Atherosclerosis Research Articles

Minimal extra-cardiac atherosclerosis in people <50 years with sudden cardiac death due to coronary disease

Abstract Background The association between severe coronary artery disease and widespread atherosclerosis in younger individuals remains uncertain. Purpose To characterise the association between severe (fatal) coronary disease and extra-cardiac atherosclerosis in a population of young and middle-aged individuals. Methods Individuals aged 1-50 years with sudden cardiac death (SCD) from 2019-23, autopsy-proven to be due to coronary artery disease, were identified using the state-wide EndUCD registry. The presence of extra-coronary atherosclerosis greater than modified American Heart Association class III was documented in five arterial beds (intra-cerebral vessels, carotid arteries, aorta, renal and femoral arteries). Results Of 3,044 individuals who experienced SCD, 372 were due to coronary artery disease and 71 of these (19.1%) had extra-coronary plaque. Plaque was identified in aorta (68/372 patients, 18.3%), carotid arteries (11/372, 3.0%), iliofemoral arteries (11/372, 3.0%), intracerebral arteries (4/157 patients who underwent examination of the brain, 2.6%) and renal arteries (7/372 patients, 1.9%). 51 patients (13.7%) had plaque in ≥2 arterial beds in addition to their coronary disease. Predictors of extra-coronary plaque were older age (median 47.7 vs 44.4 years, p<0.0001), hypertension (32.3% vs 18.9%, p=0.013), and previous percutaneous coronary intervention (9.9% vs 3.0%, p=0.01). Patients with extra-coronary plaque had higher rates of cardiomegaly (68.8% vs 51.1%, p=0.01), cardiac fibrosis indicative of previous myocardial infarction (49.3% vs 31.9%, p=0.006) and multi-vessel coronary disease (73.5% vs 55.6%, p=0.007). Conclusion Only 1 in 5 people aged 1-50 years experiencing SCD from a coronary cause exhibit extra-coronary plaque. This limits the utility of screening for carotid or aortic plaque to predict coronary atherosclerosis. Individuals with extra-coronary plaque had a higher burden of cardiovascular risk factors and more established coronary disease.

Prognostic value of quantitative anatomical and functional measures of coronary artery disease in diabetic and non-diabetic patients

Abstract Background Diabetes is associated with increased risk of coronary artery disease (CAD). However, the relative prognostic importance of anatomical and functional findings of CAD in the presence vs. absence of diabetes is incompletely understood. Technological advances have made quantitative analysis of coronary artery plaques and stenosis feasible by coronary computed tomography angiography (CTA). In turn, positron emission tomography (PET) enables absolute quantification of myocardial blood flow (MBF). Purpose To study long-term prognostic value of quantified severity of coronary atherosclerosis and myocardial perfusion in non-diabetic vs. diabetic patients with suspected CAD. Methods From two academic medical centres, we identified symptomatic patients with suspected CAD who had undergone coronary CTA and [15O]H2O PET myocardial perfusion imaging during adenosine stress. Based on artificial intelligence -guided quantitative analysis of coronary CTA scans, the anatomical severity of CAD was measured as the presence of obstructive CAD (≥50% diameter stenosis) and percent atheroma volume (PAV; higher vs. lower than median). The functional severity of CAD was measured as the presence of regional myocardial ischemia (≥2 adjacent segments with stress MBF <2.3 ml/g/min) and global stress MBF (<2.2 ml/g/min vs. ≥ 2.2 ml/g/min) by PET. Annual rates of adverse events (AER) including all-cause mortality, myocardial infarction (MI), and unstable angina pectoris (UAP) were evaluated. Results Among 1311 patients, 251 (19%) had diabetes. Patients with diabetes had more frequently obstructive CAD (55% vs. 43%, p<0.001) and regional myocardial ischemia (51% vs. 43%, p=0.015), higher plaque burden by PAV (12% vs. 7%, p<0.001), and lower global stress MBF (2.78 ml/g/min vs. 3.05 ml/g/min, p<0.001). During median follow-up of 7.1 years, 171 (13.0%) patients experienced AE (85 deaths, 56 MIs, and 30 UAPs). Patients with diabetes had higher AER than non-diabetic patients (3.1% vs. 1.6%, p<0.001). The presence of obstructive stenosis was associated with increased AER in non-diabetic (2.6% vs. 1.0%, p<0.001) and diabetic patients (4.2% vs. 1.9%, p<0.001). High plaque burden by PAV was associated with increased AER in non-diabetic (2.8% vs. 0.7%, p<0.001) and diabetic patients (3.9% vs. 1.7%, p<0.001). The presence of regional myocardial ischemia was associated with increased AER in non-diabetic (2.5% vs. 1.1%, p<0.001), but not in diabetic patients (3.4% vs. 2.7%, p=0.238). Low global stress MBF was associated with increased AER in non-diabetic (2.9% vs. 1.3%, p<0.001), but not among diabetic patients (3.2% vs. 3.0%, p=0.286). Conclusions Diabetes was associated with more advanced CAD. Quantified severity of anatomical findings predicted long-term adverse outcome in non-diabetic and diabetic patients. In contrast, functional imaging risk stratified non-diabetic patients, whereas diabetic patients had impaired long-term outcome irrespective of perfusion findings.

