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

Impact of Nonadherence to Any Antiplatelet Therapy After PCI With Drug-Eluting Stents on Critical Outcomes

BACKGROUND

Lifelong antiplatelet therapy after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is strongly recommended. However, the extent and temporal variation in the risk of nonadherence to this recommendation remain unclear.

OBJECTIVES

The aim of this study was to investigate how nonadherence to any antiplatelet therapy after PCI affects critical cardiac events and whether this effect varies over time.

METHODS

This cohort study analyzed Japanese nationwide insurance claims and health checkup records of working-age patients who underwent PCI with DES between April 2016 and March 2022. Nonadherence was defined as prescription coverage of antiplatelet therapy <50% within preceding 90 days. Landmark-time survival analysis with propensity-score matching was conducted every 5 days from 90th to 1,095th days after PCI. The primary outcome was a composite of all-cause death, myocardial infarction, or cardiopulmonary arrest. Results were synthesized to assess temporal variation in the risk magnitude.

RESULTS

Among 40,902 patients (mean [SD] age, 58.3 ± 8.3 years; 5.5% women [2,240 of 40,902], median [IQR] follow-up: 653 days [Q1-Q3: 235-1,233 days]), nonadherence was observed in 1.18% (421 of 35,582) at 90 days and 4.70% (579 of 12,312) at 1,095 days after PCI. Critical cardiac events were more frequent in nonadherent patients (HR: 2.50 [95% CI: 1.92-3.26]; P < 0.001), with no significant temporal variation across landmark times.

CONCLUSIONS

Nonadherence to any antiplatelet therapy after PCI was associated with a more than 2-fold increase in critical cardiac events, irrespective of post-PCI timing throughout 3 years. These findings emphasize the need for sustained efforts by health care providers and patients to maintain drug adherence over a prolonged period.

Volatilome and machine learning in ischemic heart disease: Current challenges and future perspectives

Integrating exhaled breath analysis into the diagnosis of cardiovascular diseases holds significant promise as a valuable tool for future clinical use, particularly for ischemic heart disease (IHD). However, current research on the volatilome (exhaled breath composition) in heart disease remains underexplored and lacks sufficient evidence to confirm its clinical validity. Key challenges hindering the application of breath analysis in diagnosing IHD include the scarcity of studies (only three published papers to date), substantial methodological bias in two of these studies, and the absence of standardized protocols for clinical implementation. Additionally, inconsistencies in methodologies-such as sample collection, analytical techniques, machine learning (ML) approaches, and result interpretation-vary widely across studies, further complicating their reproducibility and comparability. To address these gaps, there is an urgent need to establish unified guidelines that define best practices for breath sample collection, data analysis, ML integration, and biomarker annotation. Until these challenges are systematically resolved, the widespread adoption of exhaled breath analysis as a reliable diagnostic tool for IHD remains a distant goal rather than an imminent reality.

Efficacy of Sacubitril/Valsartan Combined With Metoprolol on Cardiac Function, Cardiac Remodeling, and Endothelial Function in Patients With Coronary Heart Disease and Heart Failure

