Stable Coronary Disease Research Articles

The diagnostic role of myocardial work indices in stable coronary disease - global wasted work as a novel important non-invasive parameter?

Abstract Introduction Although the non-invasive diagnostic tools for stable coronary artery disease (CAD) have developed significantly over the past years, there is no resting parameter available to recognize functionally significant CAD. The role of the novel myocardial work index (myocardial work index - MWI) calculated by the pressure-strain loop created with the help of speckle-tracking analysis and blood pressure measurement in the diagnosis of ischemic heart disease is not yet fully clarified. In our research, we examined the parameters of myocardial work analysis in stable coronary disease patients. Purpose Clarification of the diagnostic role of the myocardial work analysis, in patients with stable coronary artery disease. Methods In our prospective, single-center study, we examined 13 patients who had at least moderate stenosis (≥50%) in one main coronary branch detected on coronary CTA. A fractional flow reserve (FFR) test was performed for functional coronary assessment. Based on this measurement, we divided our patients into FFRneg (FFR value>0.8) and FFRpos groups. Echocardiography was performed before coronary angiography in all patients. In addition to the standard echocardiographic parameters, global myocardial work index (GWI), global constructive work (GCW) and global wasted work (GWW) were calculated. In the case of the FFRpos group, we performed the above examination both before and after revascularization (2 months). Results Our results show that neither the standard parameters (GLS, EF), nor the GWI and GCW showed any difference between the FFRpos and FFRneg groups. However, there was a significant difference regarding GWW (172.3±21.8 FFRneg vs. 258.2±38.4 FFRpos, p=0.048) at baseline. In the case of the FFRpos group, the analysis of our data showed that there was no significant difference in EF, GLS, GWI and GWE parameters before and after revascularization. However, global wasted work (GWW) showed a significant improvement after revascularization (preGWW 258.2±38.4 vs. postGWW 139.5±14.5, p=0.041). NT-proBNP levels were normal in our patient population and we could not detect. Conclusion Based on our results, the GWW may be suitable for non-invasive assessment of the functional significance of stable coronary disease, as it showed a significant difference in the case of functionally significant and non-significant stenosis and improved after revascularization in patients with single-vessel CAD.

Management of iatrogenic ascending aortic dissection after percutaneous intervention of chronic total occlusion.

This study highlights the prevalence and conservative management strategies of iatrogenic ascending aortic dissection after percutaneous intervention (PCI) of chronic total occlusion (CTO). Retrospective analysis on patients who underwent CTO PCI from one medical center from 2020 to 2022 was performed by two operators. Data was obtained from the Prospective Global Registry for the Study of CTO database. Out of 318 patients, there were six reported cases of iatrogenic ascending aortic dissection. The causes of dissection included guiding catheter trauma, antegrade injection, two retrograde injection, and two cases of balloon rupture after lithotripsy. IVUS-guided stenting of the coronary back to the origin to seal the entry of the dissection flap occurred in two patients. All patients had a conservative management approach. No patient had to undergo urgent surgery. While the incidence remains rare, complications, including aortic dissection, are more frequent in CTO PCI as compared to non-CTO PCI. IVUS can be used to complete coronary intervention so long as the patient remains clinically and hemodynamically stable. Patients should have formal imaging with either transesophageal echocardiogram or computed tomography angiography. The outcomes of patients who experience iatrogenic aortic dissection during CTO PCI with stable coronary disease seem to be better than in patients with acute coronary syndrome.

Randomized Comparison of NovelLow-Dose Sirolimus-Eluting Biodegradable Polymer Stent vsSecond-Generation DES: TARGET-IV NA Trial.