Screening for subclinical atherosclerosis in patients clinically diagnosed with familial hypercholesterolemia and determination of imaging-guided patient management strategy

Abstract Introduction Familial hypercholesterolemia (FH) is a monogenic dyslipidemia characterized by elevated plasma LDL-C levels, leading to early cardiovascular disease. The Dutch Lipid Clinic Network (DLCN) score is the most widely used clinical scoring system in current practice. Subclinical atherosclerosis is defined as the detection of atheromatous plaques in arterial territories, such as coronary, carotid or iliofemoral, before a symptom or event occurs. It is an early indicator of atherosclerotic burden. In this study, we investigated the presence of subclinical atherosclerosis in FH patients with a definite or probable clinical diagnosis according to DLCN score. We also tried to identify independent predictors of subclinical atherosclerosis. Methods This study is a single-center, prospective, and cross-sectional investigation involving a cohort of 215 FH patients. These patients are primary prevention patients and among them, 120 patients received a definite clinical diagnosis, while 95 patients received a probable clinical diagnosis based on the DLCN score. Carotid USG and Femoral USG were performed to screen for subclinical atherosclerosis and CAC score was calculated by non-contrast CT. Apo A-I, Apo B and Lp (a) measurements were analyzed by immunonephelometric method. Results The study population consisted of 136 (63%) women and 79 (37%) men. The mean age was 54 years (43-62) and the stigmata rate was 18%. Initially, 17% of patients were on aspirin, and 32% were receiving statin treatment; however, following subclinical atherosclerosis screening, these proportions significantly increased (aspirin usage to %32 and statin usage to %96) within the population. 148 patients (69%) had subclinical atherosclerosis in at least one site. Upon regional analysis, subclinical atherosclerosis rates were 48% in the coronary arteries, 47.5% in the carotid bifurcation region, and 40.5% in the femoral bifurcation region. Additionally, 25% of patients had atherosclerosis at one site, 27% at two sites, and 17% at all three sites. Age, male gender, pretreatment LDL-C level, Apo A-I/Apo B ratio and DM were identified as independent predictors of the presence of subclinical atherosclerosis in the FH patients. Furthermore age, male gender, pretreatment nonHDL-C level, Lp (a) ≥ 30 mg/dl and presence of femoral plaque were identified as independent predictors of coronary atherosclerosis. Conclusion Subclinical atherosclerosis is prevalent among FH patients, and this study has identified independent predictors associated with presence of subclinical atherosclerosis. However, despite this heightened risk, medication utilization among these patients remains below optimal levels and only a small proportion of the population has achieved their treatment goals. Our study highlights the influence of subclinical atherosclerosis on treatment approaches, as demonstrated by the notable rise in statin and aspirin utilization observed after screening.Clinical and biochemical characteristicsSubclinical Atherosclerosis Rates

Traditional cardiovascular risk factors and coronary microvascular disease in women and men- a single center study

Abstract Introduction Coronary microvascular dysfunction (CMD) is a common, often missed, cause for effort intolerance and angina symptoms, and is associated with adverse clinical outcomes. Risk factors for the development of CMD have not been fully elucidated, and studies examining sex associated differences in traditional cardiovascular risk factors (TCRs) for obstructive coronary artery disease (CAD) in patients with CMD have yielded conflicting results. Although several non-invasive methods for the evaluation of CMD exist, currently, catheter-based invasive assessment is the gold standard for the diagnosis of coronary microvascular dysfunction. Purpose To examine the association between TCR and CMD and sex associated differences in TCR, in a prospective cohort of patients undergoing invasive microvascular function evaluation in a large tertiary medical center. Methods In this single center, prospective registry, we enrolled patients with non-obstructive CAD undergoing clinically indicated invasive assessment of coronary microvascular function between November 2019 and March 2023. Measurements of microvascular function included CFR, IMR, RRR as well as FFR. Pathologic CFR was defined as <2.5 or <2. Associations between coronary microvascular dysfunction, traditional cardiovascular risk factors, and sex were assessed using univariate and multivariate regression models. Results Overall, 245 patients with non-obstructive CAD were included in the analysis (62.9% female; median age 68 (interquartile range [IQR]: 59,75). Microvascular dysfunction was diagnosed in 141 patients (57.5%). The prevalence of microvascular dysfunction was similar in women and men in the entire cohort (59.0% vs. 57.0%; p=0.77). In 41 patients diagnosed with functional microvascular dysfunction there were more women than men (70.7% vs. 29%). When using a threshold of CFR<2.5 no association was found between traditional risk factors for coronary atherosclerosis and CMD regardless of whether CMD was structural or functional. In women, but not in men, older age and the presence of previous ischemic heart disease were associated with lower coronary flow reserve (CFR) (β=-0.29; p<0.01 and β=-0.15; p=0.05, respectively) and lower resistive reserve ratio (RRR) (β=-0.28; p<0.01 and β=-0.17; p=0.04, respectively). When using a threshold of <2.0 for CFR similar results were found. Conclusion The prevalence of TCRs was similar in patients with and without CMD. In women, older age and previous IHD were associated with lower CFR and RRR values while no association between TCRs and indices of CMD was found in men. It is likely that there are other, currently unknown risk factors for CMD as well as unique risk factors for each of its endotypes, beyond TCRs. It is unclear which parameter of microvascular dysfunction is the most accurate, and whether different parameters should be used in women and men. Large-scale multi-center studies to further evaluate these issues are needed.Variables associated with CMDStudy inclusion process

