Suspicion Of Coronary Artery Disease Research Articles

Quantification of epicardial fat: Which method can predict significant coronary artery disease?

To compare the predictive value of three methods of epicardial fat (EF) assessment for presence of significant coronary artery disease (CAD) [i.e., epicardial fat volume (EFV), EFV indexed with body surface area (EFV/BSA) and EFV indexed with body mass index (EFV/BMI)]. The study was performed on 170 patients (85 women and 85 men) with clinical suspicion of CAD. They aged 26-89 years with a median age of 54 years. The patients were classified into three groups: Group 1: 58 patients with normal coronary arteries; group 2: 48 patients with non-significant CAD and group 3: 64 patients with significant CAD. The three methods for assessment of epicardial fat were retrospectively studied to determine the best method to predict the presence of significant CAD. The three methods for epicardial fat quantification and measurements, i.e., EFV, EFV/BSA and EFV/BMI with post- hoc analysis showed a significant difference between patients with significant coronary artery disease compared to the normal group. Receiver operating characteristic curve analysis showed no significant difference between the three methods of epicardial fat measurements, the area under curve ranging between 0.6 and 0.62. The optimal cut-off was 80.3 cm(3) for EFV, 2.4 cm(3)/m(2) for EFV indexed with BMI and 41.7 cm(3)/(kg/m(2)) for EFV indexed with BSA. For this cut-off the sensitivity ranged between 0.92 and 0.94, while specificity varied from 0.31 to 0.35. Any one of the three methods for assessment of epicardial fat can be used to predict significant CAD since all have the same equivalent predictive value.

Índice Tornozelo-Braquial como Preditor de Doença Coronariana Significativa em Pacientes Submetidos à Angiografia Coronária

Introdução: O índice tornozelo-braquial é uma ferramenta simples e efetiva para diagnosticar doença arterial periférica, porém não foi ainda validado para o diagnóstico de doença arterial coronariana. O objetivo deste estudo foi avaliar o desempenho do índice tornozelo-braquial em predizer doença arterial coronariana em pacientes submetidos à angiografia coronária. Métodos: Pacientes com suspeita clínica de doença arterial coronariana e indicação de angiografia coronária foram avaliados prospectivamente. Doença arterial coronariana significativa foi definida como estenose ≥ 70% em pelo menos uma coronária epicárdica maior ou ramo principal. Uma curva ROC foi construída para definir o ponto de corte do índice tornozelo-braquial que melhor predizia doença arterial coronariana. Resultados: Foram estudados 312 pacientes, cuja média de idades foi 57 ± 11 anos e 50% eram do sexo masculino. Tinham doença coronariana significativa 116 pacientes (37,2%). A medida do índice tornozelo-braquial nestes pacientes foi significativamente menor do que naqueles sem doença arterial coronariana (0,88 ± 0,14 vs. 0,96 ± 0,87; p < 0,01). Índice tornozelo-braquial ≤ 0,87 mostrou sensibilidade de 31%, especificidade de 95,4%, valor preditivo positivo de 75,9% e valor preditivo negativo de 71,6%. A área da curva ROC foi 0,73 (intervalo de confiança de 95% 0,67-0,79). Conclusões: Índice tornozelo-braquial ≤ 0,87 teve alta especificidade para predizer doença arterial coronariana significativa. Considerando o baixo custo e a fácil utilização, a medida do índice tornozelo-braquial pode ser adicionada na prática clínica para auxiliar no diagnóstico de doença arterial coronariana significativa.

Implication of plasma intermedin levels in patients who underwent first-time diagnostic coronary angiography: a single centre, cross-sectional study.