Drug-eluting stents (DESs) with controlled antiproliferative drug release reduce restenosis risk, but durable polymers can delay healing and inhibit reendothelialization. The Firehawk biodegradable polymer sirolimus-eluting stent (BP-SES) has a fully biodegradable sirolimus-containing polymer coating localized to recessed abluminal grooves on the stent surface and delivers roughly one-third the drug dose of other DESs. We report the primary results of the TARGET-IV NA (Firehawk Rapamycin Target Eluting Coronary Stent North American Trial) randomized controlled trial comparing clinical outcomes with BP-SES vs currently used second-generation DESs. The TARGET-IV NA study was a prospective, multicenter, single-blind, 1:1 randomized noninferiority trial comparing the BP-SES with control in North America and Europe among patients undergoing percutaneous coronary intervention for chronic or acute coronary syndromes. The primary endpoint was target lesion failure (TLF) at 12months (composite of cardiac death, target vessel-related myocardial infarction, or ischemia-driven target lesion revascularization). The primary analysis (intention-to-treat) tested noninferiority of BP-SES vs control using an absolute margin of 3.85% and 1-sided α of 0.025. Noninferiority-powered secondary endpoints were tested in an optical coherence tomography substudy (endpoint: mean neointimal hyperplasia thickness) and an angiography substudy (endpoint: in-stent late lumen loss). A total of 1,720 patients (mean age 66 years; 74% male) with 2,159 lesions were randomly allocated to receive either BP-SES (860 patients, 1,057 lesions) or control second-generation DES (860 patients, 1,084 lesions). Atotal of 61% of patients presented with stable coronary disease, 32% had unstable angina, and 7% had non-ST-segment elevation myocardial infarction (NSTEMI) or recent ST-segment elevation myocardial infarction. The rate of TLF with BP-SES was noninferior to control at 12months (3.4% vs 3.3%, absolute risk difference 0.13%, upper bound 97.5%CI: 2.03, Pnoninferiority< 0.0001). Cardiac death, myocardial infarction, and stent thrombosis rates were similar between groups. Angiographic follow-up was available in 104 patients (97.2% of those enrolled in the angiographic substudy) and 128 (94.1%) lesions. At 13months, the powered secondary endpoint of mean in-stent late lumen loss was 0.149 ± 0.263mm for BP-SES and 0.327 ± 0.463mm for control (least squares mean difference:-0.178; 90%CI:-0.2943 to-0.0632; Pnoninferiority< 0.0001). The optical coherence tomography substudy included 37 patients (42 lesions) with no difference in mean neointimal hyperplasia thickness between groups at 13months (Pnoninferiority=0.01). The biodegradable polymer sirolimus-eluting stent was noninferior to currently used second-generation DES with regard to TLF at 1 year. (Firehawk® Rapamycin Target Eluting Coronary Stent North American Trial; NCT04562532).

TCT-353 The Diagnostic Role of Myocardial Work Analysis in Stable Coronary Disease: Global Wasted Work as a Novel Important Noninvasive Parameter

TCT-353 The Diagnostic Role of Myocardial Work Analysis in Stable Coronary Disease: Global Wasted Work as a Novel Important Noninvasive Parameter

Association between statin therapy and long-term clinical outcomes in patients with stable coronary disease undergoing percutaneous coronary intervention

This longitudinal cohort study examined the long-term effect of statin therapy on clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). A total of 1760 patients with stable coronary artery disease (CAD) were divided by receipt of statin therapy or not after index PCI. Baseline clinical characteristics, risk factors, angiographic findings, and medications after interventional procedure were assessed to compare long-term clinical outcomes between groups. Predictors for all-cause death and major adverse cardiovascular events (MACE), including myocardial infarction (MI), cardiovascular death, and repeated PCI procedures, were also analyzed. The statin therapy group had higher average serum cholesterol and more elevated low-density lipoprotein cholesterol (LDL-C) than the non-statin therapy group (189.0 ± 47.9 vs 169.3 ± 37.00 mg/dl, 117.2 ± 42.6 vs 98.7 ± 31.8 mg/dl, respectively, both P < 0.001). The non-statin group had higher rates of all-cause death and cardiovascular death compared to statin group (both P < 0.001). After adjustment for age, diabetes, and chronic kidney disease, Cox proportion hazard analysis revealed statin use significantly reduced all-cause death and repeated PCI procedure (hazard ratio: 0.53 and 0.69, respectively). Statin use seemed not reduce the hazard of cardiovascular death or MI in patients with stable CAD after PCI; however, statin therapy still was associated with reduced rates of all-cause death and repeat PCI procedure.