Relationship between coronary atherosclerotic lesion and arterial stiffness in patients with coronary artery disease

Abstract Introduction Some of the previous studies demonstrated that arterial stiffness independently predicts mortality and morbidity associated with CAD. Purpose to evaluate the relationship between coronary atherosclerosis severity and arterial stiffness. Material and methods The study included 158 people aged 40 to 70 years: control group – 25 people (mean age 61,7±6,6 years; 21 men and 4 women) without cardiovascular diseases (CVD) and 133 patients (mean age 62,5±6,9 years; 80 men and 53 women) with CAD, confirmed by coronary angiography (CAG). Arterial stiffness was assessed using applanation tonometry (AT). Аssessment of the coronary calcium (CC) was performed with computer tomography (CT). Results In 133 patients with CAD, the results of AT were compared with the degree of atherosclerotic lesion according to CT and CAG data. All patients were divided into groups depending on the CC value. Group I included 19 people with a CC value of 0, group II - 55 people with a CC of up to 400, and group III - 59 patients with a CC of more than 400. With an increase in the degree of the atherosclerotic lesion, the values of peripheral and central pulse pressure (PP), augmentation index (AIx), additional augmentation index normalised for heart rate of 75 bpm (AIx@HR75) and pulse wave velocity (PWV) statistically significantly increased (Table 1). Indicators characterising augmentation of сentral PP and arterial stiffness also increased. Conclusion Increases in Pulse Pressure, Augmentation Index, and Pulse Wave Velocity reflect the worsening of atherosclerosis in coronary arteries, thereby indicating a higher risk of cardiovascular complications. Monitoring of these parameters can be crucial for early diagnosis and prevention of major adverse cardiovascular events.

Comparing predictive risk to actual presence of coronary atherosclerosis on coronary computed tomography angiography: a retrospective cohort analysis

Abstract Background There is limited data supporting the ability of cardiovascular risk scores (CVRS) to accurately predict asymptomatic coronary artery disease (CAD). Purpose To examine the predictive accuracy of CVRS in detecting presence and extent of atherosclerosis, determined by coronary computed tomography angiography (CCTA). Methods Asymptomatic individuals without known CAD, undergoing a screening CCTA with available CVRS data, were examined retrospectively. Natural language processing of the CCTA report data extracted the coronary artery calcium score (CACS) and the extent and severity of coronary plaque (low, moderate, or extensive, using a modified CAD-RADS 2.0 classification). Normal was defined as both zero plaque and zero CACS. CVRS was categorized as high (>15%), moderate (10-15%), low (1-9%) and "zero" (<1%) risk. Results 828 individuals (median age 58.6, IQR=52.0, 65.3 years, 57% male) met inclusion criteria, and a zero, low, moderate, and high CVRS was identified in 13, 483, 113 and 219 individuals, respectively. Any degree of atherosclerosis was found in 548 scans (67% male). However, of the 137 males and 68 females with extensive atherosclerosis, 47 (34%) and 38 (56%) respectively had a low CVRS classification. Overall, 23% of males and 31% of females had CAD predicted by CVRS, with little to no agreement between CVRS and atherosclerosis burden (Cohen’s kappa: males, κ=0.149; females, κ=0.096). Conclusions In asymptomatic individuals without known CAD, CVRS does not reliably predict the presence and extent of CAD, and severe disease may be present in apparently low CVRS.Graphical AbstractFigure

Impact of clinical features on in-hospital outcomes in premature coronary artery disease patients post percutaneous coronary intervention

Background: Premature coronary artery disease (PCAD) is a significant health concern globally, characterized by the onset of coronary atherosclerosis at an early age. The development of PCAD is influenced by a variety of risk factors and leading to substantial morbidity and mortality. Despite advancements in interventions, the clinical and angiographic characteristics influencing in-hospital outcomes for these patients remain underexplored. Objective: This study aims to investigate the relationship between clinical features and in-hospital outcomes in patients with premature CAD post-percutaneous coronary intervention (PCI) at Dr. Saiful Anwar Hospital. Method: A retrospective cohort study was conducted on 1279 patients who underwent PCI for premature CAD the period of January 2022–December 2023. Clinical information was gathered from medical records, including risk factors and angiographic results. Statistical analyses were conducted using SPSS 22, employing univariate, bivariate, and multivariate logistic regression analyses to determine correlations. Result: The study included 1279 patients, with 438 in the premature CAD group and 841 in the non-premature CAD group. Significant differences were observed in age, sex distribution, BMI, lipid profiles, smoking status, and family history between the groups. Premature CAD patients were younger (mean age 50 vs. 64.8, p<0.001) and had higher rates of smoking and dyslipidemia. Angiographic analysis showed significant differences in LAD and LCx involvement and occlusion rates. In-hospital outcomes indicated higher incidences of shock, cardiac complications, and in-hospital mortality in the non-premature CAD group. Conclusion: Clinical and angiographic characteristics significantly influence in-hospital outcomes for premature CAD patients. Younger age, smoking, and dyslipidemia were prevalent risk factors. Enhanced management strategies focusing on these factors could improve patient outcomes. Keyword: angiography findings, clinical characteristics, in-hospital outcomes, percutaneous coronary intervention, premature coronary artery disease

