT was positive in 28 patients (31.1%) for reversible myocardial ischaemia (RMI), and among them, 16 patients consented to CAG, of which 14 required coronary angioplasty and the remaining two (7.1%) had to undergo coronary artery bypass grafting (CABG). The remaining 12 TMT positives (42.9%) were managed medically. To conclude, there is a high prevalence of silent CAD in T2DM. They need regular screening to detect the same and prevent the morbidity and mortality associated with overt CAD. Hence, it is important to screen people with type 2 diabetes, to prevent the morbidity and mortality associated with overt CAD.

Cardiac Alarmins as Residual Risk Markers of Atherosclerosis under Hypolipidemic Therapy.

Increased levels of low-density lipoproteins are the main risk factor in the initiation and progression of atherosclerosis. Although statin treatment can effectively lower these levels, there is still a residual risk of cardiovascular events. We hypothesize that a specific panel of stress-sensing molecules (alarmins) could indicate the persistence of silent atherosclerosis residual risk. New Zealand White rabbits were divided into: control group (C), a group that received a high-fat diet for twelve weeks (Au), and a treated hyperlipidemic group with a lipid diet for eight weeks followed by a standard diet and hypolipidemic treatment (atorvastatin and PCSK9 siRNA-inhibitor) for four weeks (Asi). Mass spectrometry experiments of left ventricle lysates were complemented by immunologic and genomic studies to corroborate the data. The hyperlipidemic diet determined a general alarmin up-regulation tendency over the C group. A significant spectral abundance increase was measured for specific heat shock proteins, S100 family members, HMGB1, and Annexin A1. The hypolipidemic treatment demonstrated a reversed regulation trend with non-significant spectral alteration over the C group for some of the identified alarmins. Our study highlights the discriminating potential of alarmins in hyperlipidemia or following hypolipidemic treatment. Data are available via ProteomeXchange with identifier PXD035692.

Prevalence of silent coronary artery disease among patients with type 2 diabetes mellitus in Suleimani, Iraq

Objective: To study the prevalence of silent coronary artery disease among patients with Type 2 Diabetes Mellitus and associated variables.
 Methods: A cross sectional multi-center design study in the Sulaymaniyah city. The data collected from patients admitted to medical wards of Shar teaching Hospital, Shahid Hemn teaching Hospital and Faruq medical city. It was conducted during the period of 10 months starting from April, 2017 to Jan, 2018. All patients with type 2 Diabetes Mellitus without symptoms of coronary heart disease were included. Symptoms were evaluated by history, physical examination including blood pressure measurement and searching for other risk factors. The patients were investigated for HbA1c, Lipid profile, resting Electrocardiography (ECG), Echocardiography, Exercise Treadmill test, and CT coronary angiography.
 Results: A total of 106 patients, 55 male (51.9%) and 51 female (48.1%) were enrolled in this study, the mean age of the patients was (58.50yr ± 10.94), Nine(8.4%) patients had ischemic change by resting ECG, 10 (9.4%) had ischemic change by Echocardiography, Exercise treadmill test (ETT) was done for 20 patients and revealed positivity for ischemia in only 3(15%) patients, CT coronary angiography was done for three patients and were conclusive for CAD.
 Conclusion: Silent coronary artery disease is common in patients with type 2 diabetes mellitus, therefore patients with DM should be carefully evaluated to detect early cardiovascular adverse effect to avoid fatal consequences.

Incremental value of global longitudinal strain to predict stress echocardiography positivity in asymptomatic diabetic patients