Aims/Background Coronary heart disease (CHD) combined with heart failure results in a rapidly progressing disease with an acute onset, posing a significant threat to a patient's survival. Metoprolol, a β-blocker, is effective in treating heart failure; however, due to its complex pathogenesis, the efficacy of monotherapy in managing disease progression remains suboptimal. Sacubitril/valsartan, an angiotensin II receptor antagonist, is another widely used drug for treating heart failure. The combination of the two drugs may play a synergistic role in effectively managing heart failure through different mechanisms. This study aims to investigate the effects of sacubitril/valsartan combined with metoprolol on cardiac function, cardiac remodeling, and endothelial function in patients with CHD and heart failure. Methods This retrospective analysis included 138 CHD patients combined with heart failure who received care at Linhai Hospital of Traditional Chinese Medicine between January 2022 and January 2024. Based on the treatment regimen, patients were divided into two groups. Patients receiving metoprolol monotherapy were included in the Metoprolol group (n = 61), while those receiving a combination of sacubitril/valsartan and metoprolol were assigned to the Combination group (n = 77). The cardiac function [New York Heart Association (NYHA) cardiac function classification], myocardial injury markers [serum cardiac troponin I (cTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP)], cardiac remodeling function [left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD)], endothelial function [serum endothelin-1 (ET-1), nitric oxide (NO)] were compared between these two groups before treatment and 3 months post-treatment. Additionally, the two groups were comparatively assessed for the incidence of adverse reactions during the treatment period. Results Following treatment, the NYHA cardiac function grading was significantly improved in the Combination group than in the Metoprolol group (p = 0.014). After treatment, the Combination group demonstrated significantly lower serum cTnI and NT-proBNP levels than the Metoprolol group (p < 0.05). After treatment, the Combination group had substantially higher LVEF and lower LVEDD and LVESD than the Metoprolol group (p < 0.05). Furthermore, the Combination group showed a significant decrease in serum ET-1 levels and an increase in serum NO levels compared to the Metoprolol group (p < 0.05). During the treatment period, there was no significant difference in the incidence of adverse reactions between the two groups (p > 0.05). Conclusion Sacubitril/valsartan combined with metoprolol is a safe, effective, and viable treatment option for patients with CHD combined with heart failure. This combination therapy may further improve cardiac and endothelial function by reducing cardiac remodeling, without increasing the risk of adverse reactions. This study offers a new drug combination regimen (sacubitril/valsartan combined with metoprolol) for patients with CHD combined with heart failure. This regimen further improves the cardiac and endothelial function, inhibits cardiac remodeling, and has good safety.

Non-Dipping Pattern Is Associated with Periprocedural Myocardial Infarction in Hypertensive Patients Undergoing Elective Percutaneous Coronary Intervention

Background and Objectives: Non-dipping blood pressure (BP) patterns are associated with increased cardiovascular risk, but their role in periprocedural myocardial infarction (PMI) during elective percutaneous coronary intervention (PCI) remains insufficiently clarified. The objective was to investigate whether a non-dipping BP profile independently predicts PMI in hypertensive patients undergoing elective PCI. Materials and Methods: This prospective observational study enrolled 462 hypertensive patients undergoing elective PCI, categorized as dipping or non-dipping based on 24 h ambulatory BP monitoring (ABPM). Clinical, laboratory, and angiographic data were compared. PMI was defined according to the Fourth Universal Definition of Myocardial Infarction. Independent predictors of PMI were identified using multivariate logistic regression. Results: Of the 462 patients, 243 (52.6%) exhibited a non-dipping BP pattern. Non-dipping status was significantly associated with higher incidence of PMI (32.5% vs. 13.7%, p < 0.001) and a worse metabolic profile, including elevated blood glucose (p = 0.001), Hemoglobin A1c (p = 0.002), and white blood cell count (p = 0.001), and lower high-density lipoprotein cholesterol (p = 0.047). These patients more frequently underwent complex PCI (25.1% vs. 5.0%, p < 0.001). In multivariate analysis, the non-dipping BP pattern emerged as the strongest independent predictor of PMI (odds ratio 25.99, 95% confidence interval 3.16-213.92, p = 0.002), followed by complex PCI, number of stents, stent length, and diabetes mellitus. Conclusions: Non-dipping BP pattern is a powerful and independent predictor of PMI in hypertensive patients undergoing PCI. Incorporating ABPM into routine cardiovascular risk assessment may improve the identification of high-risk patients and allow for tailored preventive strategies.

Advanced Cardiac Magnetic Resonance Imaging for Assessment of Obstructive Coronary Artery Disease - ADVOCATE-CMR Study Rationale and Design

BACKGROUND

First-pass stress perfusion cardiovascular magnetic resonance (CMR) imaging is the guidelines-recommended non-invasive test for the detection of obstructive coronary artery disease (CAD). Recently developed quantitative perfusion CMR (QP CMR) allows quantification of myocardial blood flow. Moreover, the latest developments established several methods of CAD assessment without the need for a contrast agent, including stress T1 mapping reactivity (∆T1) and oxygenation-sensitive CMR (OS-CMR). These methods might eliminate the need for contrast administration in clinical practice, reducing time, invasiveness, and costs, thereby simplifying the evaluation of patients with suspected obstructive CAD. The ADVOCATE-CMR study aims to validate QP CMR, ∆T1 and OS-CMR imaging against invasive fractional flow reserve (FFR) for the detection of obstructive CAD. The study also aims to head-to-head compare the diagnostic accuracy of these CMR techniques with the conventional visual assessment of stress perfusion CMR and to correlate them to short- and long-term clinical outcomes.