Assessment of Coronary Stenoses for Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis of Randomized Trials

Evidence regarding the comparative efficacy of the different modalities to determine the significance of coronary stenoses in the catheterization laboratory is lacking. We aimed to compare all available modalities guiding the decision to perform percutaneous coronary intervention (PCI). We searched Medline, Embase, and CENTRAL until October 5, 2023. We included trials that randomized patients with greater than 30% stenoses undergoing potential PCI and reported major adverse cardiovascular events (MACE). We performed a frequentist random-effects network meta-analysis and assessed the certainty of evidence using the GRADE approach. We included 15 trials with 16,333 participants with a mean weighted follow-up of 34 months. The trials contained a median of 49.3% (IQR 32.6%, 100%) acute coronary syndrome (ACS) participants. Quantitative flow ratio (QFR) was associated with a decreased risk of MACE compared to coronary angiography (CA) (Risk ratio (RR) 0.68, 95% Confidence Interval (CI) 0.56, 0.82; high certainty), fractional flow reserve (FFR) (RR 0.73, 95%CI 0.58, 0.92; moderate certainty), and instantaneous wave-free ratio (iFR) (RR 0.63, 95%CI 0.49, 0.82; moderate certainty), and ranked first for MACE (88.1% probability of being the best). FFR (RR 0.93; 95%CI 0.82, 1.06; moderate certainty) and iFR (RR 1.07, 95%CI 0.90, 1.28; moderate certainty) likely did not decrease the risk of MACE compared to CA. Intravascular imaging (IVI) may not be associated with a significant decrease in MACE compared to CA (RR 0.85; 95%CI 0.62, 1.17; low certainty) when used to guide the decision to perform PCI. In conclusion, a decision to perform PCI based on QFR was associated with a decreased risk of MACE compared to CA, FFR and iFR in a mixed stable coronary disease and ACS population. These hypothesis-generating findings should be validated in large, randomized, head-to-head trials.

Predictors of late lumen enlargement after drug-coated balloon angioplasty for de novo coronary lesions.

Late lumen enlargement (LLE) - a positive remodelling phenomenon - after drug-coated balloon (DCB) angioplasty for stable coronary disease contributes to a lower restenosis rate. However, lesion characteristics promoting LLE remain unclear. This study aimed to investigate predictive lesion characteristics for LLE using serial optical frequency domain imaging (OFDI) following DCB angioplasty for de novo coronary artery lesions. This retrospective, single-centre observational study included patients with angina pectoris who underwent paclitaxel-coated balloon angioplasty without stenting under OFDI guidance as well as follow-up OFDI. OFDI endpoints were lumen volume, plaque phenotype, and procedure-associated dissection. LLE was defined as a ≥10% increase in the lumen volume of the treated lesion at follow-up. Between August 2016 and December 2019, among patients with successful DCB angioplasty, 108 lesions (83 patients) had available follow-up imaging after a median of 6.1 months. LLE was detected in 44 (40.7%) lesions. Fibrous/fibrocalcific and layered plaques had significantly larger lumen volumes at follow-up than immediately after the index procedure, whereas lipid plaques exhibited no significant difference. Medial dissection with an arc >90° revealed an increased lumen volume. Multivariate analysis showed that layered plaques (odds ratio [OR] 8.73, 95% confidence interval [CI]: 1.92-39.7; p=0.005) and medial dissection with an arc >90° (OR 4.65, 95% CI: 1.63-13.3; p=0.004) were independent LLE predictors. Layered plaques and extensive medial dissection after DCB angioplasty were associated with higher LLE occurrence in de novo coronary lesions. These findings may be clinically applicable to DCB therapeutic strategies based on plaque features.

