2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes

Direct evaluation of antiplatelet therapy in coronary artery disease by comprehensive image-based profiling of circulating platelets

Coronary artery disease (CAD) is a leading cause of death globally. Antiplatelet therapy remains crucial in preventing and treating CAD-associated thrombotic complications, but it concurrently amplifies the risk of bleeding. Unfortunately, traditional platelet function measurement methods cannot directly evaluate its efficacy and safety. Here we demonstrate comprehensive image-based profiling of circulating platelets to directly observe thrombotic conditions and assess antiplatelet therapy in CAD patients. Deep learning-based analysis of whole blood samples from 207 CAD patients revealed elevated concentrations of circulating platelet aggregates, especially in acute versus chronic coronary syndrome patients. It also indicated a regimen-dependent reduction in these concentrations upon treatment with antiplatelet drugs, thereby verifying the direct efficacy of the therapy. Notably, consistent concentrations of these aggregates were found in both venous and arterial blood, suggesting venous blood as a reliable therapy efficacy indicator, despite CAD's arterial nature. These findings support personalized and improved antiplatelet therapy in CAD management.

Deep learning techniques for automated coronary artery segmentation and coronary artery disease detection: A systematic review of the last decade (2013-2024)

BACKGROUND

Coronary artery disease (CAD) is the most common cardiovascular disease, exacting high morbidity and mortality worldwide. CAD is detected on coronary artery imaging; coronary artery segmentation (CAS) of the images is essential for coronary lesion characterization. Both CAD detection and CAS require expert input, are labor-intensive, and error-prone.

OBJECTIVES

Deep learning (DL) techniques have achieved significant success in CAS and CAD detection, with many studies published recently. This study is an up-to-date systematic review of research on automated DL models for CAS and CAD detection in the past decade (2013-2024).

METHOD

Using PRISMA methodology, an initial literature search of 1,589 publications was conducted, from which 97 high-impact Q1 studies were selected based on pre-defined eligibility criteria. These studies were analyzed in terms of DL techniques employed, datasets, modalities, and performance metrics.

RESULTS

Of the 97 studies, most of which were published after 2016, 47 focused on CAS, 49 on CAD detection, and one on both tasks. CNN-based models were dominant in both domains. For CAS, CCTA was the most frequently used input modality, and U-Net was employed in 38 out of 48 studies, with recent works incorporating attention mechanisms and graph neural networks. ASOCA was the most widely used benchmark dataset. For CAD detection, ECG was the most common modality, with 45 out of 50 studies utilizing CNNs, and 20 of those relying purely on CNN architectures. Hybrid and multimodal models have become more prominent in recent years.

CONCLUSION

This review identified several challenges, including limited public datasets, variability in performance metrics, and model complexity. Future studies should focus on larger, diverse datasets and lightweight models integrating explainable artificial intelligence and uncertainty quantification to improve clinical applicability.

A Remote Nursing-Guided Secondary Prevention Programme in Acute Coronary Syndrome. The SPRING Randomised Controlled Trial

AIM

To assess the impact of a nurse-led remote secondary cardiovascular prevention programme versus usual follow-up in patients who have suffered an acute coronary syndrome in terms of major adverse clinical events (MACE), diet, physical exercise, smoking, emotional state, adherence to medical treatment, cardiometabolic profile and anthropometric parameters within one year of discharge.

DESIGN

Prospective, randomised, open-label, evaluator-blinded, multicentre trial.

METHODS

Between October 17, 2017, and February 5, 2023, patients were randomly assigned to either a usual follow-up of two cardiology visits over 12 months or the nurse-led remote secondary cardiovascular prevention programme, which also included 5 nursing visits (one face-to-face and four remote).

RESULTS

At 12 months, the nurse-led remote prevention programme group (interventional group) had lower smoking rates, greater adherence to medication, greater adherence to the Mediterranean diet, more physical activity, and better perceived health status compared to the usual follow-up group. The interventional group demonstrated a reduction in major adverse clinical events (20.7%) compared to the usual follow-up group (12.4%). This reduction was observed particularly in Acute Coronary Syndrome recurrence, all-cause hospitalisation, and hospitalisation for cardiovascular causes.

CONCLUSIONS

Patients randomised to the nurse-led remote prevention programme showed a significant reduction of the MACE, improved lifestyle, and medication adherence at 12 months compared to the usual follow-up group.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This study illustrates the feasibility and efficacy of a remote secondary cardiovascular prevention programme led by advanced practice nurses in patients who have suffered an Acute Coronary Syndrome.

REPORTING METHOD

CONSORT.

PATIENT OR PUBLIC CONTRIBUTION

None.

TRIAL REGISTRATION

The study was prospectively registered at www.

CLINICALTRIALS

gov: NCT03234023.

Design and rationale of "a pragmatic approach to the investigation of stable chest pain: A UK, multicenter, randomized trial to assess patient outcomes, quality of life and cost effectiveness (CE-MARC 3)"

RATIONALE

The optimal noninvasive diagnostic imaging strategy for patients with suspected coronary artery disease (CAD) is widely debated. Computed Tomography Coronary Angiography (CTCA) and functional imaging are both guideline-recommended, although comparative effectiveness in patients with intermediate-high pretest likelihood (PTL) is limited. Primary Hypothesis: We aim to establish if a personalized investigation strategy compared to CTCA first-line for allcomers, leads to improved patient outcomes.

DESIGN

In a multi-center, randomized trial, 4,000 patients newly referred for the investigation of suspected cardiac chest pain will be recruited and randomized (1:1) to either personalized care (first-line CTCA or functional imaging based on PTL) or CTCA first-line for allcomers. The primary endpoint is time to a composite of cardiovascular death, myocardial infarction, or unobstructed coronary arteries on invasive angiography. Follow up will occur at 6 and 12 months and then annually for up to 4 years for symptoms, quality of life, and guideline directed medical therapy usage. A cost-effectiveness analysis will be performed capturing impacts on health, measured in quality adjusted life years (QALYs) using the EQ-5D-5L, and costs (including investigations, procedures, procedural complications, medical treatment costs and any future hospital admissions) calculated. It will be possible for the whole trial pathway to be conducted remotely with the option to perform non-face-to-face consent, randomization, and follow-up data collection including health-related quality of life.

SITES

About 20 UK sites.

ENROLMENT

First site opened April 2022 and recruitment is due to complete by July 2025, with an average recruitment of 135 patients a month to date.

CURRENT STATUS

About 3,407 patients recruited and randomized by the end of February 2025 CONCLUSION: This trial will address whether, in patients with suspected cardiac chest pain, a strategy of personalized investigation according to pretest likelihood (PTL), compared to CTCA for allcomers, leads to improved patient outcomes, quality of life and cost-effectiveness.

Current and future applications of photon-counting computed tomography in cardiovascular medicine

Photon-counting CT (PCCT) represents a transformative advancement in cardiac imaging, addressing key limitations of conventional CT. This review synthesises current evidence to demonstrate how PCCT's superior spatial resolution, enhanced tissue characterisation and multienergy capabilities broaden the diagnostic potential of cardiac CT. Applications include the precise detection and quantification of coronary artery calcifications, evaluation of coronary plaque burden and composition, improved assessment of coronary stents, and comprehensive myocardial tissue characterisation and perfusion analysis. By offering high-quality spectral information and detailed tissue characterisation, PCCT provides a non-invasive alternative for assessing coronary artery disease and myocardial pathology, reducing the need for invasive coronary angiography and cardiac MRI. Despite ongoing challenges in technology and clinical implementation, PCCT has the potential to revolutionise cardiovascular diagnostics, optimise diagnostic workflows and enhance patient care through more accurate, streamlined and comprehensive assessments.

Frailty Burden and Efficacy of Initial Invasive Strategy in Chronic Coronary Disease: The ISCHEMIA Trials

BACKGROUND

Frailty is common among patients with chronic coronary disease and is associated with worse outcomes.

METHODS

A pooled, post hoc analysis of the ISCHEMIA and ISCHEMIA-CKD trials was conducted. Baseline frailty was assessed using a Frailty Index (FI), and participants were categorized into data-derived tertiles. Multivariable Cox models with multiplicative interaction terms (frailty × treatment arm) were constructed to evaluate whether baseline frailty status modified the treatment effect of the initial invasive (vs conservative) strategy on a composite outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest and the secondary outcome of HRQoL (Seattle Angina Questionnaire [SAQ]).

RESULTS

Among 5322 participants (mean 64 years, 24% female), a high frailty burden (tertile 3 vs. tertile 1) was associated with lower baseline SAQ scores and increased risk of adverse clinical outcomes on follow-up. Baseline frailty burden did not significantly modify the effect of the initial invasive strategy on the primary composite outcome (Pinteractionfrailty × intervention arm = 0.30). However, frailty significantly modified the effect of the initial invasive strategy on HRQoL, with higher baseline frailty burden associated with greater improvement in SAQ scores at 1 year with initial invasive (vs. conservative) treatment (Pinteractionfrailty × intervention arm < 0.001). The treatment effect of an initial invasive vs. conservative strategy on 12-month SAQ score change was most pronounced in individuals with lower baseline SAQ scores in both higher and lower frailty burden groups.

CONCLUSION

Patients with chronic coronary disease with a higher frailty burden are more likely to experience greater improvements in HRQoL with initial invasive management without a higher risk of adverse clinical events. Lower baseline SAQ scores predicted greater improvement in HRQoL with initial invasive management, independent of frailty burden.

BMAL1 in Ischemic Heart Disease: A Narrative Review from Molecular Clock to Myocardial Pathology

The biological clock is crucial for controlling the circadian rhythm of the human body and maintaining the stable cyclic changes of various human life activities. Cardiovascular disease has become one of the primary problems affecting human life and health in today's society. Cardiovascular disease exhibits distinct circadian rhythms, with the core clock gene protein Brain and muscle ARNT-like protein 1 (BMAL1) playing critical roles in both physiological cardiac function and pathological processes. BMAL1 regulates myocardial gene expression, maintains normal structures, and stabilizes circadian rhythms to preserve cardiac homeostasis. In the pathological state of myocardial ischemia, BMAL1 ameliorates myocardial ischemic injury by regulating intrinsic mechanisms such as oxidative stress response, energy metabolism, immune-inflammatory response, and apoptosis and autophagy in cardiomyocytes. This review systematically examines BMAL1's involvement in myocardial ischemic injury through the circadian regulation of cardiac function. We analyze its multidimensional impacts on oxidative stress, energy metabolism, immune-inflammatory responses, apoptosis, and autophagy, highlighting the biological significance of this clock gene in ischemic pathophysiology.