French guideline recently added the presence of an “abnormal left ventricle” on transthoracic echocardiography (TTE) to define very high-risk diabetic patients who may benefit from silent coronary artery disease (CAD) screening. We aimed to investigate the incremental value of resting Global Longitudinal Strain (GLS) in predicting stress TTE positivity in asymptomatic patients with diabetes mellitus (DM). Consecutive asymptomatic patients with DM referred for screening for silent CAD by stress TTE (effort of dobutamine) between January 2017 and December 2018 were included ( n = 273). Stress test positivity was defined as stress-induced new or worsening of preexisting left ventricular wall motion abnormalities. Patients with a positive stress test ( n = 28; 10%) were more likely to be smokers (71% vs. 17%), to have known diabetes for more than 10 years, carotid atheroma, diabetic nephropathy, diabetic retinopathy (57.1% vs. 18.0%), moderate or severe aortic or mitral calcifications and a lower GLS (−16.7 ± 2.9 vs. −18.9 ± 2.2%) than those with a negative test (all P ≤ 0.014). On multivariate logistic regression analysis, a DM duration > 10 years, diabetic retinopathy and lower GLS (OR [95% CI] = 0.76 [0.64–0.93] per % decrease) remained independently associated with a positive stress TTE. The Chi 2 of the model was significantly improved by the addition of GLS on top of the baseline clinical variables, repolarization abnormalities and DM related complications (Chi 2 56.9 to 73.8; P < 0.001) ( Table 1 , Fig. 1 ). Screening CAD in asymptomatic patients with DM is challenging and debated. In this context, it is crucial to identify early markers of CAD in this population. Our study shows that GLS is strongly associated with the presence of silent ischemia and could be one of these new parameters to be routinely assessed in this population.

Pivotal role of the sympathetic nerves of the human heart in mental stress responses and triggered cardiovascular catastrophes.

Mental stress can trigger cardiac catastrophes, explicitly evident during national disasters such as earthquakes. Activation of the cardiac sympathetic outflow and inhibition of the cardiac vagus are important mediating mechanisms. This manuscript describes efforts by the Human Neurotransmitters Research Laboratory of the Baker Institute in Melbourne to develop investigative methods to study the sympathetic nerves of the human heart, and to apply these in mental stress research. With laboratory mental stress, activation of the adrenal medulla was found to occur, accompanied by a regionalized sympathetic nervous response directed to the heart, but sparing the sympathetic outflow to the skeletal muscle vasculature. Patients with panic disorder are at increased cardiovascular risk. They exhibit high-level sympathetic activation during a panic attack, sometimes accompanied by coronary artery spasm. Patients with sudden ventricular arrhythmias causing collapse in the community were found to have as the predisposing substrate high baseline cardiac sympathetic activity, from previously unrecognized mild heart failure; it was surprising at the time that we did not find critical coronary artery stenosis as the substrate. In some the arrhythmia event had a behavioural trigger. In Takotsubo cardiomyopathy ("Broken Heart Syndrome") the myocardial stunning appears to represent a catecholamine cardiomyopathy, from astronomically high plasma adrenaline concentrations, rather than be caused by activation of the cardiac sympathetic nerves. Some diseases (essential hypertension, heart failure, panic disorder) have forms of sympathetic neural enhancement which contribute to cardiovascular risk: reuptake of noradrenaline by sympathetic nerves after release is faulty and single sympathetic fibres fire in multiple salvos within a single cardiac cycle. Paradoxically, obesity-hypertension does not share in this sympathetic neural augmentation, which is present only in normal-weight hypertensive patients, providing the possible basis for an observed "Obesity Paradox" (longer survival in obesity-hypertension than in normal weight hypertension). Community-wide specific prevention of cardiovascular triggering is not currently possible, due to there being no available simple screening tests which could be applied to the community at-large for the commonest substrates, silent coronary artery disease and mild heart failure. Standard medical preventive measures for coronary atherosclerosis will of course be helpful. Targeted prevention of triggering can be done in those with a detected predisposing substrate, such as genetic Long QT Syndrome, and in survivors of a serious triggered event, who need detailed, appropriate testing.

