Stenosis Of Major Coronary Artery Research Articles

Coronary CT angiography for preoperative evaluation of non-cardiac surgery in patients with thoracic tumors: preliminary exploratory analysis in a retrospective cohort

PurposeNoninvasive coronary CT angiography (CCTA) was used to retrospectively analyze the characteristics of coronary artery disease (CAD) in patients with thoracic tumors and the impact of the results on clinical surgery decision-making, thus increasing the understanding of perioperative cardiac risk evaluation.MethodA total of 779 patients (age 68.6 ± 6.6 years) with thoracic tumor (lung, esophageal, and mediastinal tumor) scheduled for non-cardiac surgery were retrospectively enrolled. Patients were divided into two groups: accepted or canceled surgery. Clinical data and CCTA results were compared between the two groups, and multivariate logistic regression analysis was performed to determine predictors of the events of cancellations of scheduled surgeries.Results634 patients (81.4%) had non-significant CAD and 145 patients (18.6%) had significant CAD. Single‑, 2‑, and 3‑ vessel disease was found in 173 (22.2%), 93 (11.9%) and 50 (6.4%) patients, respectively. 500 (64.2%), 96 (12.3%), 96 (12.3%), 56 (7.2%) and 31 (4.0%) patients were rated as CACS 0, 1–99, 100–399, 400–999 and > 1000, respectively. Cancellations of scheduled procedures continue to increase based on the severity of the stenosis and the number of major coronary artery stenosis. The degree of stenosis and the number of vascular stenosis were independent predictors of cancelling scheduled surgery.ConclusionsFor patients with thoracic tumors scheduled for non-cardiac surgery, the results suggested by CCTA significantly influenced surgery planning and facilitated to reduce perioperative cardiovascular events.

A STUDY TO IDENTIFY THE PRESENCE OF SEVERE CORONARY ARTERY DISEASE IN PATIENTS WITH NO ELECTROCARDIOGRAPHIC, BIOCHEMICAL AND ECHOCARDIOGRAPHIC EVIDENCE OF CAD USING CT CORONARY ANGIOGRAPHY

INTRODUCTION:Acute chest pain is one of the most common reasons for seeking care in the emergency department (ED), accounting for approximately 10% of all visits. The difficulty lies in discriminating patients with ACS or other lifethreatening conditions from those with non-cardiovascular,non-life-threatening chest pain.The diagnosis ofACS is missed in approximately 2%ofpatients.But itis essential to rule out cardiovascular etiology of chestpain to avoidunnecessary cost and complications of investigations and treatment. This study aims at identifying the prevalence of significant coronary artery disease in patients with no electrocardiographic and biochemical evidence of coronary artery disease. AIM OF STUDY: To identifying the presence of severe coronary artery disease in the patients with no electrocardiographic, biochemical and echocardiographic evidence of CAD using CT Coronary Angiography. MATERIAL AND METHODS: The study was conducted on 50 patients during a period of 4 months,admitted with history of chest pain without any ECG evidence of STEMI, negative cardiac markers, no evidence of RWMA on 2D ECHO, or previous history of myocardial infarction.RESULTS: Out of the 50 patients studied, 38 (76%) were males and 12 (24%) were females.A total of 6 patients (12%) were found to have severe stenosis in major coronary arteries (stenosis > 70%) of which 4 were males (10.5%) and 2 were females (16.67%).CADRAD score≥3 was found in 9 patients (18%):6 males (15.78%) and 3 females (12%).Average age of patients who presented with chest pain with no electrocardiographic and biochemical evidence of coronary artery disease was found to be 61.7 years in males and 60.1 in females.66.7% of the female patients and 78.94% of male patients were over the age of 55 years.CONCLUSION: Furtherworkupofpatientswith chestpainwith no electrocardiographic and biochemicalevidenceofcoronaryarterydiseaseisnecessarytoavoidmissingdiagnosisofCAD

Machine learning-based marker for coronary artery disease: derivation and validation in two longitudinal cohorts