Cardiac imaging for the detection of ischemia: current status and future perspectives

INTRODUCTION

Coronary artery disease is the main cause of mortality worldwide mandating early detection, appropriate treatment, and follow-up. Noninvasive cardiac imaging techniques allow detection of obstructive coronary heart disease by direct visualization of the arteries or myocardial blood flow reduction. These techniques have made remarkable progress since their introduction, achieving high diagnostic precision. This review aims at evaluating these noninvasive cardiac imaging techniques, rendering a thorough overview of diagnostic decision-making for detection of ischemia.

AREAS COVERED

We discuss the latest advances in the field such as computed tomography angiography, single-photon emission tomography, positron emission tomography, and cardiac magnetic resonance; their main advantages and disadvantages, their most appropriate use and prospects. For the review, we analyzed the literature from 2009 to 2024 on noninvasive cardiac imaging in the diagnosis of coronary artery disease. The review included the 78 publications considered most relevant, including landmark trials, review articles and guidelines.

EXPERT OPINION

The progress in cardiac imaging is anticipated to overcome various limitations such as high costs, radiation exposure, artifacts, and differences in interpretation among observers. It is expected to lead to more automated scanning processes, and with the assistance of artificial intelligence-driven post-processing software, higher accuracy and reproducibility may be attained.

Associations of circulating omentin-1 levels and long noncoding RNA MALAT1 expression with coronary heart disease in patients with type 2 diabetes mellitus

Coronary heart disease (CHD) is a severe diabetic vascular complication and the main cause of mortality among diabetes patients. Early diagnosis of CHD could prevent its development. Both omentin-1 (Oment-1) and the long noncoding RNA MALAT1 (lncRNA MALAT1) can be detected in peripheral blood and exhibit protective or detrimental effects on CHD. However, whether these two factors could be predictive of CHD in T2DM patients remains unclear. Therefore, this study aimed to investigate the associations of circulating Oment-1 levels and the expression of MALAT1 with CHD in T2DM patients and to assess their predictive efficacy. A total of 137 T2DM patients were enrolled, including 68 patients without CHD (T2DM group) and 69 patients with CHD (T2DM + CHD group). Clinical parameters were collected, and plasma Oment-1 was measured by enzyme-linked immunosorbent assay (ELISA). RNA was isolated from peripheral monocytes, and the expression of MALAT1 was determined by quantitative PCR. Cardiac function was measured by echocardiography. Compared with that in T2DM patients, the plasma Oment-1 level was significantly lower, while the expression of MALAT1 was significantly greater in T2DM + CHD patients (all P values < 0.01). Bivariate correlation analysis indicated that Oment-1 was positively correlated with the left ventricular ejection fraction (LVEF) (P < 0.01). MALAT1 expression was negatively correlated with LVEF but positively correlated with age and DM duration (P < 0.05). Binary logistic regression suggested that Oment-1 and MALAT1 were significantly associated with the presence of CHD. Receiver operating characteristic (ROC) curve analysis demonstrated that both Oment-1 (AUC = 0.663, sensitivity = 75%, specificity = 49%) and MALAT1 (AUC = 0.749, sensitivity = 73%, specificity = 66%) had significant diagnostic value for CHD among T2DM patients. Notably, the combination of Oment-1 and MALAT1 exhibited better diagnostic efficiency (AUC = 0.771, sensitivity = 66.7%, specificity = 75.3%). In conclusion, decreased circulating Oment-1 levels and increased MALAT1 expression are closely associated with CHD in T2DM patients, and their combination offers superior diagnostic efficiency, suggesting Oment-1 and MALAT1 may serve as a non-invasive tool for the early CHD detection and risk stratification in high-risk T2DM patients. Further studies are warranted to explore the pathophysiological mechanisms of Omentin-1 and MALAT1 in the pathogenesis of CHD in T2DM and to validate their clinical utility as potential biomarkers in large cohort studies.

Reduced blood EPAC1 protein levels as a marker of severe coronary artery disease: the role of hypoxic foam cell-transformed smooth muscle cells

BACKGROUND

Vascular smooth muscle cells loaded with cholesterol (foam-VSMCs) play a crucial role in the progression of human atherosclerosis. Exchange Protein Directly Activated by cAMP 1 (EPAC1) is a critical protein in the regulation of vascular tone, endothelial function, and inflammation. Our objectives were to identify proteins specifically secreted by foam human coronary VSMCs (foam-hcVSMC) to evaluate their potential as circulating biomarkers for diagnosing coronary artery disease (CAD), and to ascertain the mechanisms underlying their levels in the blood of patients with CAD.

METHODS AND RESULTS

Differential proteomics identified EPAC1 as a differential foam-hcVSMC-secreted protein. Circulating EPAC1 levels were measured by ELISA in blood from 202 patients with suspected CAD who underwent coronary computed tomography angiography (CCTA). Blood EPAC1 levels were significantly lower in CAD patients compared to controls (p < 0.001). EPAC1 levels were reduced in both men and women with severe CAD (SIS > 4) compared to those with moderate CAD (SIS 1-4). ROC analysis identified 9.16 ng/ml as the optimal EPAC1 cut-off for severe CAD. At this threshold, EPAC1 predicted severe CAD (SIS > 4) with 69.6% sensitivity and 79.4% specificity, outperforming hs-CRP and hs-TnT in predicting CAD severity. Real-time PCR and Western blot analysis revealed that human foam-SMCs under hypoxic conditions exhibited a significant reduction in EPAC1 mRNA (p = 0.013) and protein (p < 0.001) levels.

CONCLUSIONS

These findings suggest that circulating EPAC1 protein levels lower than 9.16 ng/mL are predictive of severe CAD in humans. Hypoxic foam-SMCs, characteristic of advanced atherosclerotic lesions, exhibit diminished production of EPAC1, potentially contributing to the decreased circulating EPAC1 levels in patients with severe CAD.

Sex differences of interferon-gamma levels according to burden of coronary atherosclerosis identified by CT coronary angiography

BACKGROUND AND AIMS

The burden of coronary atherosclerosis differs between men and women. Beyond traditional cardiovascular risk factors, inflammatory biomarkers can influence plaque progression. We analyzed the influence of sex on coronary atherosclerosis and inflammatory cytokines.

METHODS AND RESULTS

Coronary CT angiography was performed in 301 patients and the extent of coronary atherosclerosis was assessed using semi-automated software. We analyzed total (TPV), non-calcified (NCPV), calcified (CPV) and low-density plaque volume in mm3. Serum was analyzed for various cytokines. Out of 301 patients, 94 (31 %) were female and 207 (69 %) were male. Significant differences were seen between women and men respectively for age, BMI and smoking status (all p < 0.05). All plaque types showed significantly higher volumes in men as compared to women (all p < 0.05). In men, significantly lower serum levels for IL-2 (3.2vs.4.3; p = 0.01) and interferon-gamma (3.2vs.8.8; p < 0.001) but higher levels for MCP-1 (224vs.155; p < 0.001) were seen. In regression analysis, interferon-gamma - but not IL-2 or MCP-1 - showed significant inverse association with male sex (OR 0.32; 95 %CI: 0.16-0.67; p = 0.002). Of note, interferon-gamma levels significantly differed according to high and low TPV in men (16.8vs.9.9; p < 0.001) but not in women (14.5vs. 8.9; p = 0.65).

CONCLUSION

In our cohort of individuals with suspected CAD undergoing coronary CTA, serum levels of interferon-gamma were significantly higher in women, in spite of a lower coronary plaque burden. Higher interferon-gamma levels were associated with higher plaque burden among men, but not in women, which suggests an influence of sex on the role of interferon-gamma in atherogenesis and atherosclerosis progression.

Diagnostic accuracy of segmental strain analysis by cardiac magnetic resonance feature tracking for chronic myocardial ischemic scar assessment

RATIONALE AND OBJECTIVE

This study investigates the potential of segmental strain parameters derived from cine magnetic resonance imaging (MRI) using feature tracking (FT) to detect chronic ischemic scars in patients with ischemic heart disease, offering an alternative to late gadolinium enhancement (LGE) MRI, which has limitations such as long scan times and contraindications to gadolinium.

PATIENTS AND METHODS

A total of 47 patients with chronic coronary syndrome and 20 healthy controls were enrolled, with CMR examinations performed on a 1.5 Tesla MRI system. Strain parameters were analyzed from 1072 myocardial segments. Myocardial segments were categorized into four groups: healthy controls, remote myocardium (no late gadolinium enhancement), scarred-viable (<50 % scar transmurality), and nonviable (>50 % scar transmurality).

RESULTS

Results showed significant differences in segmental peak circumferential strain (SPCS), peak radial strain (SPRS), and peak longitudinal strain (SPLS) between scarred viable and nonviable segments compared to remote and control segments, with all p-values <0.001. Specifically, SPCS had a superior ability to distinguish scarred myocardium from remote tissue, showing an area under the curve (AUC) of 0.77, with a sensitivity of 71.5 % and specificity of 70 %. For differentiating nonviable from viable myocardium, SPCS achieved an AUC of 0.80, with a sensitivity of 82.02 % and specificity of 70.21 %.

CONCLUSION

CMR-FT strain analysis is promising complementary tool, particularly in situations where contrast administration is contraindicated or when a rapid, non-contrast assessment of myocardial viability and potential scar burden is desired.

Development and validation of a risk prediction model for adverse outcomes in patients with suspected coronary artery disease and no significant stenosis on angiography: a retrospective cohort study

OBJECTIVES

To develop and validate a risk prediction model for adverse outcomes in patients with angina with non-obstructive coronary arteries (ANOCA) confirmed by invasive coronary angiography.

DESIGN

Retrospective cohort study.

SETTING

A tertiary cardiovascular care centre in China.

PARTICIPANTS

From 17 816 consecutive patients undergoing coronary angiography for suspected coronary artery disease, 5934 met ANOCA criteria after rigorous exclusion: (1) significant stenosis (≥50% luminal narrowing), (2) established coronary artery disease history, (3) incomplete baseline/follow-up data, (4) non-cardiovascular life-limiting conditions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a composite of all-cause death, non-fatal myocardial infarction (MI), stroke and repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The secondary outcome was major adverse cardiovascular events, defined as cardiac-related death, non-fatal MI, non-fatal stroke, repeat PCI and CABG.