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

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

A Prospective, Multicenter, Real-World Registry of Coronary Lithotripsy in Calcified Coronary Arteries: The REPLICA-EPIC18 Study

BackgroundIntravascular lithotripsy (IVL) has demonstrated effectiveness in the treatment of calcified lesions in selected patients with stable coronary disease. ObjectivesThe authors sought to assess the performance of coronary IVL in calcified coronary lesions in a real-life, all comers, setting. MethodsThe REPLICA-EPIC18 study prospectively enrolled consecutive patients treated with IVL in 26 centers in Spain. An independent core laboratory performed the angiographic analysis and event adjudication. The primary effectiveness endpoint assessed procedural success (successful IVL delivery, final diameter stenosis <20%, and absence of in-hospital major adverse cardiovascular events [MACE]). The primary safety endpoint measured freedom from MACE at 30 days. A predefined substudy compared outcomes between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) patients. ResultsA total of 426 patients (456 lesions) were included, 63% of the patients presenting with ACS. IVL delivery was successful in 99% of cases. Before IVL, 49% of lesions were considered undilatable. The primary effectiveness endpoint was achieved in 66% of patients, with similar rates among CCS patients (68%) and ACS patients (65%). Likewise, there were no significant differences in angiographic success after IVL between CCS and ACS patients. The rate of MACE at 30 days (primary safety endpoint) was 3% (1% in CCS and 5% in ACS patients [P = 0.073]). ConclusionsCoronary IVL proved to be a feasible and safe procedure in a “real-life” setting, effectively facilitating stent implantation in severely calcified lesions. Patients with ACS on admission showed similar angiographic success rates but showed a trend toward higher 30-day MACE compared with patients with CCS. (REPLICA-EPIC18 study [Registry of Coronary Lithotripsy in Spain]; NCT04298307)

Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction.

Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated. The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups. The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013). AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BackgroundAlthough many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG. MethodsAll patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit. ResultsA total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG. ConclusionsMultiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

The Relationship Between the Bilirubin Levels and Coronary Artery Disease in Patients With Stable Coronary Disease

Objectives: Coronary artery disease (CAD) is an atherosclerotic disease that is a major cause of mortality worldwide. Bilirubin has been considered an antioxidant that protects patients against atherosclerosis. Therefore, the present study examines the relationship between serum bilirubin levels with CAD. Methods: In this cross-sectional, analytical study, the patients with suspected CAD were electively scheduled for angiography. Their blood samples were measured for total, direct, and indirect bilirubin levels. Following angiography, comparisons were made between the two groups of CAD and non-CAD subjects. Results: Of 140 studied patients, 73(52.1%) were male and 67(47.9%) were female. The mean age of subjects was 55.32±10.71 years which was statistically significantly significant (P˂0.001). The mean total, direct, and indirect bilirubin levels between the groups were 0.74±0.57 (P=0.79), 0.22±0.07 (P=0.77), and 0.48±0.45 (P=0.77) mg/dL, respectively, which were not significant. The mean total (0.77±0.57 vs 0.71±0.57) and indirect bilirubin levels (0.53±0.53 vs 0.44±0.35) were higher in men than women and mean direct bilirubin was similar between men and women (0.23±0.07 vs 0.22±0.07). There was a statistically significant relationship between male and female groups in total and indirect bilirubin (P=0.05). Discussion: No significant relationship was found between bilirubin levels and CAD either in terms of protective or aggravating role.

Sudden sustained monomorphic ventricular tachycardia in a previously healthy adult with many causes for it, but which one is the correct? A case report