Expression of cardiomyopathy-related genes in mononuclear blood cells predicts all-cause mortality in patients presenting with acute versus chronic coronary syndrome requiring revascularisation

Abstract Objective Despite advances in the revascularisation techniques their net clinical benefit differs substantially between patients presenting with myocardial infarction (ACS) and chronic coronary syndrome (CCS) due to obstructive coronary atherosclerosis. Considering that leukocytes represents a key pathophysiological component of myocardial ischaemia, exploration of mononuclear blood cell (PBMC) gene expression profile in CCS and ACS setting could reveal clinically relevant transcriptomic signals. The aim of the present study was to identify differences in PBMC transcriptome between ACS and CCS patients which are linked to mortality after revascularisation. Methods and Results We analysed PBMC transcriptomes from719 ACS and 486 CCS patients creating discovery cohort. The results of transcriptomic analysis were verified in replication cohort (ACS: N=682 for CCS: N=489) generated based on propensity score matching. Median time from revascularisation to blood collection (IQR) was 15.68 (-4.52, 23.23) hrs. Patients with ACS showed consistent differential expression of 8173 genes (4544 upregulated, 3629 downregulated) when compared with CCS patients. The subsequent pathway analysis also showed significant enrichment of several canonical pathways involved in major cardiovascular pathologies i.e. atherosclerosis (p = 1.22-06, enrichment = 3.39), vascular endothelial growth factor production (p = 1.16-06, enrichment = 16.73), positive regulation of vascular development (p = 2.78-06, enrichment = 5.30) and heterotopic cell adhesion including gene desmocollin 2 (DSC2, p = 3.64-04, enrichment = 6.30). In der multivariate survival analysis with differentially expressed genes, increased expression of DCS2, lamin A/C (LMNA), and UGGT2, and decreased expression of SNRNP70 predicted poor survival over the median follow-up 11.35 yrs. Consistently, controlling the false discovery rate at ≤ 5% these genes enriched pathways involved in cardiomyopathies such as arrhythmogenic right-ventricular cardiomyopathy (p = 4.19x10-4, enrichment = 58.9) and collagen disease (p = 2.29x10-3, enrichment = 23.8). Conclusion We found altered PBMC expression of multiple genes in patients requiring revascularisation for ACS versus CCS. Several differentially expressed genes included in cardiomyopathy pathways predicted long-term all-cause mortality in these patients.

Vitamin K2 and the Vitamin-K-Cycle-Enzyme VKORC1L1 improve endothelial regeneration by inhibiting endothelial-mesenchymal transition, inflammatory cell activation and ferroptosis

Abstract Introduction Vascular inflammation is a crucial contributor to atherosclerosis, in which oxidative stress, endoplasmic reticulum (ER) stress and transition of endothelial to mesenchymal cells (EndMT) are of critical importance. Vitamin-K-antagonists (VKA) promote vascular dysfunction, while dietary vitamin K intake was proposed to reduce incidence of coronary artery disease, but the mechanisms remain unresolved. Key enzyme for regeneration of vitamin K is the Vitamin K epoxide reductase complex subunit 1 (VKORC1), which also represents the pharmacological target of VKA. VKOR-like1 (VKORC1L1) is an isoenzyme of VKORC1, which resides at the ER-membrane, exerts antioxidative properties and is involved in vitamin K maintenance. Aim of this study was to investigate the role of Vitamin K2 and the VKOR-enzymes in endothelial cell inflammation. Methods and Results In human coronary artery endothelial cells (HCAEC), Vitamin K2 improves endothelial regeneration by increasing proliferation and cell viability and by reducing both apoptosis and ferroptosis (relative viability: RSL3 0.11 ± 0.01 vs 0.32 ± 0.05 RSL3+K2-1µM vs. 0.44 ± 0.11 RSL3+K2-10µM, p<0.001). Moreover, Vitamin K2-supplementation inhibits EndMT by reducing expression of mesenchymal markers (Calponin, SM22; Fig.1). In silico analyses of the proteome of human coronary atherosclerosis revealed increased expression of VKORC1L1, but not of VKORC1. In vitro induction of oxidative stress and ER-Stress promoted time- and dose-dependent enhanced expression of VKORC1L1, without altering VKORC1 expression (H2O2: 2.3-fold vs. 0.8-fold after 40 minutes, p=0.04; tunicamycin: 1 μg/ml: 1.43-fold vs. 0.8-fold, p<0.01). Likewise, siRNA-mediated VKORC1L1 knockdown induces an inflammatory gene signature with upregulation of NFkB-signalling and endoplasmic reticulum stress (NF-κB: 1.95-fold ± 0.13, GRP78: 1.32-fold ± 0.04 vs. control, p<0.01). Furthermore, VKORC1L1 downregulation increased formation of reactive oxygen species (ROS) and reduced proliferation (EdU signal: 0.56 ± 0.02 vs. control, p < 0.01). In contrast, VKORC1-knockdown does not impair endothelial regeneration and function (Fig.2). Vitamin K2 reduces vascular inflammation and endoplasmic reticulum stress in the case of VKORC1-, but not VKORC1L1-knockdown. In addition, inducing EndMT resulted in a reduction of VKORC1L1, but not of VKORC1, while VKORC1L1-knockdown aggravates EndMT. Conclusion VKORC1 and its isoenzyme VKORC1L1 exhibit divergent effects on endothelial cell inflammation. Further studies are warranted to shed light on the regulation of the enzymes to improve our understanding regarding vascular side effects of VKA treatment and beneficial effects of vitamin K supplementation.