Binary diagnosis of coronary artery disease does not preserve the complexity of disease or quantify its severity or its associated risk with death; hence, a quantitative marker of coronary artery disease is warranted. We evaluated a quantitative marker of coronary artery disease derived from probabilities of a machine learning model. In this cohort study, we developed and validated a coronary artery disease-predictive machine learning model using 95 935 electronic health records and assessed its probabilities as in-silico scores for coronary artery disease (ISCAD; range 0 [lowest probability] to 1 [highest probability]) in participants in two longitudinal biobank cohorts. We measured the association of ISCAD with clinical outcomes-namely, coronary artery stenosis, obstructive coronary artery disease, multivessel coronary artery disease, all-cause death, and coronary artery disease sequelae. Among 95 935 participants, 35 749 were from the BioMe Biobank (median age 61 years [IQR 18]; 14 599 [41%] were male and 21 150 [59%] were female; 5130 [14%] were with diagnosed coronary artery disease) and 60 186 were from the UK Biobank (median age 62 [15] years; 25 031 [42%] male and 35 155 [58%] female; 8128 [14%] with diagnosed coronary artery disease). The model predicted coronary artery disease with an area under the receiver operating characteristic curve of 0·95 (95% CI 0·94-0·95; sensitivity of 0·94 [0·94-0·95] and specificity of 0·82 [0·81-0·83]) and 0·93 (0·92-0·93; sensitivity of 0·90 [0·89-0·90] and specificity of 0·88 [0·87-0·88]) in the BioMe validation and holdout sets, respectively, and 0·91 (0·91-0·91; sensitivity of 0·84 [0·83-0·84] and specificity of 0·83 [0·82-0·83]) in the UK Biobank external test set. ISCAD captured coronary artery disease risk from known risk factors, pooled cohort equations, and polygenic risk scores. Coronary artery stenosis increased quantitatively with ascending ISCAD quartiles (increase per quartile of 12 percentage points), including risk of obstructive coronary artery disease, multivessel coronary artery disease, and stenosis of major coronary arteries. Hazard ratios (HRs) and prevalence of all-cause death increased stepwise over ISCAD deciles (decile 1: HR 1·0 [95% CI 1·0-1·0], 0·2% prevalence; decile 6: 11 [3·9-31], 3·1% prevalence; and decile 10: 56 [20-158], 11% prevalence). A similar trend was observed for recurrent myocardial infarction. 12 (46%) undiagnosed individuals with high ISCAD (≥0·9) had clinical evidence of coronary artery disease according to the 2014 American College of Cardiology/American Heart Association Task Force guidelines. Electronic health record-based machine learning was used to generate an in-silico marker for coronary artery disease that can non-invasively quantify atherosclerosis and risk of death on a continuous spectrum, and identify underdiagnosed individuals. National Institutes of Health.

Association of Anxiety and Depression in Patients Undergoing Cardiac Catheterization With Number of Major Coronary Artery Stenosis: A Cross-Sectional Study.

IntroductionThe relationship between the level of anxiety and depression among coronary artery disease (CAD) patients and coronary angiographic findings is ambiguously mentioned in studies. Past evidence shows that the relationship between anxiety and depression with coronary artery disease can be bidirectional. There is a paucity of literature on the association of levels of anxiety and depression with the number of coronary arteries involved in coronary artery disease.MethodsThis study was conducted in a tertiary care hospital to find the level of anxiety and depression in patients undergoing cardiac catheterization and their association with the numbers of the major coronary artery involved. Patients undergoing cardiac catheterization in the Department of Cardiovascular Science of a tertiary care hospital in India from May 2020 to December 2020 were considered for inclusion in the study. Coronary artery disease was diagnosed based on the combination of clinical, ECG, echocardiography, or biomarker parameters in various combinations. These patients were further subjected to coronary angiogram to know the extent of stenosis and the number of coronary vessels involved in the disease. The level of anxiety and depression was measured by using the Hospital Anxiety and Depression Scale (HADS) during the period of admission and at least 24 hours after diagnosis and at least 12 hours before cardiac catheterization. The data was entered into SPSS software version 22.0 (Armonk, NY: IBM Corp.) for statistical analysis. Chi-square test, Kolmogorov-Smirnov test, and Kruskal-Wallis test were used for the interpretation of data and find an association between severity of anxiety and depression with the number of major coronary vessels involved.ResultsAnxiety was seen in 83.3% of the patients with 31.5% having severe anxiety. Depression was found in 77.8% with 38.9% suffering from severe depression. The anxiety and depression scores of HADS were significantly higher in those with triple-vessel disease compared to the double-vessel or single-vessel disease.ConclusionScreening and management of anxiety and depression is an essential part of the care of patients with coronary artery disease. People with triple-vessel disease need the most attention and appropriate management of anxiety and depression.

Circulating C1q/TNF-related protein-12 levels are associated with the severity of coronary artery disease