STUDY DESIGN

ADVOCATE-CMR is a single-center, observational, prospective, cross-sectional cohort study. The study will enroll 182 symptomatic patients with suspected obstructive CAD scheduled for invasive coronary angiography (ICA). Before ICA, all participants will undergo CMR imaging including OS-CMR with breathing maneuvers, rest and adenosine stress T1 mapping and rest and adenosine stress first-pass perfusion. Subsequently, ICA will be performed including FFR, instantaneous wave-free ratio (iFR), resting Pd/Pa, coronary flow reserve (CFR) and index of microvascular resistance (IMR) measurements in all main coronary arteries. A follow-up CMR scan with the same protocol will be performed at 3 months after ICA. Clinical follow-up will be performed at 3, 6 months, 1 and 3 years after ICA.

CONCLUSION

The ADVOCATE-CMR will be the first study comprehensively evaluating and comparing head-to-head the diagnostic performance of a range of contrast- and non-contrast agent-based CMR imaging methods (including QP CMR, ∆T1 and OS-CMR) for the detection of FFR-defined obstructive CAD. We expect to establish a validated and time-efficient diagnostic workflow available to a wide range of general CMR services. Finally, these improvements may enable CMR to become an effective non-invasive, radiation-free gatekeeper for ICA in patients with suspected obstructive CAD, potentially without the need for a contrast agent.

Pullback pressure gradient: A paradigm shift in physiology-guided revascularization

Optimizing decision-making remains essential in the management of stable coronary artery disease (CAD). Recent studies of the pullback pressure gradient (PPG), a novel tool for evaluating CAD patterns, have demonstrated that the effectiveness of percutaneous coronary intervention (PCI) is strongly influenced by the baseline CAD pattern (focal vs diffuse). The capacity of PPG to predict the success of PCI provides a means to better inform decision-making, revascularization strategies and, potentially, improve clinical outcomes.

Lipoproteins predicting coronary lesion complexity in premature coronary artery disease: a supervised machine learning approach

Introduction

We aimed to assess the usefulness of lipoprotein(a) [Lp(a)] and LDL-C levels as potential predictors of coronary lesions' complexity in patients with premature coronary artery disease (pCAD).

Methods

This study enrolled 162 consecutive patients with pCAD undergoing coronary angiography. The SYNTAX score (SS) was used to assess coronary lesions' complexity. Linear discriminant analysis (LDA) was employed to construct a multivariate classification model enabling the prediction of coronary lesions' complexity in SS.

Results

The Lp(a) levels among patients with SS ≥ 23 and with SS 1-22 were significantly higher than those with SS = 0 (p = 0.021 and p = 0.027, respectively). The cut-off point for the Lp(a) level of 63.5 mg/dl discriminated subjects with SS ≥ 23 from those with SS ≤ 22 (sensitivity 0.546, specificity 0.780; AUC 0.620; p = 0.027). An LDA-based model involving the Lp(a) level, age, sex and LDL-C provided improved discrimination performance (sensitivity 0.727, specificity 0.733, AUC 0.800; p = 0.0001).

Conclusions

Lp(a) levels in pCAD patients are associated with the advancement of coronary artery lesions in SS patients. An Lp(a) level of 63.5 mg/dl can be the cut-off point for the identification of subjects with SS ≥ 23. LDA-based modelling using Lp(a), LDL-C, age and gender may be an applicable tool for the preliminary identification of patients at risk of more complex coronary artery lesions.

Dilated cardiomyopathy evaluation with Imagenomics: combining multimodal cardiovascular imaging and genetics