Pericardial adipose tissue (PAT) as a cell model to assess patient responsiveness to docosahexaenoic acid (DHA) and eicopentaenoic acid (EPA)

Abstract Background The abundance of epicardial (EAT) and pericardial adipose tissue (PAT) is associated with several cardiac risk factors and a higher carotid intima-media thickness, with a potential contributory role to the development of atherosclerosis and coronary artery disease (CAD). Under conditions promoting obesity, both epicardial and pericardial adipose tissue undergo a metabolic shift, acquiring an inflammatory and pro-atherogenic phenotype. Addressing dysmetabolism and inflammation associated with EAT and PAT are a promising and innovative therapeutic approach for preventing coronary atherosclerosis. Recent data have highlighted a noteworthy association between the abundance of adipose tissue n-3 polyunsaturated fatty acids (PUFA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as their ratio to the omega-6 FA arachidonic acid (AA), with a lower risk of myocardial infarction. Purpose To develop an efficient method for isolation of adipocytes from human PAT and evaluation of adipocyte response to DHA and EPA. Methods PAT samples were collected from 9 CAD patients, undergoing coronary artery bypass graft surgery and immediately processed before to assess more than 50 experimental conditions. Isolated adipocytes were morphologically and molecularly characterized. Cell responsiveness was evaluated by cell exposure to inflammatory stimuli, with or without variable amounts of DHA, EPA, or AA assessing a spectrum of gene expressions and pro-inflammatory functional activities. Results Pure cultures of pericardial adipocytes exhibited prolonged viability (beyond 72 hours). and retained responsiveness to pro-inflammatory and lipolytic stimuli, while also showing the capacity to activate the insulin signalling pathway. Cell exposure to DHA or EPA resulted in a downregulation of messenger (m)RNA expression for monocyte chemoattractant protein (MCP)-1, interleukin (IL)-6 and metalloproteinase (MMP)-9 (p<0.05) and in upregulation of uncoupling protein-(UCP)-1, UCP-2 and peroxisome proliferator-activated receptor (PPAR)γ (p< 0.05) (Figure 1). In line with mRNA expression, a significant reduction in both cytokines and MMP-9 protein release was observed (p<0.05) (Figure 2). These effects paralleled a significant incorporation of DHA and EPA into total cell lipids (p<0.05). Functionally, the cell supernatant from DHA- or EPA-conditioned cells displayed diminished ability to attract monocytes in chemotaxis assays. AA exhibited no such activities. Conclusion(s) In a novel cellular model of isolated and cultured adipocytes from PAT, DHA and EPA attenuated the inflammatory and dysmetabolic characteristics of this cardiac adipose tissue.

Prevalence and prognostic relevance of non-obstructive coronary atherosclerosis in MINOCA: a meta-analysis of 35 studies

Abstract Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) can result from a variety of pathological mechanisms, not always associated with atherosclerosis. It has been suggested to distinguish between patients without obstructive coronary artery disease (NObs-CAD, stenosis diameter 1-49%), and patients with smooth coronary arteries (NCA), but differences in terms of prognosis or therapeutic approaches have not been clearly elucidated. Objectives The aim of this study is to evaluate the prevalence and prognostic impact of NObs-CAD as assessed by invasive coronary angiography (ICA) in MINOCA. Methods A meta-analysis was performed including studies reporting the prevalence of NObs-CAD versus NCA in MINOCA patients. Data on prognosis stratified by the presence of NObs-CAD were collected. Random-effects models were used to estimate the prevalence of NObs-CAD. Pooled risk ratios (RR) with 95% confidence intervals (CI) for all-cause death, myocardial infarction (MI), and the composite of both outcomes of patients with NObs-CAD compared to NCA were calculated at short-term (<1 month), 1-year and long-term follow-up (more than 1 year). Results Thirty-five studies were analysed. The pooled prevalence of NObs-CAD estimated by ICA was 53% [95% CI 47-60%]. Heterogeneity was high (I2=98.0%), but none of the clinical and instrumental characteristics tested in meta-regression analyses had a significant impact on the I2, except for age (residual I2=97.2%, p=0.014) and geographical context. Specifically, studies conducted outside Europe reported a higher prevalence of NObs-CAD with lower I2 values. Thirteen studies provided prognostic data. The presence of NObs-CAD was associated with an increased risk of death or MI compared to NCA, as well as the risk of MI at 1-year follow-up (RR = 1.49 [95% CI 1.17-1.90] and RR = 1.80 [95% CI 1.26-2.59], respectively), whereas the risk of death was comparable. Similar results were observed at long-term, but not at short-term follow-up. Out of 13 studies, 4 provided information regarded the medications at discharge stratified by the presence or absence of NObs-CAD. NObs-CAD patients received more often aspirin (89% vs 69%; p<0.01), P2Y12-inhibitors (52% vs 29%; p<0.01), angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (53% vs 40%; p<0.01), beta-blockers (70% vs 57%; p<0.01), and statins (86% vs 60%; p<0.01) compared to NCA. Conclusions Stratification of patients according to the degree of coronary stenosis has prognostic implications in the setting of MINOCA, since NObs-CAD patients present a higher risk of reinfarction. Further dedicated trials are needed to clarify whether these patients may benefit from a tailored approach in terms of secondary prevention strategies.Central illustration