BackgroundCoronary artery disease (CAD) is the world's largest cause of death. The association of CAD with inflammation is well established. Recently, it has been confirmed that the C1q/TNF-related protein 12 (CTRP12) has a great anti-inflammatory effect. However, few data are available regarding the serum CTRP12 concentration levels in CAD patients. ObjectiveThe study was performed to evaluate the correlation between the serum levels of CTRP12 and the CAD severity regarding to the number of affected vessels. MethodsAbout 200 suspected CAD patients and 50 healthy ones as a control, were evaluated based on case-control study. According to the results of angiography, patients were divided into CAD+ (n = 150) with any major coronary artery stenosis ≥50% and CAD− (n = 50) with <50% stenosis of the arteries. The CAD+patients were categorized into one- (1VD), two- (2VD) and three-vessel disease (3VD) based on the number of stenotic vessels. In the current study, different parameters such as CTRP12, tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), total oxidant status (TOS), total antioxidant capacity (TAC), and malondialdehyde (MDA) levels were evaluated, and also lipid profiles, hs-CRP and demographic factors were investigated as well. ResultsData revealed that CTRP12 and TAC levels in CAD + group were significantly lower than control subjects (P < 0.05). CTRP12 levels were found to be significantly lower in the 3VD compared with 1VD and 2VD subgroups (p < 0.01 and p < 0.05, respectively). ConclusionOur results confirmed that serum CTRP12 level is inversely associated with CAD severity. Therefore, it may be used as a prediction marker for CAD.

Effects of salvianolate on microcirculatory disturbance in patients with stable coronary heart disease: study protocol for a randomized controlled trial

BackgroundObstruction of coronary microcirculation can lead to myocardial ischemia and poor prognosis. Salvianolate exerts cardiovascular protection at cellular levels. However, no studies have confirmed the effect of salvianolate on stable coronary heart disease (CHD) with high fractional flow reserve (FFR) and myocardial microcirculatory disturbances.Methods/designThis study will enroll 78 patients who have stable coronary disease with 50 to 70% stenosis in major coronary arteries and whose FFR > 0.80 and index of microcirculatory resistance (IMR) > 25. Patients will be randomly divided into the salvianolate group or the placebo group. After above evaluations, salvianolate 200 mg will be intravenously dripped immediately for the next 30 min and subsequent 7 days in the salvianolate group, and matching 0.9% normal saline will be arranged in the placebo group. IMR will be reevaluated in immediate phase after first 30 min of salvianolate or placebo treatment. The primary end point will be the IMR change in this phase, and the secondary end points will be the total ischemic burden assessed by the Seattle angina scale, quality of life scale, Holter electrocardiography, and 6-min walk test after 7 days before discharge.DiscussionThis study will firstly clarify the improvement effect of salvianolate on coronary microcirculation and provide an effective treatment method for stable CHD patients with high FFR and myocardial microcirculatory disturbance.Trial registrationChinese Clinical Trial Registry ChiCTR1800018772. Registered on 9 October 2018 and updated on 2 March 2020

Impact of pre-operative coronary artery disease on the clinical outcomes of patients with aortic aneurysms.

Aortic aneurysm is an increasingly important public health problem with high morbidity and mortality. It is associated with coronary artery disease (CAD), which is a comorbidity of high incidence that is reported to worsen perioperative complications and long-term clinical outcomes in patients with an aortic aneurysm. Patients with significant coronary artery stenosis may require coronary revascularization and/or optimal medical therapy in the perioperative period of aneurysm surgery. However, the prognostic impact of non-significant coronary artery stenosis not indicated for coronary revascularization on clinical outcomes of patients with aortic aneurysms remains unclear. We performed coronary angiography on 239 consecutive patients with thoracic and abdominal aortic aneurysms before endovascular aortic repair or surgical repair. The patients were divided into the following 3 groups according to the severity of stenosis of major coronary arteries: non-CAD group (with < 25% stenosis), non-significant CAD group (with ≥ 25% but < 75% stenosis), and significant CAD group (with ≥ 75% stenosis). CAD was diagnosed in 133 (56%) patients consisting of 48 (20%) patients with non-significant CAD and 85 (36%) patients with significant CAD. Thirty-nine major adverse cardiovascular and cerebrovascular events (MACCEs) occurred in a median follow-up period of 723days. Kaplan-Meier analysis revealed that the risk of MACCEs was higher in the significant and non-significant CAD groups than in the non-CAD group. Multivariate Cox proportional hazard regression analysis showed that the risk of MACCEs was equally high in the non-significant CAD and significant CAD groups compared to that in the non-CAD group after adjustment for confounding factors. CAD is significantly associated with poor outcomes in patients with aortic aneurysms, irrespective of the significance of CAD.

Clinical and Angiographic Predictors of Patient-Reported Angina 1 Year After Coronary Artery Bypass Graft Surgery.