Introduction. Sustained monomorphic ventricular tachycardia (VT) ? SMVT is a rare, underdiagnosed pathology with a very poor prognosis. Along with ventricular fibrillation, SMVT is responsible for nearly all of the arrhythmic sudden cardiac deaths (SCD). The most common cause of VT is ischemic heart disease, but there are many other reasons, among which are arrhythmogenic right ventricular cardiomyopathy (ARVD) and myocardial bridging phenomenon. Treatment options include a hybrid approach consisting of antiarrhythmic drugs, catheter ablation, and implantable cardioverter defibrillators (ICD). Case report. We present a case of a 46-year-old man, a military officer, who experienced chest pain, palpitations, and nausea during regular physical activity at home. Due to the symptoms described, he was examined immediately and diagnosed with SMVT. Shortly after the diagnosis, he lost consciousness and was successfully resuscitated. A complete non-invasive and invasive cardiology examination was performed. It revealed that the patient had stable coronary disease and a muscle bridge on the left anterior descending artery. An ARVD was suspected after transthoracic echocardiography and heart magnetic resonance imaging. Genetic testing for ARVD was negative, but according to the Heart Rhythm Society expert consensus criteria, we had enough for a definitive diagnosis. The patient was hospitalized for ten days and treated with drugs without recurring VT or other disorders. We implanted an implantable loop recorder before the discharge and monitored the heart rhythm for one year. During a three-year follow-up, all of his electrocardiographic findings presented sinus rhythm without heart rhythm disorders. Conclusion. Sudden SMVT is the most common cause of SCD. It is of inestimable importance to carry out a detailed examination and determine the immediate cause of the arrhythmia and the right therapy, which, for these patients, is a life-saving form of treatment. Therapy includes medications, electrophysiology or ICD, or a combination of these treatment approaches.

Normobaric hypoxia and exercise training effects on cardiac biomarkers, left ventricular function and aerobic performance in patients after myocardial infarction

Abstract Background Chronic total occlusion (CTO) has a negative impact on the left ventricle function and long-term prognosis of the patients after myocardial infarction. Scientific evidence suggests that some patients with CTO develop collateral arteries which provide an alternative source of blood supply to myocardium and can help to preserve myocardial function. One of the factors influencing the formation of collateral circulation is hypoxia, which induces angiogenesis and arteriogenesis. Physical activity is the most effective stimulus for adaptive changes in cardiovascular hemodynamics. However, the use of hypoxia and endurance exercise training on hemodynamic parameters of the heart and angiogenic factors have not been thoroughly studied yet. The aim of the present study was to examine the effect of endurance training under normobaric hypoxia on cardiac-specific troponin T (cTnT), creatinine kinase-myocardial band (CK-MB), heart-type fatty acid binding protein (H-FABP), vascular endothelial growth factor (VEGF), cytokines and cardiovascular function in patients after myocardial infarction. Methods Patients aged 60.4 ± 4.4 years who had undergone angioplasty with stent implantation participated in the study. Due to high risk of the occurrence of side effects cause by normobaric hypoxia only patients with stable coronary diseases (participants of the second stage of cardiac rehabilitation program) were included. The training program included 3 weeks of endurance training in normobaric hypoxia (HypTr) corresponding to an altitude of 2000 m above the sea level (FiO2 = 15.0%; (HYP-123 Hypoxic Generator, LOWOXYGEN Technology GmbH, Germany). The training regimen comprised 5 sessions/week with 5 min of warm-up, 30 min of interval training (intensity 80% of HRpeak) and 5 min of cooling down. Spiroergometry (CORTEX METAMAX 3B analyzer ) was performed using the cardiopulmonary test Electrocardiography and cardiac biomarkers were evaluated before and after the three weeks of the training programme. Results An increase in average distance covered (622.7 ± 119.0 vs. 687.0 ± 126.7 m, p&amp;lt;0.01) and the test duration (10.4 ± 1.0 vs. 11.0 ± 1.7 m, p&amp;lt;0.05) were observed in response to exercise training in hypoxia. CK-MB (p&amp;lt;0.05) and cTnT (p&amp;lt;0.05) levels were lower post-training compared to the pre-training (p &amp;lt; 0.05). Training in hypoxia had a significant effect on hemoglobin (F=14.7 p&amp;lt;0.001), TNF β (F = 8.2 p&amp;lt;0.01) and VEGF (F = 7.4 p&amp;lt;0.1) levels. Left ventricular (LV) function was altered post-training and the alteration was characterized by favorable changes in end-diastolic and end-systolic dimensions and LV ejection fraction (p&amp;lt;0.05). Conclusions Exercise training in normobaric hypoxia had a significant positive effect on the left ventricular function and concentration of the specific cardiac biomarkers, therefore it may play a crucial role in the cardiovascular adaptive mechanisms in patients after myocardial infarction.