BackgroundIntermedin (IMD) is involved in the prevention of atherosclerotic plaque progression, possessing cardioprotective effects from hypertrophy, fibrosis and ischemia-reperfusion injury. Elevated plasma IMD levels have been demonstrated in patients with acute coronary syndromes. No human study has examined the role of IMD in stable patients who underwent diagnostic coronary angiography with suspicion of coronary artery disease (CAD). Thus we investigated the role of IMD as a biomarker to discriminate patients with CAD and predict those with severe disease who require early and intensive therapeutic intervention before presenting with acute coronary syndrome.MethodsEligible two hundred and thirty-eight consecutive patients (123 males, mean age 58.4 ± 10.0 years) who underwent first-time diagnostic coronary angiography were included in this study. Plasma concentrations of IMD were measured from arterial blood samples by the enzyme-linked immunosorbent assay. Patients were divided into three groups according to the presence and degree of CAD, consisting of 48 patients with normal coronary anatomy (Group 1), 111 patients with < 50% coronary stenosis (Group 2), and 79 patients with ≥ 50% stenosis in at least one of the major coronary arteries (group 3). The severity and extent of CAD was evaluated by calculations of the vessel, Gensini, and SYNTAX scores.ResultsCirculating plasma IMD levels in patients with CAD were significantly higher than those in patients without CAD (157.7 ± 9.6, 134.8 ± 11.9, and 117.6 ± 7.9 pg/mL in groups 3, 2 and 1 respectively; p < 0.001). Besides, plasma IMD levels were correlated with Gensini and SYNTAX scores (rs = 0.742, and rs = 0.296, respectively; p < 0.05). The presence of ≥50% coronary artery stenosis could be predicted if a cut-off value of 147.7 pg/mL for plasma IMD was used with 88.6% sensitivity and 88.7% specificity. Moreover, a plasma IMD level of <126.6 pg/mL could discriminate a patient with normal coronary arteries from patients with angiographically proven CAD with a sensitivity and specificity of 84.7%, and 83.3% respectively.ConclusionsWe demonstrated that IMD might be used as a biomarker to predict CAD and its severity in patients who underwent first time diagnostic coronary angiography.

Comparação entre a razão de viabilidade subendocárdica obtida por tonometria de aplanação e alterações de perfusão miocárdica pela cintilografia

Introdução: Estudos recentes correlacionam índices obtidos por análise do contorno da onda de pulso pela tonometria de aplanação com fatores de risco cardiovascular, rigidez arterial e aterosclerose. Destes índices, a razão de viabilidade subendocárdica (RVSE), obtida pela razão da área diastólica e a área sistólica da onda de pulso, é considerada uma estimativa de perfusão coronariana. No entanto, não há estudo da correlação da RVSE com provas de perfusão, como a cintilografia. Métodos: Foram avaliados 52 pacientes com indicação de cintilografia de perfusão miocárdica para avaliação de suspeita de doença coronariana, dos quais foram obtidas as medidas de tonometria de aplanação pelo aparelho SphygmoCor®. Após a coleta dos dados, foi realizada a análise estatística para avaliar correlações entre os índices tonométricos e os achados cintilográficos. Resultados: O exame de cintilografia de perfusão miocárdica revelou alteração em 23 indivíduos (44,2%), sendo mais frequente em homens e naqueles com mais de 4 fatores de risco associados. A RVSE foi estatisticamente semelhante nos pacientes com (162,4±22,7%) ou sem alteração (164,7±32,2%) na cintilografia de perfusão miocárdica, mesmo considerando apenas as alterações isquêmicas transitórias. Os demais índices obtidos pela tonometria também não mostraram diferença entre os grupos com ou sem alteração na cintilografia. Conclusões: Em pacientes com suspeita de doença arterial coronariana observou-se mais alterações de perfusão na cintilografia miocárdica em homens e em pacientes com múltiplos fatores de risco. A RVSE assim como os demais índices obtidos pela análise da onda de pulso não se correlacionaram com alterações de perfusão miocárdica da cintilografia.

Screening in asymptomatic coronary artery disease: helpful, redundant or harmful?