Prognostic significance of coronary flow velocity reserve in patients with peripheral arterial disease

Abstract Background Patients with lower extremity peripheral arterial disease (PAD) have a higher risk of cardiovascular events. Stress echocardiography (SE) based on regional wall motion abnormality (RWMA) is imperfect for risk stratification in PAD, but it can be complemented with an assessment of coronary flow velocity reserve (CFVR) in the mid-distal left anterior descending coronary artery. Purpose To assess the value of SE with RWMA and CFVR to predict survival in PAD. Methods In a retrospective analysis of prospectively acquired data in an observational, multicenter study, we recruited 359 patients (age 69±8 years, 240 [67%] males) with PAD referred for dipyridamole SE in 3 accredited laboratories. We assessed RWMA and CFVR (abnormal value <2.0). All patients were followed up for a median of 4.7 (interquartile range: 2.0 to 8.2 years). All-cause death was the outcome end-point. Results The positivity rate was 37/359 (10%) for RWMA and 159/359 (44%) for CFVR. During follow-up, 97 (27%) deaths were registered. At multivariable analysis, inducible RWMA and/or CFVR <2.0 (HR 2.58, 95% CI 1.65-4.04; p<0.0001), age ≥70 years, diabetes, dialysis treatment, and ejection fraction ≤50% were associated with decreased survival. The annual mortality was 7.4% in patients with RWMA and/or CFVR <2.0 and 2.7% in those with no RWMA and CFVR >2.0 (Figure, p<0.0001). Conclusion In patients with PAD, SE shows more than 4-fold higher prevalence of abnormal CFVR compared to RWMA. The prognostic value of CFVR outperforms RWMA, showing the importance of coronary microvascular dysfunction and diffuse, subcritical coronary atherosclerosis in determining the outcome.

Deciphering the Role of Copper Homeostasis in Atherosclerosis: From Molecular Mechanisms to Therapeutic Targets.

Cardiovascular disease (CVD) is a leading cause of death globally, with atherosclerosis (AS) playing a central role in its pathogenesis as a chronic inflammatory condition. Copper, an essential trace element in the human body, participates in various biological processes and plays a significant role in the cardiovascular system. Maintaining normal copper homeostasis is crucial for cardiovascular health, and dysregulation of copper balance is closely associated with the development of CVD. When copper homeostasis is disrupted, it can induce cell death, which has been proposed to be a novel form of "cuproptosis", distinct from traditional programmed cell death. This new form of cell death is closely linked to the occurrence and progression of AS. This article elaborately describes the physiological mechanisms of copper homeostasis and explores its interactions with signaling pathways related to AS. Additionally, we focus on the process and mechanism of cell death induced by imbalances in copper homeostasis and summarize the relationship between copper homeostasis-related genes and AS. We also emphasize potential therapeutic approaches, such as copper balance regulators and nanotechnology interventions, to adjust copper levels in the body, providing new ideas and strategies for the prevention and treatment of CVD.

Searching for Hub Genes of Quince–Basil Co-Administration Against Atherosclerosis Using Bioinformatics Analysis and Experimental Validation

Background: Atherosclerosis (AS) has one of the highest rates of morbidity and death globally. Cydonia oblonga Mill. (quince, COM) and Ocimum basilicum L. (basil, OB) are Uyghur medicines that are often used for anti-inflammatory, anti-tumor, and cardiovascular disease treatment. This study aimed to uncover the hub genes of the quince-basil co-administration against AS and validate them. Methods: Network pharmacology analysis and bioinformatics analysis methods were utilized to map the network and obtain four hub genes. Experiments were performed in vivo and in vitro using HUVEC and zebrafish to validate the therapeutic effect of COM-OB co-administration against AS. Finally, the hub genes were validated by Western blot. Results: Screening by network pharmacology analysis and bioinformatics analysis obtained a total of 3302 drug targets, 1963 disease targets, and 1630 DEGs. A series of bioinformatic analyses were utilized to ultimately screen four hub genes, and the stability was also verified by molecular docking and molecular dynamics. COM-OB total flavonoids co-administration significantly decreased PA-induced lipid deposition in HUVEC and reduced high cholesterol-induced fat accumulation in zebrafish. Western blot results showed that COM-OB co-administration significantly affected the expression of hub genes. Conclusions: The study identified and validated four hub genes, COL1A1, COL3A1, BGLAP, and NOX4, thus providing a rationale for the treatment of AS with COM and OB co-administration.