Abstract 14321: High Sensitivity C-Reactive Protein is Associated With Plaque Vulnerability and Increased Incidence of Adverse Events in Patients With Stable Coronary Disease

Introduction: Higher level of high sensitivity C-reactive protein (hsCRP) is associated with an increased risk of cardiovascular events in patients with coronary artery disease (CAD). However, the pathogenesis of the worse clinical outcomes in CAD patients with high hsCRP remains to be elucidated. Hypothesis: Higher hsCRP is associated with a higher prevalence of vulnerable characteristics in coronary plaques and an increased incidence of adverse events in patients with CAD. Methods: A total of 793 consecutive patients with stable CAD, who underwent intra coronary optical coherence tomography (OCT) imaging of the culprit vessel during percutaneous coronary intervention were included. Patients were classified into the higher hsCRP group (hsCRP ≥ 0.2 mg/dL, n=247) or the lower hsCRP group (hsCRP &lt; 0.2 mg/dL, n=546). OCT characteristics and clinical outcomes were investigated according to the level of hsCRP. Results: The prevalence of thin-cap fibroatheroma (TCFA) (32.0% vs. 20.9%, p &lt;0.001) and plaque with macrophage (53.9% vs. 46.2%, p =0.045) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Panel A). The incidence of myocardial infarction was significantly higher in the higher hsCRP group than in the lower hsCRP group (log-rank p =0.006) during a median 938 days follow-up (Panel B) although the incidence of the composite of major adverse cardiac events was comparable (log-rank p =0.282). Among the four groups classified by the hsCRP level and the presence of TCFA, the incidence of myocardial infarction was the highest in the group with higher hsCRP and TCFA (log-rank p =0.017). Conclusions: Higher level of hsCRP was associated with a higher prevalence of vulnerable characteristics in coronary plaques and worse clinical outcomes in patients with stable CAD. The risk of recurrent myocardial infarction in patients with high hsCRP levels was further increased by the presence of TCFA.

Biomarkers and cardiovascular events in patients with stable coronary disease in the ISCHEMIA Trials

Biomarkers may improve prediction of cardiovascular events for patients with stable coronary artery disease (CAD), but their importance in addition to clinical tests of inducible ischemia and CAD severity is unknown. To evaluate the prognostic value of multiple biomarkers in stable outpatients with obstructive CAD and moderate or severe inducible ischemia. The ISCHEMIA and ISCHEMIA CKD trials randomized 5,956 participants with CAD to invasive or conservative management from July 2012 to January 2018; 1,064 participated in the biorepository. Primary outcome was cardiovascular death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. Secondary outcome was cardiovascular death or MI. Improvements in prediction were assessed by cause-specific hazard ratios (HR) and area under the receiver operating characteristics curve (AUC) for an interquartile increase in each biomarker, controlling for other biomarkers, in a base clinical model of risk factors, left ventricular ejection fraction (LVEF) and ischemia severity. Secondary analyses were performed among patients in whom core-lab confirmed severity of CAD was ascertained by computed cardiac tomographic angiography (CCTA). Baseline levels of interleukin-6 (IL-6), high sensitivity troponin T (hsTnT), growth differentiation factor 15 (GDF-15), N-terminal pro-B-type natriuretic peptide (NT-proBNP), lipoprotein a (Lp[a]), high sensitivity C-reactive protein (hsCRP), Cystatin C, soluble CD 40 ligand (sCD40L), myeloperoxidase (MPO), and matrix metalloproteinase 3 (MMP3). Among 757 biorepository participants, median (IQR) follow-up was 3 (2-5) years, age was 67 (61-72) years, and 144 (19%) were female; 508 had severity of CAD by CCTA available. In an adjusted multimarker model with hsTnT, GDF-15, NT-proBNP and sCD40L, the adjusted HR for the primary outcome per interquartile increase in each biomarker was 1.58 (95% CI 1.22, 2.205), 1.60 (95% CI 1.16, 2.20), 1.61 (95% 1.22, 2.14), and 1.46 (95% 1.12, 1.90), respectively. The adjusted multimarker model also improved prediction compared with the clinical model, increasing the AUC from 0.710 to 0.792 (P < .01) and 0.714 to 0.783 (P < .01) for the primary and secondary outcomes, respectively. Similar findings were observed after adjusting for core-lab confirmed atherosclerosis severity. Among ISCHEMIA biorepository participants, biomarkers of myocyte injury/distension, inflammation, and platelet activity improved cardiovascular event prediction in addition to risk factors, LVEF, and assessments of ischemia and atherosclerosis severity. These biomarkers may improve risk stratification for patients with stable CAD.