Studies of the relationship between patient self-reported angina symptoms using the Seattle Angina Questionnaire (SAQ) and angiographic findings after coronary artery bypass grafting surgery (CABG) are lacking. Nested within a randomized controlled trial, this prospective observational cohort comparison study aimed to assess which clinical characteristics and angiographic findings are associated with self-reported angina 1 year after CABG. Patients from the ROOBY trial (Randomized On/Off Bypass) with protocol-specified 1-year post-CABG coronary angiography and SAQ assessments were included (n=1258). Patients reporting no angina (62.3%) within 4 weeks before the 1-year post-CABG study visit on the SAQ angina frequency domain were compared with patients reporting angina (37.7%). Multivariable modeling identified clinical variables and angiographic findings associated with angina. Sequential univariate and multivariable modeling found the following demographic and clinical factors were associated with angina after CABG: younger age, worse preoperative SAQ angina frequency score, smoking, diabetes mellitus, and pre-CABG depression. The only 1-year angiographic finding significantly associated with angina was incomplete revascularization of the left anterior descending (LAD) territory. Graft occlusions, incomplete revascularization of non-LAD territories, and ≥70% lesions in nonrevascularized native coronary arteries were not correlated with the presence or absence of angina. Further, only 30.6% of subjects reporting angina at 1 year had a residual major coronary artery stenosis of ≥70%. Self-reported angina 1 year after CABG is associated with younger age, worse baseline SAQ angina frequency score, smoking, diabetes mellitus, and depression. The only angiographic finding associated with angina was a poorly revascularized LAD territory. These results may help guide physicians when counseling patients on expected improvements in angina symptoms and in making decisions regarding the need for coronary angiography after CABG. Whether intensive treatment of these comorbidities improves post-CABG angina symptoms requires further study. URL: https://www.clinicaltrials.gov . Unique identifier: NCT00032630.

Thromboembolic Risk of Imaging-Confirmed Coronary Artery Disease Without Myocardial Infarction in Patients With Nonvalvular Atrial Fibrillation

The implication of coronary artery disease (CAD) without the clinical manifestation of myocardial infarction (non-MI-CAD) on thromboembolic events in patients with nonvalvular atrial fibrillation (NVAF) is not well evaluated. We hypothesized that non-MI-CAD would have a similar risk of future thromboembolism as MI-CAD. Clinical data for 17,073 consecutive patients (mean age, 64.3 years; males, 64.9%) diagnosed with NVAF at our center were analyzed. CAD was defined as stenosis of ≥50% stenosis of major coronary arteries identified using coronary artery angiography or coronary computed tomographic angiography. The main outcome of the present study was the rate of thromboembolic events (ischemic stroke and systemic embolism) during the follow-up period (3.1 ± 2.4 years). A total of 1,011 patients (5.9%) were diagnosed with CAD without clinical manifestation of MI (non-MI-CAD) and 708 (4.1%) had a history or diagnosis of MI-CAD. Thromboembolic events occurred in 1,007 patients (5.9%) during follow-up. The groups were at high risk of future thromboembolic events determined using univariate (hazard ratio [HR] 1.55; 95% confidence interval [CI] 1.25 to 1.91; p <0.001 for non-MI-CAD and HR 2.14; 95% CI 1.70 to 2.69; p <0.001 for MI-CAD) and multivariate analysis adjusted for CHA2DS2-VASc score components and relevant variables (HR 1.42; 95% CI 1.15 to 1.77; p = 0.001 for non-MI-CAD and HR 1.62; 95% CI 1.28 to 2.06; p <0.001 for MI-CAD); this trend was consistent in patients who did not receive anticoagulants during follow-up (n = 8,032, 47.0%). In conclusion, non-MI-CAD is an important predictor of thromboembolic events in patients with NVAF.

Prognostic impact of residual stenosis after percutaneous coronary intervention in patients with ischemic heart failure – A report from the CHART-2 study

BackgroundComplete revascularization with PCI is not always achieved in patients with ischemic HF. Therefore, this study aimed to elucidate the prognostic impact of residual coronary stenosis (RS) after percutaneous coronary intervention (PCI) in patients with ischemic heart failure (HF). MethodsWe analyzed a total of 1307 patients with symptomatic HF and a history of PCI registered in our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study. RS that was defined as the presence of ≥70% luminal stenosis in major coronary arteries at the last coronary angiography. ResultsAmong the study population, 851 patients (65.1%) had RS. During a median follow-up period of 3.2 years, patients with RS had higher all-cause mortality than those without it even after propensity score matching (21.9 vs. 11.6%, log-rank P = 0.027). Multivariable Cox hazard analysis also showed the negative impact of RS on all-cause death in ischemic HF patients [hazard ratio (HR):1.62, 95% confidence interval (CI): 1.07–2.46, P = 0.024]. Importantly, when divided all subjects into three subgroups by left ventricular ejection fraction (LVEF) [LVEF < 40% (HFrEF), LVEF 40–49% (HFmrEF), and LVEF ≥ 50% (HFpEF)], inverse probability of treatment weighted method provided a similar result that RS after PCI was an independent risk factor for death in the HFpEF [HR(95%CI); 1.94(1.22–3.09), P < 0.01] and HFmrEF [4.47(1.13–14.98), P < 0.01] groups, but not in the HFrEF group [1.20(0.59–2.43), P = 0.62]. ConclusionsThese results indicate that RS after PCI could aggravate long-term prognosis of ischemic HF patients with moderate- to well-preserved EF, but not those with reduced EF.