Impact of Polycystic Ovary Syndrome on Silent Coronary Artery Disease and Cardiovascular Events; A Long-term Population-based Cohort Study

The existing data regarding the impact of Polycystic Ovary Syndrome (PCOS) on the risk of developing cardiovascular disease (CVD) are conflicting. To explore the effect of PCOS status on the occurrence of silent coronary artery disease (CAD)/CVD. A total of 1591 women without CVD at baseline, aged 18-45 years, including 356 PCOS patients (defined by the Rotterdam criteria) and 1235 eumenorrheic non-hirsute women without polycystic ovarian morphology (controls), were selected from the Tehran Lipid and Glucose Study (TLGS). The median follow-up was 15.4 years, and most participants were in their late reproductive years at the end of the study. Silent CAD and CVD outcomes in PCOS and control groups were compared according to the multivariable-adjusted hazard ratios (HRs) and cumulative hazard functions. There was no difference in CVD risk factors between the PCOS and control groups. After controlling for confounders, PCOS status did not increase the risk of silent CAD (HR: 0.96, 95% CI 0.86-1.08). Regardless of PCOS status, women with a history of silent CAD showed 2.25 times higher CVD events than those without this history (95% CI 1.63-3.10). PCOS status reduced the CVD incidence by 42%, independently of silent CAD or traditional risk factors (HR: 0.58, 95% CI 0.35-0.98). Whereas silent CAD, regardless of PCOS, accelerated CVD, PCOS preserved it, most likely due to a combination of protective factors, including the endocrine pattern in the late reproductive period, environmental/social elements, and recruiting additional counseling and lifestyle modifications.

Abstract 10541: Clinical Risk Factors and Myocardial Fibrosis in Subjects Who Died Suddenly: Pilot Data from A 10-Year Post-Mortem Data Registry

Introduction: Sudden cardiac death (SCD) is responsible for approximately 380,000 deaths per year. One third of the patients dying of heart disease present with SCD as the first manifestation. There are limited data on the clinico-pathological determinants of SCD. Hypothesis: We hypothesized that, compared to overall deaths, silent coronary atherosclerosis and myocardial fibrosis could be associated with increased frequency of SCDs. Methods: We reviewed the post-mortem data registry from two tertiary care hospitals located at the Buffalo-Niagara Region. Of the 1,314 subjects that underwent comprehensive post-mortem analysis, we identified 187 subjects that died suddenly. For this initial pilot data analysis protocol, we compared the demographic, clinical, electrocardiographic and coronary vascular and myocardial histopathological characteristics of 109 subjects with sudden death vs. 34 age-matched controls with non-sudden death. Results: We found that, of the total 1,314 subjects screened, 14% had SCD. Comparison of age-matched SCD with non-SCD subjects (age in years, SCD: 60±14; non-SCD: 61±20) showed that SCD groups had larger cardiac size (heart weight in grams, SCD: 550±150; non-SCD: 480±117, P=0.03), increased wall thickness (posterior wall thickness in cm, SCD: 1.7±0.4; non-SCD: 1.5±0.2, P=0.01), but reduced LV function reported before the event (LV ejection fraction in %, SCD: 41±17; non-SCD: 58±9, P=0.007). In addition, SCD groups had higher frequency of coronary atherosclerosis (SCD, 76% vs., non-SCD, 52%, P=0.007), and myocardial fibrosis involving both left ventricular free wall (SCD, 47% vs., non-SCD, 26%, P=0.03), and interventricular septum (SCD, 29% vs., non-SCD, 3%, P=0.02). There were no differences on serum electrolytes, circulating biomarkers and the extent of right ventricular fibrosis. Conclusions: The subjects that died suddenly had larger cardiac size, reduced contractile function with myocardial interstitial fibrosis, and silent coronary atherosclerosis. Further studies are in progress to fully examine the clinico-pathological correlates of SCD in our longitudinal study cohorts.