Long-term prognostic value of quantitative-flow-ratio-concordant revascularization in stable coronary artery disease

ObjectivesConfirming the prognostic value of global QFR and evaluating the long-term prognosis of QFR-concordant therapy in stable coronary artery disease. BackgroundWire-based functional evaluation of coronary disease is linked to patient's prognosis. Quantitative Flow Ratio (QFR) is a newer index of computational physiology, linked to clinical outcomes and prognosis at 1 year follow-up. Long-term prognosis of QFR-concordant revascularization in stable coronary artery disease is however unknown hitherto. MethodsConsecutive patients with stable coronary disease undergoing coronary angiography were included. Centralized and blinded QFR analysis of three coronary territories was performed. Three vessel QFR (3vQFR) was defined as the sum of the basal QFR of each coronary territory. QFR-concordant revascularization was met if all significant lesions (QFR ≤ 0.80) were revascularized and all non-significant lesions (QFR > 0.80) were not; otherwise, the case was defined as QFR-discordant revascularization. Patient-oriented composite end-point (POCE) of cardiac death, myocardial infarction and unscheduled revascularization was the primary endpoint. ResultsA total of 803 patients from six high-volume centers were included. Canadian Cardiovascular Society (CCS) class II angina was the most frequent (48.9%) clinical presentation. Median of follow-up was 68.8 months. 3vQFR was an independent predictor of POCE (HR 1.79 CI95% 1.01–3.18), with 2.75 as optimal cut-off value, irrespective of the therapy received. QFR-discordant revascularization (QFR+/Revascularization- or QFR-/Revascularization+) was an independent predictor of POCE in multivariate analysis (HR 1.65, CI 95% 1.03–2.64). ConclusionGlobal burden of epicardial coronary atherosclerosis, as evaluated by 3vQFR, as well as QFR-discordant therapy are independent predictors of adverse clinical outcome at long-term follow-up in stable coronary artery disease.

The impact of first wave of the SARS-CoV-2 2019 pandemic in Poland on characteristics and outcomes of patients hospitalized due to stable coronary artery disease.

An investigation of baseline characteristics, treatment, and outcomes in patients with stable coronary disease after the first wave of the severe acute respiratory syndrome coronavirus 2 (SARS- -CoV-2) pandemic may provide valuable data and is beneficial for public health strategy in upcoming years. A multi-institutional registry, including 10 cardiology departments, was searched for patients admitted from June 2020 to October 2020. The baseline characteristics (age, gender, symptoms, comorbidities), treatment (non-invasive, invasive, surgical), and hospitalization outcome (mortality, myocardial infarction, stroke, composite endpoint - major adverse cardiac and cerebrovascular events [MACCE]) were evaluated. The comparison was made to parameters presented by patients from the same timeframe in 2019 (June-October). Multivariable analysis was performed. Number of hospitalized stable patients following lockdown was lower (2498 vs. 1903; p < 0.0001). They were younger (68.0 vs. 69.0; p < 0.019), more likely to present with hypertension (88.5% vs. 77.5%; p < 0.0001), diabetes (35.7% vs. 31.5%; p = 0.003), hyperlipidemia (67.9% vs. 55.4%; p < 0.0001), obesity (35.8% vs. 31.3%; p = 0.002), and more pronounced symptoms (Canadian Cardiovascular Society [CCS] III and CCS class IV angina: 30.4% vs. 26.5%; p = 0.005). They underwent percutaneous treatment more often (35.0% vs. 25.9%; p < 0.0001) and were less likely to be referred for surgery (3.7% vs. 4.9%; p = 0.0001). There were no significant differences in hospitalization outcome. New York Heart Association (NYHA) class IV for heart failure was a risk factor for both mortality and MACCE in multivariate analysis. The SARS-CoV-2 2019 pandemic affected the characteristics and hospitalization course of stable angina patients hospitalized following the first wave. The hospitalization outcome was similar in the analyzed time intervals. The higher prevalence of comorbidities raises concern regarding upcoming years.