Screening asymptomatic individuals remains the subject of intense debate in medicine. In the beginning of 2014 the use of screening for breast cancer in women was seriously questioned based on studies from Canada (Toronto) and the Netherlands (Leiden). It was shown that, particularly in women over 70 years, screening for breast cancer might even bring more harm than benefit in terms of over diagnosis and thus overtreatment. With respect to carotid artery disease, in September of this year the United States Preventive Services Task Force (USPSTF) published a recommendation to oppose the screening of the general adult population to detect asymptomatic carotid artery stenosis [1]. The Task Force found that ultrasound may produce false-positives resulting in angiography or even surgery, with the accompanying high risk of stroke, heart attack, or death. This recommendation may be important because it may influence insurance coverage. How about screening individuals with asymptomatic coronary artery disease? In a review article from the Netherlands (Rotterdam) a systematic review of guidelines on imaging of asymptomatic coronary artery disease showed the light in 2011 [2]. It turned out that guideline on risk assessment by imaging of asymptomatic coronary artery disease contained conflicting recommendations. Out of the 14 guidelines that met the inclusion criteria, eight guidelines recommended against or found insufficient evidence for testing individuals with asymptomatic coronary artery disease. The authors suggested therefore that more research, including randomized controlled trials, is needed to evaluate the impact of imaging on clinical outcomes and costs. Over the past years cardiac computed tomography (CT) has emerged as a screening tool - in addition to the proven use of major risk factors - to detect coronary artery disease in an early stage of its process [3–7]. Both calcium scoring and coronary CT angiography have been shown useful to identify coronary artery lesions. However, how does one manage the issue of using coronary CT as a screening test in asymptomatic individuals? According to the 2013 ESC Guidelines on Stable Angina Pectoris [8], both coronary calcium detection by CT and coronary CT angiography receive a Class III indication, meaning that there is ‘evidence and/or general agreement that the procedure is not useful/effective and in some cases may be harmful’. The inherent guideline recommendations were twofold: 1) coronary calcium detection by CT is not recommended to identify individuals with coronary artery disease, and 2) coronary CT angiography is not recommended as a screening test in asymptomatic individuals without clinical suspicion of coronary artery disease. Apart from the lack of usefulness of applying CT in asymptomatic individuals one should always be aware of the risk of radiation exposure using ionising imaging modalities to detect patients with coronary artery disease. To that purpose, the American Heart Association (AHA) very recently issued a scientific statement on cardiac imaging, published online on 29 September 2014 in the journal Circulation [9]. The AHA scientific statement recommended that exposure to radiation should be part of the discussion on cardiac imaging for both referring and performing physicians. Physicians should be required to know which cardiac imaging tests use ionising radiation, understand the basics of exposure, and know the typical dose estimates for the most commonly used cardiac imaging procedures. In addition, they should counsel patients on the risks as well as on potential benefits so that patients can give truly informed consent. Consequently, before referring a patient for a cardiac imaging test, the AHA recommends that physicians address important questions such as 1) how will the test help diagnose or treat the cardiac problem, 2) are there alternative modalities not using radiation, 3) what are the levels of radiation exposure, 4) how will it affect the risk of cancer later in life, and 5) how does that compare with the risk from other common activities. These questions remain pertinent despite successful technological attempts to reduce radiation exposure, which holds in particular for cardiac CT. To conclude, although screening for coronary artery disease -especially using advanced ionising cardiac imaging techniques [10] - may be helpful in patients with a intermediate to high probability of disease, it may be redundant in patients with a low prevalence of disease and even harmful in asymptomatic individuals.

MicroRNA-19b functions as potential anti-thrombotic protector in patients with unstable angina by targeting tissue factor

The activation of a hemostatic system plays a critical role in the incidence of acute coronary events. Hemostatic proteins may be regulated by microRNAs (miRNAs). Microparticles (MPs) are the major carrier of circulating miRNAs. The aim of this study was to determine the potential role of miRNAs in regulating gene expression involved in the hemostatic system in patients with unstable angina (UA). MiRNA expression profiles in the plasma from patients with UA (UA group, n=9) compared with individuals with clinical suspicion of coronary artery disease (CAD) but negative angiography (control group, n=9) showed that among 36 differentially expressed miRNAs, miR-19b was the most obvious one. Using real-time PCR, 5 selected miRNA levels in plasma (UA group, n=20; control group, n=30) and plasma MPs (UA group n=6; control group n=6) were proved to be consistent with the miRNA array. Flow cytometry analysis indicated that the amounts of plasma endothelial microparticles (EMPs) were increased in UA patients (UA group, n=4) compared to controls (control group, n=4). In cultured endothelial cells (ECs), TNF-α increased miR-19b release and expression. Tissue factor (TF) was predicted to be the target of miR-19b by bioinformatics analysis. Luciferase reporter assays demonstrated that miR-19b binds to TF mRNA. Overexpression of miR-19b inhibited TF expression and procoagulant activity. This study indicates that in UA patients, the increase of miR-19b wrapped in EMPs due to endothelial dysfunction may partially contribute to the circulating miR-19b elevation and miR-19b may play an anti-thrombotic role by inhibiting the expression of TF in ECs.

Noninvasive cardiac imaging for the diagnosis of coronary artery disease in women.