Resting Left Ventricular Global Longitudinal Strain to Identify Silent Myocardial Ischemia in Asymptomatic Patients with Diabetes Mellitus

Screening for silent coronary artery disease in asymptomatic patients with diabetes mellitus (DM) is challenging and controversial. In this context, it seems crucial to identify early markers of coronary artery disease. The aim of this study was to investigate the incremental value of resting left ventricular (LV) global longitudinal strain (GLS) for the prediction of positive results on stress (exercise or dobutamine) transthoracic echocardiography in 273 consecutive asymptomatic high-risk patients with DM. Positive results on stress transthoracic echocardiography were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities). Compared with patients with negative stress results, those with positive stress results (n=28 [10%]) more frequently had cardiovascular risk factors, complications of DM, vascular disease, moderate and severe calcification of the aortic valve and mitral annulus, and worse resting LV GLS (-16.7±2.9% vs -19.0±1.9%, P<.001). On multivariable logistic regression analysis, DM duration > 10years, diabetic retinopathy, LV hypertrophy, and impaired LV GLS (odds ratio, 1.39 [95% CI, 1.14-1.70] per percentage increase; odds ratio, 5.16 [95% CI, 1.96-13.59] for LV GLS worse than -18%) were independently associated with positive results on stress transthoracic echocardiography. The area under the curve to predict positive results was 0.74 for LV GLS with a cutoff of -18.0% (sensitivity 68%, specificity 78%). The area under the curve of the multivariable model to predict test results was improved by the addition of LV GLS (P<.001), with a bias-corrected area under the curve after bootstrapping of 0.842 [95% CI, 0.753-0.893]. The present findings show that resting LV GLS is associated with the presence of silent ischemia and could be useful to better identify asymptomatic patients with DM who might benefit from coronary artery disease screening.

Renal Function, Albumin-Creatinine Ratio and Pulse Wave Velocity Predict Silent Coronary Artery Disease and Renal Outcome in Type 2 Diabetic and Prediabetic Subjects.

Silent coronary heart disease is frequently undetected in type 2 diabetes mellitus (DM2) and pre-diabetes determined by glucose intolerance (GI). Pulse wave velocity (PWV) and albumin-creatinine ratio (ACR) have been considered markers of cardiovascular mortality, coronary heart disease and chronic renal failure. To evaluate the incidence of coronary artery disease (CAD) and the relationship between urinary albumin-creatinine ratio, glomerular filtration rate (GFR) and PWV in type 2 DM with silent CAD. We analyzed 92 individuals (44 male), 49 (60±7y) type 2 DM non-insulin dependents and 43 prediabetics (43±4y), with Grade I-II hypertension and no symptoms of CAD. All type 2 DM patients were under antidiabetic treatment with A1C hemoglobin between 5.5 and 6.5%. Every patient underwent a myocardial perfusion SPECT scan. In those subjects with ischemic patterns, coronary angiography was performed. In addition, PWV, glomerular filtration rate, and ACR were evaluated. mean±SEM, and ANOVA among groups. 48.59% of DM2 and 25.58% of GI patients had silent coronary artery had silent coronary artery disease and higher ACR, PWV and reduced GFR. Higher ACR and PWV and reduced GFR. DM2 and GI showed a negative relationship between GFR and ACR. Moreover, this relation was also observed in different levels of GFR (>60 ml/min and <60ml.min (p<0.05) in patients with CAD, suggesting a cardio-renal interaction in DM2. Higher PWV, lower GFR and ACR predict the incidence of CAD in DM2. Dysglycemic individuals also represent a group of higher risk for coronary artery disease with similar predictors as in DM2. Diabetic and prediabetics still develop renal microalbuminuria. Thus, PWV seems to represent a reliable marker of renal impairment and coronary artery disease.

Risk of a coronary event in patients after ischemic stroke or transient ischemic attack.

Coronary artery disease (CAD) together with stroke are the leading causes of death worldwide, and together, they pre-sent a health and economic burden. Ischemic stroke survivors and patients who suffered transient ischemic attack (TIA) have a higher prevalence of coronary atherosclerosis, and they have a relatively high risk of myocardial infarcti-on and nonstroke vascular death. Pubmed was searched for studies focused on investigating coronary atherosclerosis in ischemic stroke survivors or patients who suffered TIA and their cardiovascular risk assessment. There were corona-ry plaques in 48%-70% of stroke survivors without a known history of CAD, and significant stenosis of at least one coronary artery can be found in 31% of these patients. CAD is a major cause of morbidity and mortality in stroke survivors. Detection and treatment of silent CAD may improve the long-term outcome and survival of these patients.