The Rationale for Performance of CoronaryAngiography and Stenting Before Transcatheter Aortic Valve Replacement: From the Interventional Section Leadership Council of the American College of Cardiology.

Transcatheter aortic valve replacement (TAVR) is an effective, nonsurgical treatment option for patients with severe aortic stenosis. The optimal treatment strategy for treating concomitant coronary artery disease (CAD) has not been tested prospectively in a randomized clinical trial. Nevertheless, it is standard practice in the United States to perform coronary angiography and percutaneous coronary intervention for significant CAD at least 1 month before TAVR. Allexisting clinical trials were designed using this strategy. Therefore, it is wrong to extrapolate current American College of Cardiology/American Heart Association Appropriate Use Criteria against invasive procedures in asymptomatic patients to the TAVR population when evaluating the quality of care by cardiologists or hospitals. In this statement from the Interventional Section Leadership Council of the ACC, it is recommended that percutaneous coronary intervention should be considered in all patients with significant proximal coronary stenosis in major coronary arteries before TAVR, even though the indication is not covered in current guidelines.

Effect of the glucagon-like peptide-1 analogue liraglutide on coronary microvascular function in patients with type 2 diabetes - a randomized, single-blinded, cross-over pilot study.

BackgroundImpaired coronary microcirculation is associated with a poor prognosis in patients with type 2 diabetes. In the absence of stenosis of major coronary arteries, coronary flow reserve (CFR) reflects coronary microcirculation. Studies have shown beneficial effects of glucagon-like peptide-1 (GLP-1) on the cardiovascular system. The aim of the study was to explore the short-term effect of GLP-1 treatment on coronary microcirculation estimated by CFR in patients with type 2 diabetes.MethodsPatients with type 2 diabetes and no history of coronary artery disease were treated with either the GLP-1 analogue liraglutide or received no treatment for 10 weeks, in a randomized, single-blinded, cross-over setup with a 2 weeks wash-out period. The effect of liraglutide on coronary microcirculation was evaluated using non-invasive trans-thoracic Doppler-flow echocardiography during dipyridamole induced stress. Peripheral microvascular endothelial function was assessed by Endo-PAT2000®. Interventions were compared by two-sample t-test after ensuring no carry over effect.ResultsA total of 24 patients were included. Twenty patients completed the study (15 male; mean age 57 ± 9; mean BMI 33.1 ± 4.4, mean baseline CFR 2.35 ± 0.45). There was a small increase in CFR following liraglutide treatment (change 0.18, CI95% [-0.01; 0.36], p = 0.06) but no difference in effect in comparison with no treatment (difference between treatment allocation 0.16, CI95% [-0.08; 0.40], p = 0.18). Liraglutide significantly reduced glycated haemoglobin (HbA1c) (-10.1 mmol/mol CI95% [-13.9; -6.4], p = 0.01), systolic blood pressure (-10 mmHg CI95% [-17; -3], p = 0.01) and weight (-1.9 kg CI95% [-3.6; -0.2], p = 0.03) compared to no treatment. There was no effect on peripheral microvascular endothelial function after either intervention.ConclusionsIn this short-term treatment study, 10 weeks of liraglutide treatment had no significant effect on neither coronary nor peripheral microvascular function in patients with type 2 diabetes. Further long-term studies, preferably in patients with more impaired microvascular function and using a higher dosage of GLP-1 analogues, are needed to confirm these findings.Trial registrationClinicalTrials.gov: NCT01931982.Electronic supplementary materialThe online version of this article (doi:10.1186/s12933-015-0206-3) contains supplementary material, which is available to authorized users.

Abstract 13697: Glucagon-like Peptide-1 Analogue Liraglutide Does Not Improve Microvascular Myocardial Function in Patients With Type 2 Diabetes - a Randomized, Single-blinded Cross Over Trial