RESULTS

The derivation cohort (n=4452) and validation cohort (n=1482) demonstrated comparable baseline characteristics. The nomogram incorporated eight prognosticators: age, haemoglobin, serum urea, serum sodium, alanine aminotransferase/aspartate aminotransferase ratio, N-terminal pro-B-type natriuretic peptide (NT-proBNP), left atrial diameter and left ventricular ejection fraction. The prediction model showed robust discrimination for primary endpoint, achieving area under the curve (AUC) values of 0.82 (1 year), 0.90 (2 years) and 0.89 (3 years) in the derivation cohort, with corresponding validation cohort AUCs of 0.75, 0.77 and 0.78. Calibration plots revealed close alignment between predicted and actual event-free survival probabilities in both cohorts. Risk stratification identified two distinct prognostic groups with significant survival differences (log-rank p<0.0001).

CONCLUSIONS

This predictive model integrates routinely available clinical parameters to accurately stratify mortality and cardiovascular risk in ANOCA patients, providing a potential valuable decision-support tool for personalised therapeutic strategies.

Coronary Artery Disease Doubles Excess Mortality in Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Assessment of coronary artery disease (CAD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) varies between countries and there are only limited data on the long-term impact of CAD in these patients. We examined the association between CAD and mortality in patients with HFrEF undergoing coronary angiography.

METHODS AND RESULTS

Using Danish registries, we identified patients with HFrEF (EF ≤40%) undergoing coronary angiography from 2003 to 2016. We estimated 10-year cumulative incidence proportions and adjusted hazard ratios (aHR) for all-cause death, comparing patients with HFrEF with CAD with patients with HFrEF without CAD. Both groups were further compared with an age- and sex-matched general population cohort in a 1:5 ratio. We included 3294 patients with HFrEF, of whom 1436 (44%) had CAD, as well as 16 365 matched general population individuals. Median follow-up was 5.3 years. Patients with HFrEF with CAD had higher 10-year mortality than patients with HFrEF without CAD (55% versus 33%; aHR, 1.38 [95% CI, 1.19-1.59]). These estimates were consistent across ages, whereas greater extent of CAD was associated with higher mortality (Ptrend<0.01). Compared with the matched general population, the 10-year excess mortality was 29% for patients with HFrEF with CAD (55% versus 26%; aHR, 2.18 [95% CI, 1.92-2.48]), and 15% for patients with HFrEF without CAD (33% versus 17%; aHR, 1.87 [95% CI, 1.63-2.14]).

CONCLUSIONS

Presence and extent of CAD are strongly associated with all-cause mortality in patients with HFrEF and, when compared with a matched general population, presence of CAD doubles excess mortality. This highlights the importance of CAD assessment for prognostication in patients with HFrEF.

Sex differences in guideline adherence for coronary angiography in patients with suspected chronic coronary syndrome in Germany: insights from the ENLIGHT-KHK trial

BACKGROUND

For the management of acute coronary syndrome, literature shows lower healthcare providers' guideline adherence for women than for men. Since less is known about the management of chronic coronary syndrome (CCS), this study investigated patient-related sex differences in providers' guideline adherence for invasive coronary angiography (CA) performed in patients with suspected CCS.

METHODS

Using data from the German ENLIGHT-KHK trial, patients with suspected CCS who underwent a CA were analysed. To assess the association between patient sex and physicians' adherence to the German National Disease Management Guideline "Chronic coronary artery disease" of 2019, binary logistic regression models were developed. Covariates included age, symptoms, risk factors, comorbidities, and non-invasive testing and its results. To examine sex differences in predictors of guideline adherence, models were run separately for women and men.

RESULTS

Two hundred seventy-three women and three hundred eighty-six men were included (aged 67 ± 10 years). Physicians' guideline adherence for CA was lower for women than for men (19.4% vs. 30.1%, p = 0.002). CAs were less likely to be guideline-adherent for women with suspected CCS than men (OR 0.4, p < 0.05). Guideline adherence predictors differed between women and men. For example, men's predictors included non-invasive testing and its results, age, typical angina and smoking; of these, only a positive non-invasive test result had an impact for women.

CONCLUSION

Our results indicate a less guideline-adherent diagnostic workup of CA for women with suspected CCS than men. This might reflect a limited awareness of CCS in women and insufficiently sex-specific guideline recommendations.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00015638, Registered February 19, 2019; Universal Trial Number (UTN): U1111-1227-8055.

Semiquantitative metrics of coronary artery disease burden: Intra-individual comparison between ultrahigh-resolution photon-counting detector CT and energy-integrating detector CT

BACKGROUND

Quantitative coronary stenosis and plaque volumes have demonstrated intra-individual differences between ultrahigh-resolution (UHR) photon-counting detector (PCD)-CT and energy-integrating detector (EID)-CT. This study aimed to assess the impact of UHR PCD-CT on semiquantitative scores of coronary artery disease (CAD) burden compared with EID-CT.

METHODS

Patients undergoing coronary CT angiography (CCTA) on an EID-CT system for stable chest pain or pre-transcatheter aortic valve replacement evaluation were prospectively enrolled for UHR PCD-CT scan within 30 days. Both datasets were visually evaluated using five established semiquantitative scores: Segment Involvement Score (SIS), Segment Stenosis Score (SSS), Multivessel Aggregate Stenosis Score (MVAS), CCTA-adapted Leaman score (CT-LeSc), and Coronary Artery Disease Reporting and Data System (CAD-RADS). Additionally, the total number of detected plaques and high-risk features were reported (positive remodeling, spotty calcification, low-attenuation, and napkin-ring sign).

RESULTS

The cohort comprised 46 patients (37 men, 68.4 ​± ​6.9 years). When assessing stenosis severity, PCD-CT showed lower SSS (3.5 [1.3-5.0] vs 6.5 [3.0-9.8], p ​< ​0.001), MVAS (5.5 [4.0-7.0] vs 7.0 [5.0-9.0], p ​< ​0.001), and CT-LeSc (10.4 [8.5-13.9] vs 11.2 [8.8-15.4], p ​= ​0.032). Furthermore, 52 ​% (24/46) of patients were reclassified to a lower CAD-RADS category compared to EID-CT. In terms of CAD extent, PCD-CT demonstrated higher SIS (8.0 [6.0-9.0] vs 7.0 [6.0-8.8], p ​= ​0.018) and plaque count (9.0 [7.0-13.8] vs 7.0 [7.0-9.8] p ​< ​0.001). Positive remodeling was less frequent in PCD-CT datasets (2.0 [1.0-4.3] vs 1.0 [0.0-3.0], p ​= ​0.012), with no significant differences in other high-risk features.

CONCLUSION

The use of UHR PCD-CT detects less severe, but more extensive CAD compared to EID-CT. The effect of such CCTA-based differences on individual risk stratification needs further investigation.

Effects of complications associated with chronic obstructive pulmonary disease on lung function and hospitalization expenses: A retrospective study

This study investigates the impact of complications associated with chronic obstructive pulmonary disease (COPD) on pulmonary function and inpatient medical expenditures in the Zhongshan region. A retrospective analysis of data from January 2012 to December 2021 was conducted, focusing on lung function and hospitalization expenses for COPD patients (n = 272). The included cases were initially categorized into a simple group (without comorbidities, n = 99) and a nonsimple group (with comorbidities, n = 173). Changes in lung function within each subgroup over a decade were evaluated, along with the average annual hospitalization rate, average duration of hospital stay, and mean hospitalization cost for COPD patients. A comparison between the simple group and the nonsimple group of COPD patient's uncovered statistically significant distinctions (P < .05) in age, extent of lung function alteration, average annual hospitalization frequency, and average hospitalization cost. Moreover, multivariable logistic regression analysis showed that, after adjusted for age, sex, smoking, and hospitalizations, patients with comorbidities (nonsimple group) were independently associated with lung function changes (β = 4.048, 95% CI: 1.435-6.659, P = .003) compared to those without comorbidities (simple group). Comorbidities have a substantial impact on the lung function of COPD patients. Furthermore, they are associated with increased hospitalization frequency, elevated hospitalization costs, and a higher economic burden of hospitalization for COPD patients.

Cost-effectiveness of implementing a genotype-guided de-escalation strategy in patients with acute coronary syndrome

AIMS

A genotype-guided P2Y12-inhibitor de-escalation strategy, switching acute coronary syndrome (ACS) patients without a CYP2C19 loss-of-function allele from ticagrelor or prasugrel to clopidogrel, has shown to reduce bleeding risk without affecting the effectivity of therapy by increasing ischaemic risk. We estimated the cost-effectiveness of this personalized approach compared to standard dual antiplatelet therapy (DAPT; aspirin plus ticagrelor/prasugrel) in the Netherlands.

METHODS AND RESULTS

We developed a 1-year decision tree based on results of the FORCE-ACS registry, comparing a cohort of ACS patients who underwent genotyping with a cohort of ACS patients treated with standard DAPT. This was followed by a lifelong Markov model to compare lifetime costs and quality-adjusted life years (QALYs) for a fictional cohort of 1000 patients. The cost-effectiveness analysis was performed from the perspective of the Dutch healthcare system. A genotype-guided de-escalation strategy led to an increase of 57.73 QALYs and saved €808788 compared to standard DAPT based on a lifetime horizon. Probabilistic sensitivity analysis showed that the genotype-guided strategy was cost-saving in 96% and increased QALYs in 87% of simulations. The intervention remained cost-effective in the scenario where prices for all P2Y12 inhibitors were equalized. The genotype-guided strategy remained dominant in various other scenarios and sensitivity analyses.

CONCLUSION

A genotype-guided de-escalation strategy in patients with ACS was both cost-saving and yielded higher QALYs compared to standard DAPT, highlighting its potential for implementation in clinical practice. Trial registration: ClinicalTrials.gov identifier: NCT03823547.

The use of glycoprotein IIb/IIIa inhibitors in elective PCI - A systematic review and meta-analysis of randomised trials

BACKGROUND

Glycoprotein IIb/IIIa inhibitors (GPIs) improve 30-day outcomes when used as an adjunct to percutaneous coronary intervention (PCI) in acute coronary syndromes, but their role in stable coronary artery disease (CAD) remains uncertain in the context of modern stents and oral antiplatelet therapy.

METHODOLOGY

A systematic search of PubMed, EMBASE, Central and clinicaltrials.gov databases was conducted from inception to October 2022. Randomised trials comparing GPI to placebo in elective PCI were included. Outcomes included target vessel revascularisation (TVR), stent thrombosis (ST) and a composite of TVR, myocardial infarction and death (MACE) at 30-days and 6-12 months. Bleeding was assessed using Thrombolysis In Myocardial Infarction bleeding score or equivalent. A random-effects model was used for all analyses.