Cardiovascular diseases are the foremost cause of morbidity and mortality for both genders worldwide. Appropriate diagnostic tests with increased accuracy and safety provide the decisive relationship between diagnosis and treatment of coronary artery disease (CAD). However, it has been known that women at risk for occurrence of CAD are less often conducted for the proper diagnostic tests compared to men. Many noninvasive diagnostic modalities (exercise/stress electrocardiogram, echocardiography, nuclear imaging, magnetic resonance imaging and coronary computerized tomography) are available for this purpose in the women. In this review, we present the current data on the role of both conventional and modern noninvasive diagnostic tests in the assessment of women with CAD suspicion.

Conus Artery in Cardiac Computed Tomography

Patients and Methods: In 79 consecutive patients (aged 56 ± 12.9 years; 13 women), 64-slice CT was performed due to a suspicion of coronary artery disease. The standard protocol for scanning with retrospective gating was used for all the patients. Results: It was possible to visualize the conus artery in coronary CT angiography in 64 (81%) patients. The course of the conus artery in the right ventricle was commonly in the outflow tract direction. The conus artery was visualized at a distance of 33.2 ± 16.3 mm. The average diameter of the conus artery was 2.3 ± 0.8 mm. The conus artery most frequently originated from the first segment of the right coronary artery (53%) and directly from the aorta (37.9%). In the rest of the cases, there was a common trunk for both vessels (CA/RCA). Conclusions: In most cases, the conus artery can be visualized in cardiac CT. A description of the conus artery should be a part of the standard clinical coronary CT angiography description.

Prognostic Value of Aortic and Mitral Valve Calcium Detected by Contrast Cardiac Computed Tomography Angiography in Patients With Suspicion of Coronary Artery Disease

Aortic valve calcium (VC) detected on noncontrast cardiac computed tomography angiography (CCTA) is known to be associated with all-cause mortality in asymptomatic and primary prevention population. However, the clinical significance of aortic and mitral VC remains unknown in symptomatic patients with suspected coronary artery disease (CAD). The aim of the present study was to assess whether aortic and mitral VC is independently associated with cardiac events and all-cause mortality in symptomatic patients with suspected CAD. A total of 369 symptomatic patients (mean age 55 ± 11 years, 60% men) who were referred for CCTA because of suspected CAD were included in the study. Aortic and mitral VC was detected and quantified by volume on contrast CCTA. Median follow-up for events (coronary events and all-cause mortality) was 2.8 (interquartile range 1.6 to 4.0) with a maximum of 5.5 years. A total of 39 patients (11%) had VC. Increased age, hypertension, and increased Agatston coronary artery calcium score were associated with VC. During the follow-up, patients with VC had higher risk for a coronary event (38.8% vs 11%, log-rank p <0.001) and worse survival rate (92.3% vs 99.1%, log-rank p = 0.002) compared with those without VC. Volume of VC was independently associated with outcome after adjusting for clinical variables (hazard ratio 1.88, p <0.001), Agatston coronary artery calcium score (hazard ratio 1.47, p = 0.03), and significant CAD (hazard ratio 1.81, p = 0.001). In conclusion, aortic and mitral VC volume quantified on contrast CCTA was independently associated with coronary events and all-cause mortality in patients with suspected CAD.

Co-Existence of Carotid Artery Disease, Renal Artery Stenosis, and Lower Extremity Peripheral Arterial Disease in Patients With Coronary Artery Disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Pulmonary embolism after coronary angiography with femoral approach

Cardiologia CROATICA Objectives: Pulmonary embolism after elective coronary angiography is a very rare complication. Herein we report on a case of pulmonary embolism after diagnostic coronary angiography with femoral approach, and we also evaluate various pathophysiologic mechanisms possibly contributing to local vascular complications and also consequently safer and more efficient approaches for percutaneous coronary procedures. Case report: A 66 year-old female patient was admitted to our department for diagnostic coronary angiography due to high clinical suspicion for coronary artery disease. Coronary angiography was performed with the right common femoral artery access, and no coronary artery stenosis was verified on the examination. Although all the standard postangiography procedures were applied and hemostasis completed, subsequently an access site hematoma and a pseudoaneurysm developed. The day after the procedure, during verticalization, the patient complained of malaise, nausea and vertigo, and due to a high level of D-dimers, we performed MSCT angiography which confirmed pulmonary embolism (Figure 1). The doppler ultrasound of the lower extremity veins showed no signs of deep venous thrombosis, and we have not discovered any predisposing factors for pulmonary embolism. Discussion: Pulmonary embolism is rarely reported as a consequence of coronary angiography with femoral approach, probably since it is underdiagnosed considering its frequent asymptomatic course. Predisposing factors for deep venous thrombosis and pulmonary embolism with the femoral approach for coronary angiography are manual compression of the puncture site with unintentional compression of the femoral vein, compression with the sandbag and a gauze, puncture site hematoma or a femoral artery pseudoaneurysm, along with prolonged immobilization and bed rest. Conclusion: We assume that the cause of pulmonary embolism in our patient was transient deep venous thrombosis due to a combination of puncture area compression, hematoma and a femoral pseudoaneurysm with immobilization and postprocedural bed rest. Optimal placement of the arterial sheath, use of smaller sheaths, careful manual compression with shorter period of immobilization and bed rest, can significantly contribute to reducing the incidence of deep venous thrombosis and pulmonary embolism.