Background: Impaired coronary microcirculation is associated with a poor prognosis in patients with type 2 diabetes. In the absence of stenosis of major coronary arteries, coronary flow reserve (CFR) reflects coronary microcirculation. Studies have shown beneficial effects of glucagon-like peptide-1 (GLP-1) on the cardiovascular system. The aim of the study was to explore the short-term effect of GLP-1 treatment on coronary microcirculation estimated by CFR in patients with type 2 diabetes. Methods: Twenty patients with type 2 diabetes and no history of coronary artery disease were treated with the GLP-1 analogue Liraglutide for 10 weeks, in a randomized single-blinded crossover setup. The effect of GLP-1 on coronary microcirculation was evaluated using non-invasive trans-thoracic Doppler-flow echocardiography during dipyridamole induced stress. Data were analysed as two-sample t-test after ensuring no carry over effect. Results: A total of 20 patients (15 male; mean age 57 ± 9; mean BMI 33.1 ± 4.4, mean baseline CFR 2.35 ± 0.45) completed full protocol. There was a small increase in CFR following GLP-1 treatment (change 0.18, CI95% [-0.01; 0.36], p=0.06) but with no difference in effect compared with the no treatment group (0.16, CI95% [-0.08; 0.40], p=0.18). GLP-1 significantly reduced glycated haemoglobin (-10.1 mmol/mol CI95% [-13.9; -6.4], p=&lt;0.001) systolic blood pressure (-10 mmHg CI95% [-17; -3], p=0.01) and weight (-1.9 kg CI95% [-3.6; -0.2], p=0.03). Conclusion: Despite a significant weight-loss, reduction in HbA1c and systolic blood pressure, we did not find a significant improvement in coronary microcirculation after 10 weeks treatment with GLP-1. In our short-term treatment study, we therefore conclude that the GLP-1 analogue Liraglutide does not improve coronary microcirculation in patients with type 2 diabetes. Further long-term studies are needed to explore mechanisms to improve coronary microcirculation in patients with type 2 diabetes.

The Role of Myocardial Perfusion Gated SPECT Study in Women with Coronary Artery Disease: A Correlative Study

Objective: We aimed to evaluate the role of gated myocardial perfusion SPECT (MPS) and to investigate whether only the invasive coronary angiography (CAG) is sufficient in the diagnosis of the coronary artery disease (CAD) in women. Material and Methods: Sixty-four women (62±10 years) with known CAD were included in this study. They had echocardiography (ECHO), stress/rest gated MPS and invasive CAG. Coronary stenosis as of > 50 % in invasive CAG was accepted as significant. Gated MPS data were compared with invasive CAG and ECHO. Results: Invasive CAG results were abnormal in 34 patients, and normal in 30 cases. Myocardial ischemia was detected by gated MPS in 22/ 30 cases with normal invasive CAG, 6 had mild coronary stenosis in major coronary arteries ranging from 30% to 50% in invasive CAG. 16/ 22 women were diagnosed as metabolic syndrome according to MetSend Diagnostic Criteria and only 8 of 30 patients with normal invasive CAG had false positive MPS data on the reevaluation by a nuclear cardiologist.Conclusion: We think that invasive coronary angiography method is not sufficient alone in the diagnosis of CAD in women. Gated MPS study is recommended to achieve the final decision for myocardial ischemia in the cases with CAD and raw data must always be evaluated to avoid attenuation artifacts. Conflict of interest:None declared.

15 Can Blood Biomarkers Improve the Assessment of Severity of Allograft Vasculopathy?

Long term survival of cardiac transplant (Tx) recipients is largely limited by the development of cardiac allograft vasculopathy (CAV). Currently, the diagnosis of CAV involves assessment of luminal stenosis in major coronary arteries of the transplanted heart via angiography or intravascular ultrasound. In the current study, we examined blood-derived mRNA and proteins in cardiac Tx patients to identify biomarkers that specifically reflect the severity of angiographically-defined coronary artery stenosis.

Abstract 3711: Increased Expression of Plasma Granzyme B in the Patients with Coronary Artery Disease Complicated with Chronic Kidney Disease

Background: Recent clinical studies have revealed that chronic kidney disease (CKD) is a significant independent risk factor for major cardiovascular events. However, the mechanisms in which CKD increases the incidence of cardiovascular diseases are still not fully understood. Hypothesis: Granzyme B is a member of serine protease family released from cytotoxic T lymphocytes and plays an important role in cellular apoptosis via an activation of caspases. We hypothesized that granzyme B is involved in formation of coronary artery lesions in patients with CKD. Objectives: To elucidate the role of granzyme B in coronary artery disease (CAD) in patients complicated with CKD. Subjects and methods: We employed 141 patients (116 men and 25 women, mean age: 64.2±9.6 years old ). Diagnosis of CAD was confirmed by selective coronary angiography. CKD was defined as sustained decrease in estimated glomerular filtration rate less than 60 mL/min/1.73m 2 over 3 months. We assigned patients into three groups; CAD without CKD (CAD group, n=46), CKD without CAD (CKD group, n=17) and CAD with CKD (CAD/CKD group, n=78). Patients with acute coronary syndrome, immunological disorder, malignancy and acute inflammatory diseases were excluded from the study. Results: Analysis of variance showed that plasma levels of high-sensitive CRP (hsCRP) and granzyme B in CAD/CKD group were significantly higher than those in the other groups (hsCRP: CAD; 2420±763, CKD; 1802±584, CAD/CKD: 7419±2171 ng/mL, p&lt;0.05, granzyme B: CAD: 9.1±2.3, CKD: 42.2±2.4, CAD/CKD: 159±51.8 pg/mL, p&lt;0.01). A significant positive correlation was observed between plasma hsCRP and granzyme B levels (r=+0.30, p&lt;0.05). A significant negative correlation was observed between eGFR and granzyme B levels (r=−0.32, p&lt;0.01). Multiple regression analysis revealed that granzyme B and hs CRP levels were independent predicting variables for the number of stenosis in major coronary arteries (F=5.35, p=0.002, beta coefficients: granzyme B=+0.24, p=0.006, hsCRP=+0.18, p=0.03). Conclusions: These results indicate that granzyme B might be a critical enzyme for formation of coronary atherosclerosis by inducing apoptosis of vascular tissues in patients with CKD.