RESULTS

Of 2375 abstracts screened, 16 studies (6428 patients) were included. GPIs significantly reduced 30-day MACE (risk ratio [RR] 0.58, 95 % CI, 0.39-0.86, p < 0.01; number needed to treat = 33), intermediate-term MACE at 6-12 months (RR 0.67; 95 % CI, 0.49-0.92; p = 0.01) and ST (RR 0.29, 95 % CI, 0.10-0.83, p = 0.02). There was no significant difference in TVR or major bleeding, although minor bleeding was increased (RR 1.72, 95 % CI, 1.14-2.61, p = 0.01, number needed to harm = 77). Meta-regression suggested that the benefit of GPIs has diminished over time.

CONCLUSION

GPI use during elective PCI reduces MACE and ST whilst increasing minor bleeding. The observed benefit appears to have waned over time, highlighting the importance of selective use in patients at low bleeding risk.

Sex related coronary plaque progression patterns among patients with family history as the sole cardiovascular risk factor: A PARADIGM sub-study

BACKGROUND AND AIMS

How sex may influence the prevalence and progression of coronary atherosclerosis in patients with positive family history for CAD is still unclear. Aim of the present study was to explore the role of family history of CAD in coronary atherosclerosis expression and progression in male and female subjects.

METHODS

A total of 2252 patients who underwent clinically indicated serial CCTAs at an interscan interval of more than 2 years were enrolled in the PARADIGM Study. For the present sub-analysis, a selected population was identified after applying the following exclusion criteria:1)uncomplete plaque analysis data; 2)occurrence of any MACE between CT scans; 3) positive history for coronary artery disease before the first CT scan; 4) the presence of any traditional risk factors a part from positive family history of CAD. Subjects enrolled were classified according to family history of CAD status and separate analysis for male and female were performed.

RESULTS

Among 210 subjects finally enrolled, no differences in annual total plaque progression according to family history of CAD were detected even when plaque subtypes were evaluated. On the contrary, an higher annual fibrous-fatty plaque progression was evident only among male subjects with family history of CAD [0.3 mm3(IQR 0-3.7) vs 0 mm3(IQR -0.5-0.9), p = 0.0302 for patients with vs without family history respectively] but not among female. At multivariate analysis significative annual fibrous-fatty plaque progression was recorded only among male with family history [OR 3.29(95 % CI 1.05-10.35),p = 0.0412].

CONCLUSIONS

Family history of CAD resulted to be associated with rapid high risk plaque volume progression among males but not among females.

Non-invasive physiological assessment of intermediate coronary stenoses from plain angiography through artificial intelligence: the STARFLOW system

BACKGROUND

Despite evidence supporting use of fractional flow reserve (FFR) and instantaneous waves-free ratio (iFR) to improve outcome of patients undergoing coronary angiography (CA) and percutaneous coronary intervention, such techniques are still underused in clinical practice due to economic and logistic issues.

OBJECTIVES

We aimed to develop an artificial intelligence (AI)-based application to compute FFR and iFR from plain CA.

METHODS AND RESULTS

Consecutive patients performing FFR or iFR or both were enrolled. A specific multi-task deep network exploiting 2 projections of the coronary of interest from standard CA was appraised. Accuracy of prediction of FFR/iFR of the AI model was the primary endpoint, along with sensitivity and specificity. Prediction was tested both for continuous values and for dichotomous classification (positive/negative) for FFR or iFR. Subgroup analyses were performed for FFR and iFR.A total of 389 patients from 5 centers were enrolled. Mean age was 67.9 ± 9.6 and 39.2% of patients were admitted for acute coronary syndrome. Overall, the accuracy was 87.3% (81.2-93.4%), with a sensitivity of 82.4% (71.9-96.4%) and a specificity of 92.2% (90.4-93.9%). For FFR, accuracy was 84.8% (77.8-91.8%), with a sensitivity of 81.9% (69.4-94.4%) and a specificity of 87.7% (85.5-89.9%), while for iFR accuracy was 90.2% (86.0-94.6%), with a sensitivity of 87.2% (76.6-97.8%) and a specificity of 93.2% (91.7-94.7%, all confidence intervals 95%).

CONCLUSION

The presented machine-learning based tool showed high accuracy in prediction of wire-based FFR and iFR.

Feasibility exploration of myocardial blood flow synthesis from a simulated static myocardial computed tomography perfusion via a deep neural network

BACKGROUND

 Myocardial blood flow (MBF) provides important diagnostic information for myocardial ischemia. However, dynamic computed tomography perfusion (CTP) needed for MBF involves multiple exposures, leading to high radiation doses.

OBJECTIVES

 This study investigated synthesizing MBF from simulated static myocardial CTP to explore dose reduction potential, bypassing the traditional dynamic input function.

METHODS

 The study included 253 subjects with intermediate-to-high pretest probabilities of obstructive coronary artery disease (CAD). MBF was reconstructed from dynamic myocardial CTP. A deep neural network (DNN) converted simulated static CTP into synthetic MBF. Beyond the usual image quality evaluation, the synthetic MBF was segmented and a clinical functional assessment was conducted, with quantitative analysis for consistency and correlation.

RESULTS

 Synthetic MBF closely matched the referenced MBF, with an average structure similarity (SSIM) of 0.87. ROC analysis of ischemic segments showed an area under curve (AUC) of 0.915 for synthetic MBF. This method can theoretically reduce the radiation dose for MBF significantly, provided satisfactory static CTP is obtained, reducing reliance on high time resolution of dynamic CTP.

CONCLUSIONS

 The proposed method is feasible, with satisfactory clinical functionality of synthetic MBF. Further investigation and validation are needed to confirm actual dose reduction in clinical settings.

Clinical and Technical Predictors of Treatment Success After Coronary Intravascular Lithotripsy in Calcific Coronary Lesions

BACKGROUND

Intravascular lithotripsy (IVL) is increasingly used to treat coronary artery calcification (CAC). This study aimed to identify clinical and procedural factors associated with IVL treatment success.

METHODS

This retrospective analysis included 454 patients (73 ± 9 years, 75% male) treated with IVL from the multicenter BENELUX-IVL registry (May 2019 to February 2024). Treatment success was defined as achieving residual coronary diameter stenosis < 30% and luminal gain, assessed by quantitative coronary analysis (QCA). Linear and binary logistic regression analyses were performed to identify factors associated with these outcomes.

RESULTS

The mean luminal gain was 1.9 ± 0.9 mm, and residual diameter stenosis < 30% was achieved in 354 (90%) lesions. Stenting after IVL for therapy completion (p < 0.001), intracoronary imaging (ICI) guidance (p = 0.024) and chronic total occlusions (CTOs; p < 0.001) were associated with increased luminal gain, while bifurcation lesions (p = 0.029) were associated with decreased luminal gain. Long (> 20 mm) lesions (p = 0.034) and post-IVL stenting for therapy completion (p = 0.041) were associated with a residual diameter stenosis < 30%, while aorto-ostial lesions (p = 0.014) were negatively associated with this outcome. Technical IVL parameters such as inflation pressure and number of pulses delivered were not significantly associated with treatment success.

CONCLUSION

Stenting after IVL for therapy completion, ICI guidance and CTOs were associated with increased luminal gain, while bifurcation lesions were linked to decreased luminal gain. Long lesions and post-IVL stenting for therapy completion were associated with residual diameter stenosis < 30%, while the presence of aorto-ostial lesions was negatively associated with this outcome. Technical IVL-related procedural factors did not significantly impact treatment success.

Clinical significance of very high IgE levels (≥1000 IU/mL): Population-based study of 118,211 adults

Background

Very high serum IgE (≥1000 IU/mL) is reported in atopic disorders. However, data on its significance in nonallergic disorders are limited.

Objective

We aimed to analyze the diagnostic value of very high IgE in adults.

Methods

A retrospective nationwide study was conducted using the electronic database of Clalit Health Services, covering adults (≥18 years) treated between 2002 and 2022. Subjects with IgE ≥ 1000 IU/mL were compared to the controls with IgE < 100 IU/mL across 3 age groups (18-30, 31-64, and ≥65 years). Outcomes included eosinophilic, autoimmune, autoinflammatory, and cardiovascular disorders (CVD), cancer, and inborn errors of immunity (IEI). A multivariable Cox regression model determined statistical significance (P < .05).

Results

The study included 118,211 subjects: 110,116 controls and 8635 with very high IgE levels. Excluding insect sting and drug allergies, very high IgE was more common across all tested allergic disorders, with asthma showing the highest rate (64.49%). Univariable analysis showed higher prevalence of CVD (3.88% vs 2.72%, P < .001), eosinophilic disorders (0.42% vs 0.06%, P < .001), and IEI (0.35% vs 0.20%, P = .004) in the very high IgE group. Multivariable analysis revealed age-dependent significant results: higher CVD risk in ages 31-64 (hazard ratio = 1.249; 95% confidence interval, 1.054-1.481; P = .010) and borderline IEI association in ages 18-30 (hazard ratio = 1.802; 95% confidence interval, 0.978-3.321; P = .059). Risk of eosinophilic disorders was increased across all age groups (P < .001).

Conclusions

Very high IgE level of ≥1000 IU/mL is associated with increased risks of CVD, IEI, and eosinophilic disorders. Physicians should consider further assessment for these conditions in nonallergic patients with very high IgE levels.

J-shaped association between apolipoprotein B and CV outcomes in statin-treated patients with chronic coronary syndrome

INTRODUCTION AND OBJECTIVES

The association between apolipoprotein B (apoB) and residual cardiovascular (CV) risk in patients with chronic coronary syndrome (CCS) remains unclear. We aimed to investigate the association between apoB levels and CV outcomes in statin-treated CCS patients.

METHODS

We enrolled 8641 statin-treated CCS patients at Fuwai Hospital. The patients were divided into 5 groups based on to apoB quintiles (Q1 to Q5). The primary endpoint was 3-year CV events, including CV death, nonfatal myocardial infarction, and nonfatal stroke.

RESULTS

During a median follow-up of 3.17 years, there were 232 (2.7%) CV events. After multivariable adjustment, a restricted cubic spline illustrated a J-shaped relationship between apoB levels and 3-year CV events, with the risk remaining flat until apoB levels exceeded 0.73g/L, after which the risk increased (nonlinear P <.05). Kaplan-Meier curves showed the lowest CV event rate in the Q3 group (0.68-0.78g/L). Compared with the Q3 group, multivariable Cox regression models revealed that both low (Q1, ≤0.57g/L) and high (Q5, >0.93g/L) apoB levels were associated with an increased risk of major adverse cardiac events (all P <.05). Notably, patients with low apoB levels (Q1) had the highest risk of CV death (HR, 2.44; 95%CI, 1.17-5.08).