Patients with coronary atherosclerosis had an altered ratio of monocyte subpopulations in the blood, which was associated with an inflammatory cell response

Coronary artery disease (CAD) is one of the leading causes of death in developed countries. Experimental data confirm the role of monocytes in the development of CAD. Three main subpopulations of circulating blood monocytes are known: classical CD14++CD16- (~80%), intermediate CD14+CD16+ (~5%) and non-classical CD14+CD16++(~15%). It is believed that each of the subpopulations of monocytes performs different functions. There are studies that demonstrate that classical monocytes respond more to the bacterial presence, whereas non-classical ones respond to the viral one. However, the functions of monocyte subpopulations have not been fully studied. Previously, we demonstrated that circulating monocytes of the blood of patients with atherosclerosis had increased proinflammatory activity. We decided to find out how the ratio of monocyte subpopulations in the blood is related to the inflammatory response of cells in atherosclerosis. The aim of our work was to investigate the relationship of the inflammatory response of primary monocytes with the distribution of monocyte subpopulations relative to the total pool of monocytes in healthy and sick CAD. The study included 20 men aged 46 to 70 years, 10 of them without CAD and 10 patients with CAD. A coronary angiography was performed, according to the results of which the patients were divided into patients with coronary atherosclerosis with detected stenosis in 2 or more arteries (CAD) and healthy ones without stenosis in the arteries. Next, blood was taken to study circulating monocytes. Monocyte subpopulations were detected by flow cytometry from the leukocyte fraction using antibodies against CD14- FITC and CD16-PB450-A. Immediately after isolation, monocytes were stimulated with LPS with a final concentration of 1 ug/mL, and a supernatant was selected 24 hours later for further enzyme immunoassay. The inflammatory response was assessed by the secretion of cytokines TNFα, IL-1β, IL-6, IL-8, IL-10, and CCL2 using ELISA. The monocytes of CAD patients had an altered inflammatory response in response to LPS stimulation compared to patients without CAD. This was manifested in increased secretion of IL-1β and TNF, and decreased secretion of CCL2 and IL-6. An increase in the number of intermediate and non-classical monocytes in patients with CAD was associated with changes in the inflammatory response of cells to the secretion of cytokines IL-1β and CCL2. It can be assumed that pathological changes in the representation of monocyte subpopulations in the bloodstream may be one of the causes of chronic inflammation in the walls of the arteries, contributing to the progression of atherosclerotic lesions.

Investigating the Role of Hub Calcification Proteins in Atherosclerosis via Integrated Transcriptomics and Network-Based Approach

Atherosclerosis (AS) is a chronic inflammatory condition of the arteries, characterized by plaque formation that can restrict blood flow and lead to potentially fatal cardiovascular events. Given that AS is responsible for a quarter of global deaths, this study aimed to develop a systematic bioinformatics approach to identify biomarkers and regulatory targets involved in plaque development, with the goal of reducing cardiovascular disease risk. AS-specific mRNA expression profiles were retrieved from a publicly accessible database, followed by differentially expressed genes (DEGs) identification and AS-specific weighted gene co-expression network (WGCN) construction. Thereafter, calcification and atherosclerosis-specific (CASS) DEGs were utilized for protein–protein interaction network (PPIN) formation, followed by gene ontology (GO) term and pathway enrichment analyses. Lastly, AS-specific 3-node miRNA feed-forward loop (FFL) construction and analysis was performed. Microarray datasets GSE43292 and GSE28829 were obtained from gene expression omnibus (GEO). A total of 3785 and 6176 DEGs were obtained in case of GSE28829 and GSE43292; 3256 and 5962 module DEGs corresponding to GSE28829 and GSE43292 were obtained from WGCN. From a total of 54 vascular calcification (VC) genes, 20 and 29 CASS-DEGs corresponding to GSE28829 and GSE43292 were overlapped. As observed from FFL centrality measures, the highest-order subnetwork motif comprised one TF (SOX7), one miRNA (miR-484), and one mRNA (SPARC) in the case of GSE28829. Also, in the case of GSE43292, the highest-order subnetwork motif comprised one TF (ESR2), one miRNA (miR-214-3p), and one mRNA (MEF2C). These findings have important implications for developing new therapeutic strategies for AS. The identified TFs and miRNAs may serve as potential therapeutic targets for treating atherosclerotic plaques, offering insights into the molecular mechanisms underlying the pathogenesis and highlighting new avenues for research and treatment.

Immunohistochemical Localization of Fibroblast Activation Protein in Coronary Arteries with Different Forms of Atherosclerosis

Background: Fibroblast activation protein (FAP) is a cell surface glycoprotein expressed by myofibroblasts in areas of active tissue remodeling. It plays a potentially important role in cardiac remodeling, atherosclerotic plaque formation, and plaque rupture. Given the distinct pathophysiology and morphology of different forms of atherosclerosis, we analyzed FAP expression in human coronary vessels with no coronary artery disease, atherosclerotic plaques at different levels of progression, and other distinct forms of coronary disease in post bypass vein grafting and cardiac allograft vasculopathy after a heart transplant. Methods: Immunohistochemical staining with monoclonal F19 mouse anti-human FAP antibody was performed to identify FAP in human atherosclerotic plaques, coronary bypass atherosclerosis, and post-transplant arteriosclerosis. The presence and distribution of FAP in different types and stages of human atherosclerosis were compared. Results: There was no FAP staining in patients with no significant coronary disease. All different types of human atherosclerotic lesioning lesions showed the presence of FAP expression, with different staining patterns in advanced atherosclerotic plaque, vein graft atherosclerosis lesions, and arteriosclerosis after a heart transplant. Conclusions: These data suggest that FAP may be a potential diagnostic marker and target for interventions, not only in coronary atherosclerotic plaque, but also in other forms of coronary disease, which have distinct pathophysiologies and currently limited treatment options.