The trajectory of statin compliance after coronary artery bypass grafting surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background The current guidelines about dyslipidemia classify coronary artery bypass grafting surgery (CABG) patients, as a very high-risk population. This is translated to a LDL-target ≤ 55mg/dL, based on observational studies that demonstrate better vein graft patency and deceleration of the native vessels’ atherosclerosis. Despite the well-defined benefit, the compliance of statin therapy at the secondary prevention is ailing. Purpose To capture and evaluate the trajectory of statin compliance during 4 years follow-up in patients after CABG, in a middle-income country. Methods This is a single-center, cohort, observational study, conducted in 365 consecutive post-CABG patients, from 2018-2021. We used data from the electronical files of the patients and the national electronical prescription platform, after consent. The follow-up period was divided: t1 = 6 months, t2 = 1 year, t3= 2 years, t4 = 3 years, and t5= 4 years. We defined as potent statin therapy the administration of ≥ 40mg of atorvastatin, ≥ 20mg of rosuvastatin or the concomitant use of ezetimibe. Results We included 365 patients, 52 females (14.4%). The median age was 69 years (ΙQR: 47-84). The indication for CABG was 65.7% an acute coronary syndrome and 34.3% stable coronary disease. At baseline, the mean LDL value was 108mg/dL, whereas one month post procedure was 71mg/dL, indicating reduction: Δ=34%. Alas, the achieved post-CABG LDL-level still is beyond the target of ≤ 55mg/dL. At t0 (discharge) the percentage of prescribed statins was 81%, but only in 68% of them, the statin was high potent. At t1 the rate of the compliance raised up to 92.5% and the potency rate to 74.6%. At t2 the compliance and the potency remained high, 94.3% and 74.8% respectively. At t3 the compliance is rather stable (92.3%) but the rate of potency declines (64%) and decline further at t4 (89% and 58% respectively). Finally, at t5 both indexes depleted (81% and 57.1%, respectively). The rate of escalation to a potent statin was: t1= 36.3%, t2= 13.9%, t3 = 12.4%, t4 = 3.8%, t5=2.1%. The de-escalation rate was: t1= 13.9%, t2= 2.4%, t3 = 7.3%, t4 = 0.8%, t5=0.1%. The prescribed statin remained the same at t1= 50.8%, t2= 83.6%, t3 = 76.6%, t4 = 79% and t5=75%. The rate of permanent discontinuation was null during the first year, 4.1% at 2 years, 18.2% at 3 years and 19.5% at 4 years. Conclusions The LDL level one-month post-CABG, remains out of target and a further 22% reduction is needed. We highlight the significant rate of prescribed statin at discharge and substantial compliance which is rather sustained during the follow-up period. Nota bene the rate of potency lessens over time, whereas the rate of permanent discontinuation raises, implying that as the patient enters a "stabilized period" at 2 years post-surgery, the eagerness to maintain high-potent statin therapy, declines. This real-world practice subtracts the pleiotropic benefits of potent statins, not only over the ongoing atherosclerosis.

Long-term follow-up after invasive or conservative management of stable coronary disease: the ISCHEMIA-EXTEND study.

The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.