CONCLUSIONS

Our analysis indicates that both low and high levels of apoB are associated with elevated CV risk, with the risk being particularly pronounced at higher levels (> 0.73g/L).

Comparison of cardiac computed tomography recommendations in recent ESC vs. ACC/AHA guidelines

Cardiac computed tomography (CCT) continues to expand with increasing applications and technological advancements. Growing evidence on the clinical utility of CCT necessitates evaluating how this knowledge is incorporated into European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. We aimed to provide a comprehensive comparison of CCT indications between ESC and ACC/AHA guidelines to identify areas of consensus and divergence in the current landscape of CCT utilization. ESC and ACC/AHA guidelines were systematically reviewed for CCT recommendations. The class of recommendation (COR) and level of evidence (LOE) were compared using χ2 or Fisher exact tests. The latest ESC guidelines included 40 recommendations regarding CCT: 18 (45%) COR-I, 14 (35%) COR-IIa, 6 (15%) COR-IIb, and 2 (5%) COR-III. Two (5%) recommendation had LOE-A, 20 (50%) had LOE-B, and 18 (45%) had LOE-C. The latest ACC/AHA guidelines consisted of 54 recommendations: 18 (33.3%) COR-I, 28 (51.9%) COR-IIa, 6 (11.1%) COR-IIb, and 2 (3.7%) COR-III. Two recommendations were assigned LOE-A (3.7%), 30 (55.6%) were classified as LOE-B, and 22 (40.7%) as LOE-C. ACC/AHA guidelines had a significantly higher proportion of COR-IIa recommendations (P = 0.04) and similar proportions of COR-I and COR-IIb recommendations (P = 0.28; P = 0.76), compared to ESC guidelines. The proportion of LOE-B and LOE-C recommendations weren't statistically different (P = 0.54; P = 0.84). ACC/AHA guidelines included more CCT recommendations with a higher COR and LOE than ESC guidelines. These findings highlight the need for continued research and consensus-building to establish standardized, evidence-based CCT recommendations in clinical practice.

Can apelins guide the diagnosis of coronary artery disease in COPD patients?

BACKGROUND

Apelins are adipokines known for their anti-inflammatory, vasodilator, and antiatherosclerotic effects. They are involved in the pathogenesis of chronic diseases like chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD).

OBJECTIVES

This study aims to investigate apelin as a potential biomarker for early diagnosis and management of CAD in COPD patients.

METHODS

The study included 73 stable COPD patients admitted between June 2023 and June 2024 and 35 healthy volunteers matched by age and gender. COPD patients were categorized into two groups: those without CAD (Group 1) and those with CAD (Group 2). Serum levels of apelin 12, 13, 17, and 36 were measured using ELISA.

RESULTS

Serum apelin levels were significantly lower in COPD patients than in controls (p < 0.001). Among COPD patients, those with CAD showed lower serum apelin levels compared to those without CAD (p = 0.005 for apelin 12, p < 0.001 for apelin 13, 17, and 36). ROC analysis indicated high sensitivity and specificity for apelin 13 and 36 in predicting CAD in COPD patients. Apelin 13 and 36 were positively correlated with ejection fraction (EF) (R = 0.43, p = 0.01; R = 0.4, p = 0.01), and apelin 12 was positively correlated with FEV1 and FVC (R = 0.24, p = 0.04; R = 0.27, p = 0.02).

CONCLUSION

While CAD worsens the prognosis in COPD patients, it remains underdiagnosed. Serum apelin, especially apelin 13 and 36, may assist in the early diagnosis and management of CAD in COPD patients.

Prognostic significance of stress dynamic myocardial CT perfusion: comparison with CT-FFR and CT angiography stenosis-the multicenter VALIDITY trial

OBJECTIVES

This study aimed to investigate the prognostic significance of stress dynamic myocardial CT perfusion imaging (CTP) and determine whether it has incremental advantages over coronary computed tomography angiography (CTA)-derived parameters.

METHODS

This prospective multicenter study included patients with suspected coronary artery disease who had undergone coronary CTA and CTP and were followed for 6 years. The endpoint was time-to-first major adverse cardiovascular event (MACE). MACEs included all-cause mortality, cardiac death, nonfatal myocardial infarction, unstable angina, late revascularization, and heart failure or aggravated angina symptoms requiring hospitalization. The CTP-derived absolute myocardial blood flow (MBF), relative MBF ratio (r-MBF), and the CTA-derived fractional flow reserve (CT-FFR) and stenosis were analyzed. The independent predictors, time-to-event distributions and the incremental prognostic value of CTP over CTA-derived parameters were assessed.

RESULTS

A total of 226 patients (66.7 ± 11.3 years, 37.6% women) were enrolled with a median follow-up time of 1233 days. Twenty-one patients (9.29%) experienced MACEs and ten patients (4.4%) experienced hard MACEs. The r-MBF was the only independent predictor for MACEs in both all patients (hazard ratio [HR]: 0.82 (0.69-0.97), p = 0.01) and patients available for CTA stenosis (%) and CT-FFR calculation (HR: 0.72 (0.57-0.91), p = 0.006). The incremental prognostic significance of r-MBF over CT-FFR was confirmed after combining with CTA-derived parameters (concordance index: 0.919 vs. 0.811; p < 0.01). Patients with r-MBF < 0.77 were more likely to experience MACEs and have a lower average survival time (1565 vs. 1790 days; p < 0.01) after stent implantation.

CONCLUSIONS

CTP-assessed r-MBF was independently correlated with MACEs and provided incremental prognostic significance.

KEY POINTS

Question The prognostic significance of CT perfusion (CTP) lacks sufficient support from clinical research. Findings In this Chinese population, CTP has the strongest prognostic significance, over CT-Fractional Flow Reserve (FFR) and CTA stenosis in predicting major adverse cardiovascular events (MACEs). Clinical relevance Relative myocardial blood flow ratio had the strongest prognostic value and incremental advantages in predicting MACEs beyond CT-FFR and coronary CTA stenosis quantification, as well as advantages in patients with stents, aiding in personalized diagnosis and treatment plans.

Significant Stenosis Without Thrombus: Is It the Third Most Common Morphology of Acute Coronary Syndrome?

Background

Significant stenosis without thrombus (SSWT) is sometimes observed in patients with acute coronary syndrome (ACS). However, its incidence and clinical features remains unclear.

Method

This substudy of the TACTICS registry included patients with ACS (n = 702) undergoing emergency percutaneous coronary intervention using optical coherence tomography. Using this registry data, we compared the clinical features of SSWT in patients with ACS. Major adverse cardiac events were defined as cardiac death, nonfatal myocardial infarction, heart failure, or ischemia-driven revascularization at 1 year.

Results

Plaque rupture (PR; n = 411, 59.1%) and plaque erosion (PE; n = 178, 25.6%) were the 2 major morphologies, followed by SSWT (n = 64, 9.1%) and calcified nodule (CN; n = 28, 4.0%). Patients with SSWT were slightly older than those with PR and PE, but younger than those with CN. In the SSWT, non-ST elevation myocardial infarction was the main type of ACS, followed by unstable angina and ST-elevation myocardial infarction (63%, 22%, and 15%, respectively). Lesions were less complex with a lower proportion of type B2 or C, shorter procedure time, lower proportion of multivessel disease, and lower syntax score, which led to a lower incidence of major adverse cardiac events.

Conclusion

SSWT was the third most common morphology of ACS, with clinical features different from those of PR, PE, and CN.

Relationship between microvascular status and diagnostic performance of stress dynamic CT perfusion imaging

OBJECTIVES

This study aimed to investigate the relationship between microvascular status in the non-ischemic myocardium and the diagnostic performance of stress dynamic CT perfusion imaging (CTP) in detecting hemodynamically significant stenosis.

MATERIALS AND METHODS

This study included 157 patients who underwent coronary computed tomography angiography (CTA), CTP, and invasive coronary angiography (ICA), including fractional flow reserve (FFR). Hemodynamically significant stenosis was defined by FFR and ICA. A relative myocardial blood flow (MBF) for each myocardial segment was normalized to the highest MBF (remote MBF) among 16 segments.

RESULTS

The receiver operating characteristic curve analysis for detecting hemodynamically significant stenosis at the vessel level indicated that patients with lower, intermediate, and higher remote MBF had areas under the curve (AUC) of 0.66, 0.70, and 0.80, respectively, for absolute MBF and AUCs of 0.63, 0.70, and 0.83, respectively, for relative MBF. The optimal cut-off values for absolute MBF were proportional to the levels of remote MBFs, while the ones for relative MBF were more consistent across lower to higher remote MBFs. For the patients with high remote MBF, the relative MBF demonstrated a sensitivity of 69%, specificity of 88%, and accuracy of 85% in detecting hemodynamically significant stenosis.

CONCLUSION

The microvascular status in the non-ischemic myocardium influenced the diagnostic performance of dynamic CTP and threshold values of absolute MBFs, suggesting the potential preference for relative MBF over absolute MBF in clinical settings. Dynamic CTP's quantification of MBF offers the benefit of indicating reliability in ischemia detection relative to microvascular status.

KEY POINTS

Question The relationship between microvascular status and diagnostic performance of dynamic CTP imaging has not been fully investigated. Findings The diagnostic performance of dynamic CTP and threshold values of absolute MBF were impacted by microvascular status. Clinical relevance The differences in diagnostic accuracy of dynamic CTP related to varying remote MBF values necessitate a personalized evaluation of myocardial perfusion in dynamic CTP images.

Serum malondialdehyde levels at admission as a predictor of inhospital mortality in patients with acute coronary syndrome

INTRODUCTION AND OBJECTIVE

Malondialdehyde (MDA) is a predictive marker of cardiovascular events in patients with stable angina pectoris. However, there is limited information available regarding this marker in patients with acute coronary syndrome (ACS). The aim of the study was to explore the association of MDA levels with inhospital mortality among patients with ACS.