Typical atrial flutter but not fibrillation predicts coronary artery disease in formerly healthy patients.

Long-term mortality after ablation of typical atrial flutter has been found to be increased two-fold in comparison to atrial fibrillation ablations through a period of 5 years with unclear mechanism. We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of AF was the first manifestation of cardiac disease. According to the clinical standards of our centre, the routine recommendation was to evaluate for coronary artery disease (CAD) by invasive angiogram or computed tomography scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; P = 0.15), body mass index (BMI; 28.8 vs. 28.5 kg/m2; P = 0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; P = 0.35), smoking status (22.2% smokers vs. 28.4%; P = 0.23), and renal function (GFR >60 mL/min in 96.7% of all patients vs. 95.7%; P = 0.76). There were significantly lower values for left ventricular ejection fraction (52.5% vs. 59.7%; P < 0.001), female sex (17.0% vs. 47.5%; P < 0.001), hyperlipidaemia (37.9% vs. 58.9%; P < 0.001), and family history of cardiovascular disease (CVD) (15.0 vs. 31.9%; P = 0.001) in the AFL vs. AFIB cohorts. Coronary artery disease with stenoses >50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (P < 0.001). Coronary artery disease with stenoses >75% in 16.4% in AFL whereas only in 1.4% in AFIB (P < 0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (P < 0.001). After correction for age, left ventricular ejection fraction, BMI, CHA2DS2-VASc-Score and its individual components, smoking status, hyperlipidaemia, and family history of CVD, there was a more than five-fold increase in the likelihood of CAD with stenosis >50% in AFL as compared to AFIB [odds ratio (OR 5.26)]. A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (>75%) were older (70.6 years vs. 63.8 years; P = 0.001), had a higher number of risk factors (3.08 vs. 2.24; P ≤ 0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs. 2.00; P < 0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. These data suggest that typical atrial flutter constitutes a manifestation of previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and chronic in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.

A systematic review and meta-analysis of delayed coronary artery access for coronary angiography with or without percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR).

Coronary artery disease (CAD) and severe aortic valve stenosis frequently coexist. Given the progressive nature of CAD, silent or non-significant CAD may become symptomatic or functionally relevant years after TAVR. However, there is a paucity of data documenting the feasibility of either coronary angiography and/or PCI after TAVR. We systematically searched Medline, Pubmed, Embase, Cochrane database, Google Scholar, Science Direct, Web of Science, and conference abstracts from conception to March 2020 using OvidSP in TAVR patients undergoing coronary angiography with or without PCI at least 6months after TAVR. Patients and procedural characteristics were summarized. The primary outcome of interest was successful coronary angiography for either the left main coronary artery (LMCA) or right coronary artery (RCA) with or without PCI. Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO. Eleven reports for a total of 696 coronary angiograms and 287 PCI were included in the analysis. Patients were slightly predominantly male, older and had a mean left ventricular ejection fraction of more than 50% with an intermediate STS. The summary estimate rates of successful LMCA and RCA angiography with a Medtronic self-expandable valve (SEV) were 84% (95% CI 73-90%, I2 = 79, p = 0.015) and 69% (95% CI 37-89%, I2 = 86, p = 0.23), respectively, while with the Edwards Lifesciences balloon expandable valve (BEV), the summary estimate rates for successful LMCA and RCA angiography were 94% (95% CI 72-99%, I2 = 66, p = 0.003) and 95% (95% CI 48-99%, I2 = 83, p = 0.05), respectively. The summary estimate rate of successful PCI post TAVR with either a Medtronic SEV or Edwards Lifesciences BEV was 93% (95% CI 86-96%, I2 = 33, p = 0.0001). The overall achievement of a successful coronary angiography with or without PCI in post-TAVR patients is high, with a lower success rate for RCA angiography in patients with the Medtronic SEV Mortality and bleeding did not differ in our analysis.