The Relation of Serum Pentraxin-3 Levels with Coronary Artery Ectasia

Giriş: Koroner arter ektazisi, koroner arterlerin tamamının veya bir bölümünün arterin normal kısmındaki çapına göre 1.5 kat veya daha fazla olmasıyla karakterize durum olup patofi zyolojisinde infl amasyon, nörohormonal aktivite ve ateroskleroz sorumlu tutulmaktadır. Koroner arter ektazisiyle infl amatuvar belirteçlerin ilişkisini gösteren çalışmalar mevcuttur, ancak koroner arter ektazisinin yeni tanımlanan bir infl amatuvar belirteç olan pentraksin-3 (PTX-3) ile ilişkisi konusunda yeterli veri yoktur. Bu çalışmamızda koroner arter ektazisi hastalarında serum PTX-3 ve yüksek duyarlı (high sensitive) C-reaktif protein (hs-CRP) seviyeleri arasındaki ilişkiyi incelemeyi amaçladık. Hastalar ve Yöntem: Bu çalışmaya anjinal semptomları ve pozitif iskemi bulguları olduğu için koroner anjiyografi yapılan 66 hasta ve 32 kontrol hastası dahil edilmiştir. Hastalar koroner arter hastalığı grubu (n= 32) ve koroner arter ektazisi grubuna ayrılmıştır (n= 34). Serum PTX-3 ve hs-CRP seviyeleri ölçülmüştür. Bulgular: Koroner arter ektazisi ve koroner arter hastalığı grubunda kontrol grubuna göre hs-CRP seviyesi yüksekti (koroner arter hastalığı ve kontrol hastası grubu için, 1.4 ± 0.7 vs. 0.8 ± 0.5, p< 0.001; koroner arter ektazisi ve kontrol hastası grubu için, 1.2 ± 0.5 vs. 0.8 ± 0.5, p< 0.001). Koroner arter hastalığı ve koroner arter ektazisi grubunda PTX-3 seviyeleri arasında (0.67 ± 0.29 vs. 0.66 ± 0.34, p= 0.63) belirgin fark olmamasına karşın koroner arter hastalığı (0.67 ± 0.29 vs. 0.32 ± 0.24, p < 0.001) ve koroner arter ektazisi (0.66 ± 0.34 vs. 0.32 ± 0.24, p< 0.001) grubundaki hastaların PTX-3 seviyesi kontrol grubuna göre daha yüksekti. Korelasyon analizi sonucu serum PTX-3 ve hs-CRP seviyeleri birbirleriyle ilişkili bulundu (Rho= 0.24, p= 0.016).Sonuç: Koroner arter ektazisi olan hastalarda yeni bir infl amatuvar belirteç olan PTX-3 yüksek bulunmuştur. Bu durum infl amasyonun koroner arter ektazisi patofi zyolojisinde önemli bir role sahip olduğunu düşündürmektedir.