MATERIALS AND METHODS

The study sample consisted of 556 ACS patients. The leftover plasma samples collected in EDTA vials for troponin T estimation within 24 h of chest pain were used for analysis. Blood samples were collected into tubes for MDA, nitric oxide (NO), inducible nitric oxide synthase (i-NOS), endothelial nitric oxide synthase (e-NOS), total sialic acid (TSA), NT-proBNP, ANP, homocysteine, and cardiac troponin I (cTnI). The blood samples were centrifuged (4000 g , 4 °C) for 10 min, and the obtained serum then kept at -25 °C until the analyses were carried out. The relationship between these markers and inhospital mortality of ACS patients was investigated.

RESULTS

Univariate logistic regression analysis revealed significant correlations among sex, age, creatine, MDA, NT-proBNP, ANP, homocysteine, cTnI, NO, e-NOS, i-NOS, and TSA. Further analysis of these variables using the multivariate logistic regression analysis indicated that age, creatine, MDA, and NT-proBNP were independent predictors. Optimal MDA cutoff value of >33.1 predicted inhospital mortality with 85% sensitivity and 88.17% specificity [AUC: 0.905 (95% CI: 0.878-0.928, P  < 0.001)].

CONCLUSION

We demonstrated that MDA levels were elevated in cases of inhospital mortality among ACS patients and the optimal MDA cutoff value of >33.1 predicted inhospital mortality with 85% sensitivity and 88.17% specificity.

Assessment of inter- and intrareader agreement among different stenosis quantification methods in coronary CT angiography

PURPOSE

To assess the inter- and intrareader agreement among different subjective and objective measurement methods to grade coronary artery stenosis in coronary CT angiography (CCTA).

METHODS

In this retrospective study, consecutive patients of a one-year cohort who received a clinically indicated CCTA in 2023 and had a CAD-RADS2.0 score of 3 or 4 were included. Five different radiologists (three subspecialized in cardiac imaging) independently graded the most severe coronary artery stenosis using different measurement methods: visual stenosis grading and objective stenosis grading measuring stenosis diameter and area. Interreader agreement of percentage stenosis were calculated for each measurement method and stratified by the coronary calcium score (CACS) using Krippendorf α. Intrareader assessment was performed for one subspecialized radiologist.

RESULTS

A total of 61 patients were included (mean age, 65 ± 10 years; 18 women). Interreader agreements for percentage stenoses as determined visually and as measured by diameter and area were moderate independent of measurement method (0.42, 0.46, 0.41 for visual, diameter and area percentage stenoses, respectively) and did not depend on subspecialization. Intrareader agreement was moderate to substantial with values of 0.67, 0.57 and 0.53 for visual, diameter and area percentage stenoses. There was a trend towards lower inter- and intrareader agreement for stenoses with high CACS (e.g. for visual grading: 0.44 vs. 0.2 for interreader agreement between non-calcified stenoses (CACS = 0) and calcified stenoses (CACS ≥ 100)).

CONCLUSION

Inter- and intrareader agreement for stenosis quantification in coronary CT angiography was overall moderate and did not differ significantly among visual and objective measurement methods. A trend towards lower agreement was observed for stenoses with higher CACS.

Prognostic role of persistent angina after percutaneous revascularization in chronic coronary syndrome with altered angiography and stress CMR

INTRODUCTION AND OBJECTIVES

In patients with established chronic coronary syndrome (CCS), the significance of persistent angina is controversial. We aimed to evaluate the prognostic role of persistent angina in symptomatic CCS patients with abnormal stress cardiovascular magnetic resonance (CMR) and altered angiographic findings undergoing percutaneous revascularization.

METHODS

We analyzed 334 CCS patients with Canadian Cardiovascular Society angina class ≥2, perfusion deficits on stress CMR and severe lesions in angiography who underwent medical therapy optimization plus CMR-guided percutaneous revascularization. We investigated the association of persistent angina at 6 months postintervention with subsequent cardiac death, myocardial infarction, and hospital admission.

RESULTS

All patients had angina class ≥2 (mean: 2.8±0.7), abnormal stress CMR (mean ischemic burden: 5.8±2.7 segments), and severe angiographic lesions. The angina resolution rates were 81% at 6 months, and 81%, 81%, and 77% at 1, 2, and 5 years, respectively. During a median follow-up of 8.9 years, persistent angina was independently associated with higher rates of subsequent cardiac death (13% vs 4%; HR, 3.7; 95%CI, 1.5-9.2; P=.005), myocardial infarction (24% vs 6%; HR, 4.9; 95%CI, 2.4-9.9; P<.001), and hospital admission for heart failure (27% vs 13%; HR, 2.7; 95%CI, 1.5-5.2; P=.001).

CONCLUSIONS

In CCS patients with robust diagnostic evidence from symptoms, stress CMR, and angiography, persistent angina after percutaneous revascularization is a strong predictor of subsequent cardiac death, myocardial infarction, and hospital admission for heart failure.

Diagnostic performance of deep learning-based coronary computed tomography angiography in detecting coronary artery stenosis

PURPOSE

To validate a fully automated, deep learning model based on coronary computed tomography angiography (CCTA) for the diagnosis of obstructive coronary artery disease (CAD) with stenosis ≥ 50%, which is commonly used as a clinical threshold for further testing and management. This model aims to improve diagnostic efficiency by automating the identification of significant coronary stenosis(≥ 50%).

METHODS

This multicenter clinical trial included patients been undergone CCTA from October 13, 2022, to February 28, 2023. CCTA data from suspected coronary artery disease (CAD) patients were retrospectively analyzed using deep learning-based software for comprehensive assessment, including coronary segmentation, lumen, and stenosis determination with comparison to the reference standard of consensus by three experts. This study utilized a multi-stage deep learning framework for coronary artery segmentation and stenosis analysis from CCTA images, consisting of several key components, including the 3D Multi-resolution Cascade Convolutional Neural Network (CNN), 3D Cascade-Locally Optimized Network, and Stenosis Analysis Network. The clinical trial registry number was NCT06172985.

RESULTS

A total of 1090 patients (mean age: 59.90 ± 11.51 years, 47.3% female) were included in this multicenter study. Artificial intelligence (AI) demonstrated excellent performance at the patient level, accurately diagnosing ≥ 50% stenosis by assessing each patient's coronary artery condition. The AI system showed high values for accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The values of the above statistics were 92.8%, 95.3%, 91.4%, 85.6%, and 97.3%, respectively. Excellent agreement was seen between expert readers and deep learning-determined maximal diameter stenosis for per-patient (kappa coefficients: 0.84, 95%CI: 0.81-0.88). Regarding diagnostic efficiency, comparing the AI with expert readers, the average reading time decreased from 5.94 min to 2.01 min (p < 0.001).

CONCLUSION

A novel AI-based assessment of CCTA can accurately and rapidly identify patients with coronary artery stenosis ≥ 50%, aiding in effective triage within the defined study population.

RAAS inhibitors in pregnancy, breastfeeding and women of childbearing potential: a review of national and international clinical practice guidelines

Globally prevalent conditions such as hypertension, heart failure, ischaemic heart disease (IHD) and chronic kidney disease (CKD) are frequently and effectively treated with blockers of the renin-angiotensin-aldosterone system (RAAS) as a first line treatment in the UK and worldwide. RAAS blockers are prohibited in pregnancy due to their adverse fetal effects. We reviewed clinical guidelines from the National Institute of Health and Care Excellence (NICE) on the management of cardiovascular and kidney disease with RAAS blockers in pregnancy, with other UK, European and American guidance as comparators. Whilst guidelines agree on the strict avoidance of RAAS blockers in pregnancy, nuanced considerations regarding prescription in women of childbearing potential, contraception, timing of RAAS blocker withdrawal and breastfeeding are not consistently addressed in clinical guidelines. We call for consistent wording and more explicit advice on RAAS blocker prescription in women of childbearing potential, in pregnancy and in the postpartum period in future iterations of clinical guidelines.

Linagliptin Modulation of Inflammation in Chronic Coronary Artery Disease

INTRODUCTION

Coronary artery disease (CAD) confers a continued challenge to healthcare necessitating innovative therapies. Linagliptin, a dipeptidyl peptidase 4 inhibitor, has been shown in preclinical and clinical studies to have cardioprotective effects independent of its glycemic control. An important pathway by which linagliptin has been described to induce these effects is due to its immune regulation. This study aims to evaluate the immune modulation by linagliptin treatment in a porcine model of chronic myocardial ischemia.

METHODS

Yorkshire swine underwent ameroid constrictor placement to the left circumflex artery, which induced chronic myocardial ischemia. Two wk later, swine either received no drug (n = 8) or 2.5 mg linagliptin daily (n = 8). Five weeks later, swine were sacrificed and left ventricular tissue was harvested. Protein expression and immune cell count was measured with immunoblotting and immunofluorescence, respectively. Data were statistically analyzed via Wilcoxon rank-sum test.

RESULTS

Linagliptin treatment was associated with decreased expression of inflammatory markers interleukin (IL)-1β (P = 0.0012), IL-6 (P = 0.0073), nuclear factor kappa B (NFκB) (P = 0.0106), transforming growth factor beta (P = 0.001), and IL-4 (P = 0.0419) in chronically ischemic myocardium. There was increased expression of phosphorylated NFκB at Ser536 (p=<0.0001) and nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor alpha (P = 0.0167). Interestingly, there was increased expression of cluster of differentiation (CD) 11c (P = 0.0002) and increased cell count of CD11c dendritic cells (P = 0.014).

CONCLUSIONS

Linagliptin treatment was associated with a reduction of proinflammatory cytokines in the setting of chronically ischemic myocardium, with identified modulation of the NFκB pathway. Following treatment, there was found to be an increase in CD11c expression, demonstrating an increase in dendritic cells as a possible immune modulating cell population within the ischemic myocardium.

Different plaque types and its association with the volume and attenuation of pericoronary adipose tissue as assessed by coronary computed tomography angiography

AIM

To explore the relationship between different plaque types and pericoronary adipose tissue (PCAT) volume and attenuation values in patients with stable coronary artery disease (CAD) based on coronary computed tomographic angiography (CCTA).

MATERIALS AND METHODS

Three hundred twenty one patients with stable CAD who underwent CCTA from May 2022 to March 2023 were enrolled. Using semi-automatic software, PCAT volumes and CT attenuation values were measured around the plaque and in the segment and proximal coronary artery where the plaque was located. To compare whether there was a statistical difference in PCAT volume and attenuation values among different plaque types in the periplaque, the segment, and proximal coronary artery in which the plaque was positioned.