Abstract 2013: Long Term Clinical Prognosis of Provocation Positive Variant Angina

Background Although coronary vasospasm provocation test is widely performed in daily clinical practice, data regarding the long term prognosis of variant angina is still limited. Methods We retrospectively investigated clinical consequence of 1,736 patients who underwent elective diagnostic coronary angiography and vasospasm provocation test for the evaluation of chest pain from Sep 1994 to Dec 2006. Variant angina was defined by decrease of anterograde coronary flow less than TIMI 2, or new development of severe coronary stenosis (diameter stenosis &gt; 90%) accompanied by typical angina pain and corresponding EKG change provoked by ergonovine intracoronary infusion, followed by nitroglycerin infusion and resolution of vasospasm. Patients who developed spontaneous spasm without provocation or underwent revascularization were excluded. Results Provocation test was positive in 723 patients and negative in 1,013 patients. Median follow-up period was 1452 days (interquartile range: 711 − 2606), which was not different between two groups. 5-year all major adverse cardiac event (MACE)-free, death-free, and revascularization-free survival was significantly lower in positive provocation group compared to negative group (90.0% versus 95.4%, 92.9% versus 95.7%, 96.8% versus 99.6%, p&lt;0.05 by log-rank test), and cardiac death-free survival was marginally lower in positive provocation group (96.9% versus 98.7%, p=0.051). Although positive provocation group showed higher incidence of smoking, diabetes, hypertension, and significantly fixed stenosis in major coronary arteries (frequency: 19.4% versus 8.2%), multivariate analysis using Cox proportional hazard model revealed that positive provocation test is still an independent predictor of MACE (p&lt;0.001). Conclusion Our result shows that positive provocation test might be associated with adverse outcome in chest pain patients. It suggests that long term medical care should be provided for patients with positive provocation test.

Association between the dosage and duration of statin treatment with coronary collateral development

The coronary collateral circulation is an alternative source of blood supply to myocardium in the presence of advanced coronary artery disease and the therapeutic promotion of collateral growth appears to be a valuable treatment strategy in these patients. Although it has been shown in in-vivo studies that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) promote vasculogenesis and accelerate coronary collateral development in ischemic tissues, there are discordant results in clinical studies. Our aim was to investigate the effect of statin therapy, including dosage and duration of treatment, on coronary collateral growth in patients with advanced coronary artery disease. Study population consisted of 400 (306 men, with the mean age of 62+/-10 years) consecutive patients who have undergone clinically indicated coronary angiography and had at least one major coronary artery stenosis of > or =95%. Coronary collaterals were graded from 0 to 3 according to the Cohen-Rentrop method and patients with grade 0-1 collateral development were regarded as having poor collateral and patients with grade 2-3 collateral development were regarded as having good collateral. Among 400 patients, 196 (48%) were on statin therapy. Patients with good collateral score were more likely to have stable angina pectoris as clinical presentation (P<0.001), and were on statin therapy (P=0.001), and have multivessel disease (P=0.003). Statin therapy for less than 3 months had no effect on collateral development (P=0.19); however, patients who were on statin therapy for more than 3 months had significantly better collateral development (P=0.002). Statin therapy had no effect on coronary collateral development in patients having <10 mg atorvastatin-equivalent dose (P=0.13); however, patients having > or =10 mg atorvastatin-equivalent dose had better collateral development (P<0.001). Diabetes mellitus was the only negative predictor for coronary collateral formation (P=0.03). On multivariate analysis, stable angina pectoris [odds ratio 2.88, 95% confidence interval (1.8-4.7), P<0.001], statin therapy with > or =10 mg atorvastatin-equivalent dose [odds ratio 2.06, 95% confidence interval (1.3-2.6), P<0.001] and having multivessel disease [odds ratio 1.86, 95% confidence interval (1.16-3), P=0.01] were found to be associated with rich collateralization. Statin therapy (> or =10 mg atorvastatin-equivalent dose), stable angina pectoris and having multivessel disease are associated with enhanced coronary collateral development in patients with advanced coronary artery disease.