Coronary Artery Calcium Scores Using Nongated Computed Tomography

The coronary artery calcium (CAC) score is well established as a potent marker of increased cardiovascular risk that significantly improves risk prediction beyond traditional risk factors. A CAC score >300 has been shown to confer a 10-fold increase in the risk for a cardiovascular event compared with adults with a CAC of 0.1,2 The improvement in risk prediction is substantially greater with CAC than other imaging and serum markers of subclinical cardiovascular disease.3,4 Article see p 514 The cohort studies that have most informed our understanding of coronary calcium measured CAC scores with dedicated cardiac computed tomography (CT). Image acquisition was gated to diastole to minimize motion artifact and to decrease the likelihood that regions of CAC were missed. However, most chest CTs done for clinical purposes are ordered primarily to assess the lungs and other structures in the chest and thus are not gated. Without gating, there is a concern that assessment of CAC is not accurate. Rather than disregard readily available data, several investigators have sought to determine whether information about CAC burden from nongated CTs can be used effectively to predict cardiovascular risk. In this issue of Circulation: Cardiovascular Imaging , Xie et al5 compiled data from several studies to determine the validity and prognostic value of CAC scoring obtained on nongated thoracic CT scans. To assess the diagnostic performance, the authors performed a meta-analysis of 5 studies that directly compared CAC scores obtained using gated versus nongated CTs. The patient populations in the studies varied, with some representing adults consecutively referred for a chest CT, positron …

Impact of Location of Epicardial Adipose Tissue, Measured by Coronary Artery Calcium-Scoring Computed Tomography on Obstructive Coronary Artery Disease

Epicardial adipose tissue (EAT) is considered to play a role in the pathogenesis of coronary atherosclerosis. However, whether total EAT volume or location-specific EAT thickness may be a better predictor of obstructive coronary artery disease (CAD) is inconclusive. We investigated whether the total volume or location-specific thickness of EAT measured on computed tomography (CT) could be a useful marker of CAD on top of clinical risk factors and Agatston score. Two hundred eight consecutive subjects with clinical suspicion of CAD receiving coronary arterial calcium (CAC)-scoring CT and CT coronary angiography were retrospectively divided into 2 groups: an obstructive CAD group (n= 97) and a nonobstructive CAD group (n= 111). Total EAT volume and EAT thicknesses at different locations were measured on CAC-scoring CT. Left atrioventricular groove (AVG) EAT thickness was the sole EAT measurement that showed association with increasing number of vessels exhibiting ≥50% stenosis (p for trend <0.001). Logistic regression showed that left AVG EAT thickness was the most important EAT predictor of obstructive CAD (odds ratio 1.16, 95% confidence interval 1.04 to 1.29, p= 0.006; optimal threshold ≥15 mm, odds ratio 4.62, 95% confidence interval 2.24 to 9.56, p <0.001). Adding left AVG EAT thickness on top of clinical risk factors plus Agatston score improved prediction of obstructive CAD (area under the curve from 0.848 to 0.912, p= 0.002). In conclusion, excessive left AVG EAT adiposity is an important risk factor for obstructive CAD, independent of clinical risk factors and Agatston score. However, further trials are needed in investigation of combined assessment of location-specific EAT thickness and Agatston score on CAC scan as to whether this biomarker could improve CAD risk stratification in the general population.

Anatomical variants of left circumflex artery, coronary sinus and mitral valve can determine safety of percutaneous mitral annuloplasty

The anatomical variants of the relations of the left circumflex artery (LCx) andthe coronary sinus (CS) determine the safety of percutaneous mitral annuloplasty (PMA) as an occlusion of the LCx and its consequences might occur in some cases. Thus, knowledge ofthe anatomy of cardiac anatomy and any variations are important for surgeons. In 320 (126 women, age 59 ± 11) patients, a 64-slice computed tomography (MSCT) (Aquilion 64) was performed due to a suspicion of coronary artery disease. A scanwith ECG-gating was performed using a slice thickness of 0.5 mm during a breath-hold. The helical pitch was 12.8, rotation time: 0.4 s and average tube voltage: 135 kV at 380 mA.100 mL of non-ionic contrast agent was given in three phases at an average rate of 4.5 mL/s.In each case, ten 3D volume rendering and 2D multiplanar reconstructions of the vessels were created (Vitrea 2). The CS was visualized in all cases and the LCx in 315 (98.4%). In 302 (95.8%)cases, the CS was the dominant vessel; in 10 (3.17%) cases both vessels were equal and the LCxwas dominant in only 3 (0.9%) cases. 52 anatomical variants were identified; 3 of them werethe most common (in 164/315 cases; 50.8%). The CS usually lies above the atrioventricular(AV) sulcus (239-75.9%) and the LCx within the AV sulcus (173-54.9%). In 235 (74.6%)cases, the LCx was closer (than the CS) to the mitral valve. It was found that in 78 (24.7%) cases, the LCx was beneath the CS in selected phases (a risk of LCx occlusion by a PMA device).The LCx closer to the mitral valve, which is considered as a safe feature for PMA, was observed in only 75 (23.8%) of the cases. The most dangerous pattern was found in 19 cases(6.1%) - 2 or 3 CS/LCx crosses. The huge anatomical variability of the anatomy of the CS/LCx strengthens the role of MSCT before PMA implantation.