RESULTS

In total, 552 lesions were included, with 299 calcified plaques (CPs), 174 noncalcified plaques (NCPs), and 79 mixed plaques (MPs). There were excellent agreements between the two radiologists regarding the measured PCAT volumes and attenuation values (all interclass correlation coefficients values > 0.80). The periplaque PCAT volume was larger in CPs and MPs than in NCPs (291.98[213.25,381.03] mm3 vs. 261.00[173.25,377.85] mm3 vs. 206.54[139.72,284.07] mm3, P < 0.05), and the PCAT attenuation values around the plaque and the segment in which the plaque was positioned were higher in NCPs and MPs compared with CPs (-73.00[-79.00,-68.00] HU vs. -76.00[-79.00,-71.00] HU vs. -85.00[-92.00,-80.00] HU, -81.72 ± 0.70 HU vs. -80.73 ± 1.03 HU vs. -84.31 ± 0.49 HU; P < 0.05).

CONCLUSION

PCAT volume and attenuation values differed significantly among different plaque types, and the differences are particularly significant in measurements around the plaque.

Comparison of Fractional Flow Reserve and Myocardial Perfusion Imaging in Saphenous Vein Grafts

BACKGROUND

Revascularization decision-making for saphenous vein grafts (SVGs) relies on angiographic lesion severity estimation, as studies on fractional flow reserve (FFR) for detecting ischemia in SVGs are scarce.

AIMS

To compare FFR and quantitative coronary angiography (QCA) of SVGs against myocardial perfusion imaging (MPI) and to establish an optimal FFR threshold for SVGs.

METHODS

This cross-sectional registry study included symptomatic patients with prior coronary artery bypass grafting who underwent single-photon emission computed tomography, positron emission tomography, or stress perfusion cardiac magnetic resonance imaging and had FFR measurements of ≥ 1 SVGs. We matched the myocardial territory supplied by the SVGs to ischemia on MPI. The optimal FFR threshold for SVGs was determined using the Youden index. Diagnostic performance measures were calculated and compared for FFR (0.80 and the optimal threshold) and for QCA (diameter stenosis ≥ 50%).

RESULTS

This study included 80 patients (mean age 73 ± 7 years, 68 [85%] male) with 94 SVGs, of which 38 (40%) supplied ischemic myocardium. Areas under the curve between FFR and QCA were comparable (0.73 vs. 0.65, p = 0.181). The optimal cutoff value of FFR was 0.94. FFR ≤ 0.94 showed higher sensitivity (63%) and negative predictive value (75%) compared to FFR ≤ 0.80 (32% [p < 0.001] and 64% [p = 0.007]) and QCA (37% [p = 0.002] and 65% [p = 0.021]), but with lower specificity (75%) than FFR ≤ 0.80 (84%, p = 0.021). Positive predictive value and overall accuracy were similar across all methods.

CONCLUSIONS

FFR and QCA had comparable moderate diagnostic performance for detecting SVG failure determined by MPI. The optimal FFR cutoff in SVGs is higher than 0.80, resulting in higher sensitivity and negative predictive value compared to FFR ≤ 0.80 and QCA, at the expense of reduced specificity.

How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC

The multiplicity of coexisting comorbidities affecting patients with heart failure (HF), together with the availability of multiple treatments improving prognosis in HF with reduced ejection fraction, has led to an increase in the number of prescribed medications to each patient. Polypharmacy is defined as the regular use of multiple medications, and over the last years has become an emerging aspect of HF care, particularly in older and frailer patients who are more frequently on multiple treatments, and are therefore more likely exposed to tolerability issues, drug-drug interactions and practical difficulties in management. Polypharmacy negatively affects adherence to treatment, and is associated with a higher risk of adverse drug reactions, impaired quality of life, more hospitalizations and worse prognosis. It is important to adopt and implement strategies for the management of polypharmacy from other medical disciplines, including medication reconciliation, therapeutic revision and treatment prioritization. It is also essential to develop new HF-specific strategies, with the primary goal of avoiding the use of redundant treatments, minimizing adverse drug reactions and interactions, and finally improving adherence. This clinical consensus statement document from the Heart Failure Association of the European Society of Cardiology proposes a rationale, pragmatic and multidisciplinary approach to drug prescription in the current era of multimorbidity and 'multi-medication' in HF.

Novel 2D/3D vascular biomarkers reveal association between fundus changes and coronary heart disease

PURPOSE

To compare structural and vascular differences in the macular region of the retina using optical coherence tomography (OCT)/OCT angiography (OCTA) between coronary angiography (CAG)-confirmed coronary heart disease (CHD) patients and non-CHD individuals.

METHODS

The study included 340 eyes from 180 CHD patients and 136 eyes from 68 controls. Imaging was conducted using the AngioVue OCT device with a macula-centered 6 mm ∗ 6 mm field of view. Retinal thickness and 2D/3D vascular-related biomarkers were derived using existing retinal layer segmentation software, and our previously proposed 2D/3D vascular and 3D foveal avascular zone segmentation methods. Statistical analyses included t-tests, Mann-Whitney U tests, chi-square tests, and Pearson's correlation.

RESULTS

The CHD group exhibited significantly lower retinal nerve fiber layer (RNFL) thickness (r = -0.20, P < 0.001) in the inner inferior (I) region, based on macular region layer segmentation. For the 3D OCT images, as defined by the ETDRS grid, both the inner and outer retina layers in the outer superior (out-S) region were significantly thinner in the CHD group. The CHD group showed significantly lower overall 2D fractal dimension (FD) (1.72 ± 0.03 vs. 1.73 ± 0.02, P < 0.001) and vessel skeleton density (VSD) (26.61 ± 4.52 vs. 28.50 ± 3.40, P < 0.001) compared to the control group. The proposed 3D vascular density (VD) feature showed a significant difference between the groups (19.23 ± 5.67 vs. 20.69 ± 5.15, P = 0.048).

CONCLUSION

Thinning of retinal thickness and reduced vascular density are associated with CHD and may serve as valuable, cost-effective biomarkers for assessing coronary artery disease assessment.

Benchmarking Photon-Counting Computed Tomography Angiography Against Invasive Assessment of Coronary Stenosis: Implications for Severely Calcified Coronaries

BACKGROUND

Clinical guidelines do not recommend coronary computed tomographic angiography (CTA) in elderly patients or in the presence of heavy coronary calcification. Photon-counting coronary computed tomographic angiography (PCCTA) introduces ultrahigh in-plane resolution and multienergy imaging, but the ability of this technology to overcome these limitations is unclear.

OBJECTIVES

The authors evaluate the ability of PCCTA to quantitatively assess coronary luminal stenosis in the presence and absence of calcification, comparing both the ultrahigh-resolution (UHR)-PCCTA and the multienergy standard-resolution (SR)-PCCTA with the criterion-standard 3-dimensional invasive quantitative coronary angiography (3D QCA).

METHODS

The authors included 100 patients who had both PCCTA and invasive coronary angiography (ICA). They comparatively evaluated luminal diameter stenosis with PCCTA and 3D QCA, anatomic disease severity (according to CAD-RADS [Coronary Artery Disease-Reporting and Data System]) and the diagnostic performance of PCCTA in identifying coronary arteries with ≥50% diameter stenosis on 3D QCA requiring invasive hemodynamic severity evaluation and/or revascularization.

RESULTS

The authors analyzed 257 vessels and 343 plaques. UHR-PCCTA luminal evaluation relative to 3D QCA was more precise than SR-PCCTA (median difference: 3% [Q1-Q3: 1%-6%] vs 6% [Q1-Q3: 2%-11%]; P < 0.001), particularly in severely calcified arteries (median difference 3% [Q1-Q3: 1%-6%] vs 6% [Q1-Q3: 3%-13%]; P = 0.002). Per-vessel agreement for CAD-RADS between UHR-PCCTA and 3D QCA was near-perfect (κ = 0.90 [Q1-Q3: 0.84-0.95]; P < 0.001), and it was substantial for SR-PCCTA (κ = 0.63 [Q1-Q3: 0.54-0.71]; P < 0.001), especially in severely calcified arteries: κ = 0.90 (Q1-Q3: 0.83-0.97; P < 0.001) and κ = 0.67 (Q1-Q3: 0.56-0.77; P < 0.001), respectively. Per-vessel diagnostic performance of SR- and UHR-PCCTA was excellent: AUC: 0.94 (95% CI: 0.91-0.98; P < 0.001) and 0.99 (95% CI: 0.98-1.00; P < 0.001), respectively. UHR-PCCTA diagnostically outperformed SR-PCCTA: ΔAUC: 0.05 (95% CI: 0.01-0.08; P = 0.01).

CONCLUSIONS

PCCTA compares favorably with ICA for lumen assessment and anatomic disease severity classification in patients presenting with acute coronary syndrome or patients referred for ICA. UHR-PCCTA luminal evaluation is superior to SR-PCCTA, especially in patients with heavy coronary calcification. UHR-PCCTA has excellent diagnostic performance in identifying coronary arteries with ≥50% luminal stenosis on 3D QCA, outperforming standard-resolution imaging.

The impact of stress testing to guide PCI in patients with chronic coronary disease

BACKGROUND

Guidelines and international appropriate use criteria increasingly endorse non-invasive stress testing to evaluate patients with suspected chronic coronary disease (CCD). We sought to review the real-world utilisation of non-invasive stress testing and investigate whether their use prior to PCI associates with outcomes in patients with CCD.

METHODS

Consecutive patients from a multicentre registry who underwent PCI for CCD between 2006 and 2018 were included. Clinical characteristics and outcomes were stratified according to whether stress testing was performed prior to PCI (stress vs no-stress groups). The primary outcome was 3-year all-cause mortality.

RESULTS

Among the 8251 patients included, 4970 (60.2 %) underwent pre-PCI stress testing and this proportion increased over time (p-for-trend<0.001). The stress group had a lower prevalence of prior revascularization, myocardial infarction, or heart failure, and a lower incidence of triple vessel disease, in stent re-stenosis, and ACC/AHA class B2/C lesions (all p < 0.001). When comparing post-procedural outcomes, the stress group had lower rates of arrhythmia (1.5 % vs 2.6 %, p = 0.001), new heart failure (0.2 % vs 0.8 %, p = 0.001), renal impairment, and a shorter length of stay (1.6 vs 2.1 days, p < 0.001). Mortality at 3-years was lower in those undergoing PCI following stress testing (5.8 % vs 8.8 %, p < 0.001). After adjusting for key clinical variables, stress guided revascularization was associated with a significantly lower risk of 3-year mortality (adjusted Hazard Ratio 0.77, 95 % CI 0.64-0.92).