The prevalence of cardiac ectopy in elderly patients with echocardiographically normal hearts is not increased by significant coronary artery disease

Issue A higher frequency of abnormal heart rhythms has previously been shown in elderly subjects with overtly normal hearts as demonstrated by noninvasive testing. However, no prior study on elderly patients with echocardiographically structurally normal hearts has distinguished cardiac dysrhythmia incidence based on the presence or absence of angiographically documented coronary artery disease (CAD). Methods We performed 24-hour ambulatory monitoring on patients with no coronary stenosis of greater than 30% and normal left ventricular (LV) systolic function by angiography. This group was then compared with a group of elderly patients with normal LV systolic function and at least one major coronary artery stenosis of 70% or greater. All patients had echocardiographically normal LV wall thickness and systolic function and no significant valvular disease. Results The experimental group was composed of 15 patients with CAD aged 71 ± 6 years. The control group without significant CAD was composed of 20 patients aged 73 ± 4 years ( P = not significant [NS]). There was no difference with respect to prevalence of hypertension, use of calcium-channel blockers, and history of smoking. There was no difference between the groups with regard to the number of premature atrial contractions (467 ± 759 [experimental] vs 672 ± 1789 [control]; P = NS); premature ventricular contractions (359 ± 599 [experimental] vs 290 ± 858 [control]; P = NS); and prevalence of ventricular couplets, ventricular tachycardia, paroxysmal atrial fibrillation, and supraventricular tachycardia (all P = NS). Conclusions These findings indicate that the prevalence of cardiac dysrhythmias in elderly patients with echocardiographically normal hearts is not influenced by the presence of angiographically significant CAD.

The Erlanger chest pain evaluation protocol: A one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes

Study objective: We determine the overall use of a 6-step accelerated chest pain protocol to identify and exclude acute coronary syndrome (ACS) and to confirm previous findings of the use of serial 12-lead ECG monitoring (SECG) in conjunction with 2-hour delta serum marker measurements to identify and exclude acute myocardial infarction (AMI). Methods: A prospective observational study was conducted over a 1-year period from January 1, 1999, through December 31, 1999, in 2,074 consecutive patients with chest pain who underwent our accelerated evaluation protocol, which includes 2-hour delta serum marker determinations in conjunction with automated SECG for the early identification and exclusion of AMI and selective nuclear stress testing for identification and exclusion of ACS. In patients not undergoing emergency reperfusion therapy, physician judgment was used to determine patient disposition at the completion of the 2-hour evaluation period: admit for ACS, discharge or admit for non-ACS condition, or immediate emergency department nuclear stress scan for possible ACS. A positive protocol was defined as a positive result in 1 or more of the 6 incremental steps in our chest pain evaluation protocol: (1) initial ECG diagnostic of acute injury or reciprocal injury; (2) baseline creatine kinase (CK)-MB level of 10 ng/mL or greater and index of 5% or greater or cardiac troponin I level of 2 ng/mL or greater; (3) new/evolving injury or new/evolving ischemia on SECG; (4) increase in CK-MB level of +1.5 ng/mL or greater or cardiac troponin I level of +0.2 ng/mL or greater in 2 hours; (5) clinical diagnosis of ACS despite a negative 2-hour evaluation; and (6) reversible perfusion defect on stress scan compared with on resting scan. All patients were followed up for 30-day ACS, which was defined as myocardial infarction (MI), percutaneous coronary intervention/coronary artery bypass grafting, coronary arteriography revealing stenosis of major coronary artery of 70% or greater not amenable to percutaneous coronary intervention/coronary artery bypass grafting, life-threatening complication, or cardiac death within 30 days of ED presentation. Results: Discharge diagnosis in the 2,074 study patients consisted of 179 (8.6%) patients with AMI, 26 (1.3%) patients with recent AMI (decreasing curve of CK-MB), and 327 (15.8%) patients with 30-day ACS. At 2 hours, sensitivity and specificity for MI (AMI or recent AMI) of SECG plus delta serum marker measurements was 93.2% and 93.9%, respectively (positive likelihood ratio 15.3; negative likelihood ratio 0.07). At the completion of the full ED evaluation protocol (positive result in ≥1 of the 6 incremental steps), sensitivity and specificity for 30-day ACS was 99.1% and 87.4%, respectively (positive likelihood ratio 7.9; negative likelihood ratio 0.01). Conclusion: An accelerated chest pain evaluation strategy consisting of SECG, 2-hour delta serum marker measurements, and selective nuclear stress testing in conjunction with physician judgment identifies and excludes MI and 30-day ACS during the initial evaluation of patients with chest pain. [Ann Emerg Med. 2002;40:584-594.]