Omics research in atherosclerosis.

Atherosclerosis (AS) is a chronic inflammatory disease characterized by lipid deposition within the arterial intima, as well as fibrous tissue proliferation and calcification. AS has long been recognized as one of the primary pathological foundations of cardiovascular diseases in humans. Its pathogenesis is intricate and not yet fully elucidated. Studies have shown that AS is associated with oxidative stress, inflammatory response, lipid deposition, and changes in cell phenotype. Unfortunately, there is currently no effective prevention or targeted treatment for AS. The rapid advancement of omics technologies, including genomics, transcriptomics, proteomics, and metabolomics, has opened up novel avenues to elucidate the fundamental pathophysiology and associated mechanisms of AS. Here, we review articles published over the past decade and focus on the current status, challenges, limitations, and prospects of omics in AS research and clinical practice. Emphasizing potential targets based on omics technologies will improve our understanding of this pathological condition and assist in the development of potential therapeutic approaches for AS-related diseases.

Morphological phenotype of right ventricular outflow tract is associated with cardiovascular outcomes and premature death

Morphology of right ventricular outflow tract (RVOT) is potentially related to cardiovascular outcomes. However, this relationship still remains to be verified with direct evidence. We retrospectively reviewed cases from the autopsy specimen library in the Center of Forensic Medicine in Sun Yat-sen University from 2017 to 2023. Six RVOT morphological characteristics were measured and their association with cardiovascular diseases (CVDs), sudden cardiac death (SCD) and age at death was evaluated. Relationship between myocardial fibrosis in RVOT and CVDs was investigated. RVOT characteristics were recruited by machine learning algorithms for diagnosing CVDs. A total of 2370 cases were finally recruited. Perimeter of sub-valve plane (pSBV) in RVOT was positively associated with risk of CVDs and SCD (OR: 1.21, 95%CI: 1.07–1.37, p = 0.003; OR: 1.33, 95%CI: 1.16–1.52, p < 0.001). Compared with thickness of septum (tS) < 3.0 mm, tS ≥ 3.0 mm was associated with premature death in disease-dominant death (β=-0.16, 95%CI: -0.20 to -0.11, p < 0.001) and SCD (β=-0.15, 95%CI: -0.21 to -0.10, p < 0.001). Degree of myocardial fibrosis in the posterior septum was increased in coronary atherosclerosis (6.86%±2.48% vs. 4.91%±2.14%, p = 0.011) and cardiomyopathies (8.11%±3.24% vs. 4.88%±3.11%, p = 0.005). A logistic regression model, recruiting age, left and right ventricular wall thickness, pSBV, circumference of pulmonary annulus and aortic annulus, was elected as an optimal diagnostic model of CVDs, yielding AUC of 0.734 (95%CI: 0.705–0.763), 0.781 (0.740–0.821) and 0.763 (0.725-0.800) in training, validation and test sets. Increased pSBV significantly correlates with higher risk of CVDs and SCD. And tS ≥ 3.0 mm is an independent risk factor of premature death regardless of diseases.

Circulating CD31 and resistin levels reflect different stages of coronary atherosclerosis in patients with psoriasis.

Psoriasis is a skin disease with a complicated pathophysiology that includes an extensive inflammatory cytokine network. Nevertheless, the relationship between psoriasis severity, cytokine levels, and coronary artery atherosclerosis remains poorly understood. Our aim was to find serum markers as potential candidates for cardiovascular disease (CVD) risk monitoring in patients with psoriasis. Therefore, we examined coronary artery atherosclerosis via coronary computed tomography angiography (CCTA), serum cytokine levels via multiple immunoassays, and the patients' psoriasis state. Our findings reveal for the first time that the mainstream psoriasis cytokines interleukin 17A (IL-17A), IL-19, and IL-36 in the sera of Japanese patients with psoriasis showed a linear regression association with the Psoriasis Area and Severity Index score. Furthermore, the serum level of IL-19 was remarkably correlated to Th2-related serum cytokines such as IL-4 and IL-17E. When we investigated potential markers to monitor CVD in patients with psoriasis, circulating cluster of differentiation 31 (CD31) and resistin, but not psoriasis-related cytokines, were expressed differently at each stage of coronary atherosclerosis by CCTA. CD31 and resistin levels rose dramatically in individuals with psoriasis vulgaris (PV) and noncalcified atherosclerosis. In contrast, CD31 was negatively correlated with the coronary artery calcification score (CACS) in patients with PV, whereas resistin was inversely correlated with CACS in patients with psoriatic arthritis. In conclusion, the axis of IL-17A, IL-19, and IL-36 remains associated with the severity of psoriasis during the chronic phase of the disease, regardless of the application of topical or systemic treatment. Monitoring the levels of these cytokines can accurately determine the severity of skin inflammation. Resistin and CD31 are linked to coronary artery lesions and might be good candidates for tracking the progression of coronary atherosclerosis in patients with psoriasis.