CONCLUSIONS

In patients with CCD, PCI guided by non-invasive stress testing is increasingly utilized and associated with improved survival. Further studies are necessary to investigate whether this results from differences in patient characteristics, optimized patient selection, or refined choice of target vessel.

Machine learning to detect recent recreational drug use in intensive cardiac care units

BACKGROUND

Although recreational drug use is a strong risk factor for acute cardiovascular events, systematic testing is currently not performed in patients admitted to intensive cardiac care units, with a risk of underdetection. To address this issue, machine learning methods could assist in the detection of recreational drug use.

AIMS

To investigate the accuracy of a machine learning model using clinical, biological and echocardiographic data for detecting recreational drug use in patients admitted to intensive cardiac care units.

METHODS

From 07 to 22 April 2021, systematic screening for all traditional recreational drugs (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine) was performed by urinary testing in all consecutive patients admitted to intensive cardiac care units in 39 French centres. The primary outcome was recreational drug detection by urinary testing. The framework involved automated variable selection by eXtreme Gradient Boosting (XGBoost) and model building with multiple algorithms, using 31 centres as the derivation cohort and eight other centres as the validation cohort.

RESULTS

Among the 1499 patients undergoing urinary testing for drugs (mean age 63±15 years; 70% male), 161 (11%) tested positive (cannabis: 9.1%; opioids: 2.1%; cocaine: 1.7%; amphetamines: 0.7%; 3,4-methylenedioxymethamphetamine: 0.6%). Of these, only 57% had reported drug use. Using nine variables, the best machine learning model (random forest) showed good performance in the derivation cohort (area under the receiver operating characteristic curve=0.82) and in the validation cohort (area under the receiver operating characteristic curve=0.76).

CONCLUSIONS

In a large intensive cardiac care unit cohort, a comprehensive machine learning model exhibited good performance in detecting recreational drug use, and provided valuable insights into the relationships between clinical variables and drug use through explainable machine learning techniques.

Abbreviated dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is a standard post-percutaneous coronary intervention (PCI) treatment to reduce thrombosis and ischemic events. However, the optimal DAPT duration remains unclear, with concerns about bleeding risks associated with long-term potent P2Y12 inhibitors. This systematic review and meta-analysis investigates the safety and efficacy of shortened DAPT regimens.

METHODS

A comprehensive search of PubMed, Scopus, and EMBASE identified randomized controlled trials (RCTs) comparing conventional DAPT (≥ 12 months) and abbreviated DAPT (≤ 3 months) post-PCI. Primary outcomes were 1-year all-cause mortality and bleeding, assessed using the Bleeding Academic Research Consortium (BARC) classification. Secondary outcomes included cardiovascular mortality, non-fatal myocardial infarction (MI), stroke, and major adverse cardiovascular events (MACE). Risk of bias was assessed with the Cochrane tool, and meta-analyses used random-effects models.

RESULTS

Forty studies involving 54,233 participants were included. Abbreviated DAPT significantly reduced all-cause mortality (RR: 0.90, 95%CI: 0.82-0.98) and bleeding (BARC 3 or 5: RR: 0.77, 95%CI: 0.60-0.97). No significant differences were observed in cardiovascular mortality, stroke, non-fatal MI, revascularization, or in-stent thrombosis. Subgroup analyses showed lower mortality with 1-month DAPT and reduced bleeding in patients with high bleeding risk, acute coronary syndrome (ACS), and complex PCI.

CONCLUSIONS

Abbreviated DAPT post-PCI is associated with lower all-cause mortality and bleeding without compromising ischemic protection, supporting its use in specific patient populations. Individualized DAPT durations should be considered to balance bleeding and ischemic risks.

Clinical likelihood models calibrated against observed obstructive coronary artery disease on computed tomography angiography

AIMS

Models predicting the likelihood of obstructive coronary artery disease (CAD) on invasive coronary angiography exist. However, as stable patients with new-onset chest pain frequently have lower clinical likelihood and preferably undergo index testing by non-invasive tests such as coronary computed tomography angiography (CCTA), clinical likelihood models calibrated against observed obstructive CAD at CCTA are warranted. The aim was to develop CCTA-calibrated risk-factor- and coronary artery calcium score-weighted clinical likelihood models (i.e. RF-CLCCTA and CACS-CLCCTA models, respectively).

METHODS AND RESULTS

Based on age, sex, symptoms, and cardiovascular risk factors, an advanced machine learning algorithm utilized a training cohort (n = 38 269) of symptomatic outpatients with suspected obstructive CAD to develop both a RF-CLCCTA model and a CACS-CLCCTA model to predict observed obstructive CAD on CCTA. The models were validated in several cohorts (n = 28 340) and compared with a currently endorsed basic pre-test probability (Basic PTP) model. For both the training and pooled validation cohorts, observed obstructive CAD at CCTA was defined as >50% diameter stenosis. Observed obstructive CAD at CCTA was present in 6443 (22.7%) patients in the pooled validation cohort. While the Basic PTP underestimated the prevalence of observed obstructive CAD at CCTA, the RF-CLCCTA and CACS-CLCCTA models showed superior calibration. Compared with the Basic PTP model, the RF-CLCCTA and CACS-CLCCTA models showed superior discrimination (area under the receiver operating curves 0.71 [95% confidence interval (CI) 0.70-0.72] vs. 0.74 (95% CI 0.73-0.75) and 0.87 (95% CI 0.86-0.87), P < 0.001 for both comparisons).

CONCLUSION

CCTA-calibrated clinical likelihood models improve calibration and discrimination of observed obstructive CAD at CCTA.

Coronary computed tomography angiography without ECG leads; A feasibility study

BACKGROUND

Modern CT scanners with wide coverage and high temporal resolution have enabled robust coronary CT angiography (CCTA) with automated phase selection and motion correction algorithms, even at high heart rates and arrhythmia. We hypothesized that these advanced technologies may make it feasible to perform a CCTA without triggering from a patient's ECG signal.

METHODS

Forty-three subjects undergoing clinically indicated CCTA were prospectively enrolled. ECG-less CCTA data was acquired for approximately the whole cardiac cycle using a wide-coverage scanner with fast gantry rotation (Revolution Apex, GE HealthCare). Images were generated using seven sub-ranges of the acquired data and evaluated for motion artifact using a 6-point Likert scale by three experts.

RESULTS

The mean age of the study population was 62.0 ± 12.0 years; 51.2 % were male. The mean heart rate (HR) was 65.3 ± 9.0 beats per minute (bpm). Overall image quality (IQ) was higher with motion correction vs standard reconstruction (4.6 ± 0.66 vs 4.0 ± 0.95, p < 0.01). At HR ≤ 60 bpm, 61-70 bpm, ≥ 71 bpm, IQ scores were 4.9 ± 0.31, 4.5 ± 0.66, 4.4 ± 0.78, respectively. IQ from sub-ranges was similar to the reference of the study, reconstructed images from full-phase data, except in the cases where 1/4 of the scanned data was considered in HR ≤ 60 bpm and ≥ 71 bpm (4.3 ± 0.83, 4.6 ± 0.67 and 4.1 ± 0.96 respectively).

CONCLUSION

CCTA without ECG leads on an advanced CT scanner is feasible. This approach could improve patient comfort, workflow efficiency, and access to CCTA.

Strategies for the Secondary Prevention of Atherosclerotic Cardiovascular Disease

Patients with atherosclerotic cardiovascular disease (ASCVD), such as those with a history of MI or stroke, are at high risk for morbidity and mortality associated with future cardiovascular events. Ideal management of these patients requires a multifactorial strategy for risk factor mitigation and prevention of additional cardiovascular events. Traditional management of secondary prevention patients involves lipid-lowering with statins, blood pressure control, and anti-platelet treatment. Several additional targets have been identified to optimize the secondary prevention of ASCVD, such as further lipid control, inflammation management, lifestyle and weight optimization, strict diabetes control, use of β-blockers, use of renin-angiotensin-aldosterone system inhibitors, vaccinations, and additional considerations of anti-thrombotic therapies. This review will describe the interventions associated with these targets, as well as the relevant research and indications for these therapies.

Associations Between Physical Capability Markers and Risk of Coronary Artery Disease: A Prospective Study of 439,295 UK Biobank Participants

Background: The relationship between sarcopenia and the incidence of coronary artery disease (CAD) is not well understood. This study aimed to investigate this relationship and the modifying effect of potential risk factors. Methods: We conducted a prospective study including 439,295 individuals from the UK Biobank. The primary outcome was the incidence of CAD. The main physical capability markers for sarcopenia, grip strength and muscle mass, were investigated as risk factors of interest. Grip strength was measured using a Jamar J00105 (Lafayette, IN, USA) hydraulic hand dynamometer, while muscle mass was estimated through bioelectrical impedance. Cox proportional hazard models were employed to analyze the associations between the exposures and the risk of CAD. Results: A total of 41,564 incident cases of CAD were identified after a median follow-up of 13.15 years (IQR 12.29-13.88 years). Compared with the lowest quintile of grip strength, the adjusted HRs for incidences of CAD from the second to the fifth quintile were 0.81 (95% CI: 0.79-0.83), 0.71 (95% CI: 0.69-0.73), 0.61 (95% CI: 0.60-0.63), and 0.49 (95% CI: 0.48-0.51). The association remained significant in subgroup analysis and interactions were observed between the two exposures and sex, age, smoking status, inflammatory diseases, metabolic syndrome, and genetic predisposition (all p for interactions < 0.05). Conclusions: Physical capability markers of sarcopenia, grip strength and muscle mass, were independently associated with a dose-response decreased risk for CAD incidence, regardless of genetic predisposition and potential modifying risk factors.

Myocardial Ischaemic Syndromes: Shifting from a Coronary-centric to a Substrate-based Nomenclature is More Accurate and Inclusive

This article highlights the rationale for a more accurate and inclusive classification that does not focus solely on epicardial coronary lesions as the causa sine qua non for angina and myocardial ischaemia in all patients but rather represents a more comprehensive classification encompassing both obstructive and non-obstructive causes. Ischaemia may be 'silent' clinically or electrocardiographically and is observed in both acute and non-acute settings, as seen in patients with diabetes and other conditions associated with microvascular dysfunction. By pivoting away from the more restrictive and overly simplistic 'vessel-based' classification that disproportionately focuses on obstructed epicardial arteries to a 'substrate-based' nomenclature inclusive of both obstructive and non-obstructive causes, 'myocardial ischaemic syndromes' will better align and unify a patient-centric approach by harmonising the full spectrum of pathophysiologic causes.