Dilated cardiomyopathy (DCM) is a clinical diagnosis characterized by the presence of left ventricular dilatation and systolic dysfunction unexplained by abnormal loading conditions or coronary artery disease. However, a broad range of phenotypic manifestations, encompassing isolated scar, DCM with preserved ejection fraction, and overt DCM, should be regarded as a diagnostic classification representing a broad spectrum of underlying aetiologies, including both inherited and acquired heart muscle disorders. A multimodal non-invasive imaging approach is essential for accurate morpho-functional assessment of cardiac chambers and is key to establish the cardiac phenotype and to rule out an underlying ischaemic aetiology. Furthermore, advanced imaging techniques enable deep cardiovascular phenotyping and non-invasive tissue characterization. The aim of this review is to propose a systematic approach to the diagnosis of DCM, emphasizing the importance of genetics and clinical findings for a precise and practical clinical approach. Also, we strive to qualify the role of cardiac imaging in the diagnosis of DCM, particularly on the relevance of novel techniques and clinical utility of actionable parameters to improve current diagnostic schemes and risk stratification algorithms. We further elaborate on the role of cardiac imaging to deliver optimal guidance to aetiology-based therapeutic approaches, verification of treatment response and disease progression monitoring.

Feasibility of biodegradable polymer everolimus-eluting stent overexpansion: the SYNOVER study

BACKGROUND

Despite advancements in percutaneous coronary intervention (PCI), stent-related complications continue to occur, emphasizing the necessity for stent optimization. This study employed optical coherence tomography (OCT) to investigate the safety and efficacy of overexpanding the biodegradable polymer everolimus-eluting stent (SYNERGY; Boston Scientific, Marlborough, Massachusetts, USA) stent in large coronary arteries.

METHODS

This single-center observational study enrolled patients with ischemic heart disease requiring stent placement in large coronary arteries (≥4.5 mm). The patients underwent PCI guided by OCT using SYNERGY stents, incorporating postdilation techniques to enhance expansion. Stent parameters were evaluated through OCT imaging. The primary endpoints focused on the maximum stent diameter and the maximum percentage of overexpansion. Secondary clinical outcomes, including death, myocardial infarction (MI), revascularization, stent thrombosis, cerebrovascular accidents (CVAs), and heart failure readmissions, were monitored with follow-ups at 1, 6, and 12 months, as well as annually thereafter.

RESULTS

A total of 12 patients (8427 struts) were analyzed after successful PCI. OCT imaging showed adequate stent expansion, maximum stent diameter was 4.5 ± 0.2 mm, with a maximum expansion of 113.2 ± 4.1%), with no definite stent fractures or major edge dissections. During follow-up, one patient experienced an MI, but no stent thrombosis, target lesion revascularization, CVA, or death were reported.

CONCLUSION

Application of OCT-guided PCI with SYNERGY stents is safe and effective for treating large coronary arteries. It facilitates optimal stent expansion and yields favorable long-term outcomes. These results advocate for an expanded application of OCT-guided PCI in complex anatomical situations, showcasing the performance of SYNERGY stents in cases of excess expansion.

Circular PVT1 promotes cardiac fibroblast activation interacting with miR-30a-5p and miR-125b-5p

Circular RNAs (circRNAs) are involved in the pathogenesis of several cardiovascular diseases, including heart failure. In this study, we report that circular PVT1 (circPVT1) was upregulated in the left ventricle of 31 ischemic heart failure patients compared to 11 non-ischemic controls. RNA sequencing analysis following circPVT1 knockdown in immortalized human cardiomyocytes identified differentially expressed genes, mainly involved in fibrosis. Notably, in human cardiac fibroblasts, circPVT1 expression significantly increased after TGF-β1 treatment and circPVT1 silencing attenuated the levels of pro-fibrotic markers induced by TGF-β1. RNA pull-down assays validated the interaction between circPVT1 and two fibrosis-related miRNAs, miR-30a-5p and miR-125b-5p. The levels of these miRNAs were not altered upon circPVT1 knockdown. However, the expression of their mRNA targets was deregulated upon circPVT1 silencing, suggesting that circPVT1 modulates miRNA cellular bioavailability. Accordingly, inhibition of either miR-30a-5p or miR-125b-5p restored the expression of TGF-β1-induced pro-fibrotic markers following circPVT1 silencing, indicating that both miR-30a-5p and miR-125b-5p act as downstream effectors of circPVT1 in cardiac fibroblast activation. In conclusion, these findings highlight a pro-fibrotic role for circPVT1, which can regulate cardiac fibroblast activation interacting with the anti-fibrotic miR-30a-5p and miR-125b-5p. The modulation of circPVT1 expression may represent a potential strategy to reduce cardiac fibrosis and remodeling.