Maximal Exercise-Corrected QT as a Predictor of Coronary Artery Disease: Comparison of Simpler Heart Rate Corrections

Background and ObjectivesThe relationship between QT prolongation and myocardial ischemia is widely known. Due to the limited value of ST depression, we aimed to evaluate, by using four simpler heart rate corrections (Bazett, Framingham, Fridericia and Hodges), the value of maximal exercise-QTc prolongation in the diagnosis of coronary artery disease (CAD) presence and severity.Subjects and MethodsWe enrolled 234 subjects (mean age 57.3±9 years, 143 men) who had undergone exercise testing and coronary angiography due to a suspicion of CAD in the study. Evaluating CAD severity with Gensini scoring, the CAD group (n=122) and controls with non-CAD were compared in terms of corrected QT duration at maximal exercise.ResultsAge, gender, hypertension, dyslipidemia, smoking, exercise duration, resting, and peak heart rate were similar between the two groups (all p>0.05). The CAD group had higher raw QT values than the controls {268 (169-438) vs. 240 (168-348), p<0.001}. Although Framingham QTc of ≥350 ms and Fridericia QTc of ≥340 ms were seen to be useful for the diagnosis of CAD, there was no additive diagnostic value of exercise QTc in addition to ST depression. Maximal exercise-QTc Bazett (r=0.163, p=0.01), Framingham (r=0.239, p=0.001), and Fridericia (r=0.206, p=0.001) equations were weakly positively correlated with Gensini scoring.ConclusionThe patients with CAD have longer QTc intervals at peak heart rates during exercise. This finding provides insufficient evidence to support routine incorporation of QTc at peak heart rates into exercise test interpretation.

Accuracy of Two-Dimensional Speckle Tracking Echocardiography for the Detection of Significant Coronary Stenosis

BackgroundVisual assessment of wall motion abnormalities (WMA) by 2-dimensional echocardiography (2DE) is the most semi-quantitative method used to detect coronary artery disease (CAD), but it carries many limitations. Speckle tracking echocardiography (STE) overcomes these limitations and allows an objective quantification of myocardial deformation. The aim of the study to examine the accuracy of global and segmental longitudinal strain (LS) for the detection of CAD compared with visual assessment of WMA using coronary angiography as a golden standard.MethodsThe study enrolled 25 patients (mean age 51.0 ± 8.7, 64% are male) referred to coronary angiography with clinical suspicion of CAD. 2DE assessment of WMA and evaluation of LS using STE were performed using left ventricular 17-segments models. Significant CAD was defined as ≥ 50% stenosis in one or more major coronary arteries by angiography.ResultsPatients were classified into 2 groups: group I included 15 patients with significant CAD and group II included 10 patients with insignificant and/or absence of CAD. WM score was strongly correlated with the global LS in group I and II (R = 0.80, p < 0.0001 and R = 0.88, p < 0.0001 respectively). In all patients, 425 segments were analyzed. WMA was detected in 163 segments of 425 (38.3%) while abnormal LS was detected in 214 segments (50.3%). Compared with coronary angiography, the total sensitivity, specificity and accuracy for visual analysis and STE were (56%, 88.2%, and 60% vs. 68.6%, 77%, and 81.8% respectively).ConclusionSegmental LS is more accurate for the detection of ischemic myocardial segment corresponding to functionally relevant coronary anatomy than visual assessment of WM.

Glutathione S-transferase M1 and T1 genotypes and myocardial infarction

Myocardial infarction (MI), which is the most important manifestation of coronary artery disease, is the leading cause of morbidity and mortality in the world. Glutathione S transferases (GSTs) are enzymes responsible for the metabolism of numerous xenobiotics and are known to be polymorphic in humans. We investigated the association between the GSTM1 and GSTT1 gene polymorphisms and MI. The study consists of 296 healthy controls and 324 consecutive patients who had undergone coronary angiography for suspicion of coronary artery disease and with a past history of myocardial infarction. DNA was extracted from whole blood of patient and control. GSTM1 and GSTT1 gene polymorphisms were examined using multiplex PCR. We found that the null GSTM1 was associated with protective effect on MI, although this increase was not significant for GSTM1 (p < 0.054). However, GSTT1 genotype was associated with an increase in the risk of developing MI. In addition to after adjusting other all coronary risk factors, the interactive effect of GSTT1 null genotype remained statistically significant (p < 0.001) for MI disease but GSTM1 null genotype was not statistically significant. Patients, who smoke having the null genotypes of GSTM1, were at a higher risk for developing MI (p < 0.001, OR = 0.41, 95 % CI = 0.240-0.207). There was an effect of interaction of GSTM1 null genotype and smoking on MI development between patient and control groups (p < 0.001). Our results showed that individuals with the null genotypes for GSTM1 had protective effect, while GSTT1 was at a higher risk for MI disease. In addition, there was additional effects of smoking when smoking and non-smoking groups were compared.

The value of exercise treadmill test in evaluation of coronary artery disease

Objective: To evaluate the value of Exercise treadmill test (ETT) in the diagnosis of coronary artery disease (CAD). Methods: Here we reviewed 142 (men, 104, mean age, 52.7±8.6) consecutive patients admitted to the 4th Clinical Hospital of Harbin Medical University for suspicion of CAD and they underwent ETT before coronary angiography (CAG). Patients were divided into four groups to see the sensitivity of different ETT criteria: group I: ETT negative, group II: ETT positive (ST-segment depression ≥0.1mv for more than 2 minutes), group III: ETT positive (exercise induced chest pain), group IV: ETT positive (exercise induced chest pain and ST-segment depression). The severity of coronary artery stenosis was assessed by CAG, only those with >50% of narrowing in at least one of the three major arteries or their first-order branches was considered CAG positive. Results: The false negative rate was 30.6% and the accuracy rate was 69.4% in group I. In group II, III and IV, the accuracy rates and false positive rates were 53.7% and 46.3%, 78.6% and 21.4%, 86.7% and 13.3%, respectively, (p<0.05). Furthermore, we analyzed the data of male patients in each group and the accuracy rates were 67.9%, 60.7%, 76.9%, 100%, respectively, (p<0.05). Multivariate logistic regression results showed that ST-segment depression together with exercise induced chest pain were the most related factors in CAD diagnosis. Conclusion: ST-segment depression and exercise induced chest pain are the strongest factors in CAD diagnosis. Chest pain combined with ST-segment depression had a much higher accuracy rate than ST-segment depression alone.

Comparison of software programs for the assessment of left ventricular ejection fraction using 99mTc-tetrofosmin-gated SPECT/CT

The goal of this study was to compare Emory Cardiac Toolbox (ECTb), quantitative gated SPECT (QGS), four-dimensional single photon emission computed tomography (4D-MSPECT) and Myometrix cardiac software programs for the assessment of left ventricular ejection fraction (LVEF) using 99mTc-tetrofosmin-gated SPECT/CT [myocardial perfusion SPECT (MPS)] and correlate them with the LVEF values derived from equilibrium radionuclide ventriculography (ERNV) in patients with known/suspected coronary artery disease (CAD). A total of 109 patients (80 men, 29 women) were recruited into the study. Fifty-five patients had known CAD and 54 were referred with suspicion of CAD. All the patients underwent ERNV and MPS as per the standard protocol. ERNV was processed using the vendor-provided 'EF analysis' and gated MPS was processed using individual software programs. The mean LVEF on ERNV was 47.9 ± 15.5%. The mean LVEF values for ECTb, QGS, 4D-MSPECT and Myometrix were 51.5 ± 19.6, 51.0 ± 18.6, 57.1 ± 19.3 and 49.7 ± 19%, respectively. On correlation analysis, a very strong positive correlation was observed between LVEF values derived by ERNV and those derived by the MPS software programs: ECTb (r=0.842, P<0.0001), QGS (r=0.835, P<0.0001), 4D-MSPECT (r=0.830, P<0.0001) and Myometrix (r=0.875, P<0.0001). Significant correlation was also seen for LVEFs among the four software programs. Normal cutoff values for ejection fraction on ECTb, QGS, 4D-MSPECT and Myometrix were 56, 52, 54 and 51%, respectively, using a 50% or more cutoff value on ERNV. A strong correlation was observed among ECTb, QGS, 4D-MSPECT and Myometrix software programs when compared with ERNV and also between them for assessment of LVEF. However, there are subtle differences in the objective values of ejection fraction generated by individual software, which must be taken into account for clinical studies.