The Predictive Value of Preoperative Coronary Artery Calcium Score for Long-term Survival in Elderly Patients with Lung Cancer After Surgery

BACKGROUND

A large proportion of elderly lung cancer patients have coronary atherosclerosis. However, it remains unclear which coronary artery indicators provide optimal prognostic value for elderly patients with lung cancer after surgery.

METHODS

This study retrospectively analyzed the clinical data of elderly patients with lung cancer who underwent surgery between September 2013 and September 2021. Three coronary artery indicators including the severity of coronary artery stenosis, coronary artery calcium score (CACS), and computed tomography-derived fractional flow reserve (CT-FFR) and clinical data were evaluated. The Cox proportional hazards model and competing risk model were used to identify independent prognostic factors for all-cause death and non-lung cancer death, respectively. Based on these factors, a nomogram was developed and validated to predict the overall survival of elderly patients with lung cancer after surgery. The performance of the nomogram was evaluated using the concordance index, receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

The study finally included 896 elderly patients with lung cancer, randomly divided into training group (n=627) and validation group (n=269) in a 7:3 ratio. Among the three coronary artery indicators, only CACS >40 affected the long-term survival of elderly patients with lung cancer after surgery, especially for those who underwent lobectomy, but had no effect on those undergoing sublobar resection. Age, smoking, %dynamic diffusion lung capacity of carbon monoxide (DLCO), CACS >40, surgical procedure, pathological stage, and pathological type were identified as independent prognostic factors for all-cause death. Smoking and CACS >40 were identified as independent risk factors for non-lung cancer death. The nomogram incorporating CACS exhibited robust predictive performance.

CONCLUSION

This study shows that CACS has a significant predictive value for all-cause death and non-lung cancer death in elderly lung cancer patients after surgery. For elderly lung cancer patients with high CACS, sublobar resection may improve their survival compared to lobectomy.

Outcomes of complex, high-risk percutaneous coronary intervention in patients with severe aortic stenosis: the ASCoP registry

BACKGROUND

There is a lack of evidence to guide treatment of patients with a concomitant indication for transcatheter aortic valve implantation (TAVI) and complex, high-risk percutaneous coronary intervention (PCI).

AIMS

We aimed to assess different strategies of PCI timing in this high-risk TAVI cohort.

METHODS

The ASCoP registry retrospectively included patients with a clinical indication for both TAVI and PCI with at least 1 criterion of complex or high-risk PCI. The primary endpoint was a composite of all-cause death and unplanned rehospitalisation for cardiovascular causes. The secondary endpoint was a composite of all-cause death, stroke, acute myocardial infarction, major bleeding, major vascular complication and unplanned revascularisation. Multivariable analysis was used to adjust for possible confounders.

RESULTS

A total of 519 patients were included: 363 (69.9%) underwent staged procedures and 156 (30.1%) concomitant TAVI and PCI. After 441 (interquartile range 182-824) days, the primary endpoint occurred in 151 (36.5%) cases, without any significant difference between the 2 groups (p=0.98), while the secondary endpoint occurred more frequently in the concomitant group (n=36 [25.8%] vs n=57 [17.4%]; p=0.014).

CONCLUSIONS

In patients undergoing TAVI and complex/high-risk PCI, a concomitant strategy is associated with a higher rate of adverse events and increased procedural risk. (ClinicalTrials.gov: NCT05750927).

The management of antiplatelet therapy in patients with coronary artery disease and thrombocytopenia

Ischemic heart disease is the leading cause of death in the world. Patients who have acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) with significant thrombocytopenia are at high risk for bleeding. In the literature, studies conducted on this patient group are very few. For this reason, although it is difficult for physicians to manage antiplatelet therapy in these patients, the risk of bleeding can be minimized with some current guideline recommendations. This review aims to explore in detail the management of antiplatelet therapy in patients who have moderate and severe thrombocytopenia with coronary artery disease (CAD).

Late presenters with ST-elevation myocardial infarction and thromboembolic complications: a treatment challenge: a case report

BACKGROUND

Late presenters with ST-elevation myocardial infarction pose a considerable challenge in the field of cardiovascular medicine. These individuals, who delay seeking medical attention after the onset of ST-elevation myocardial infarction symptoms, often face substantial difficulties in treatment. The coronavirus disease 2019 pandemic led to a significant increase in the number of late presenters. By increasing the frequency of complications such as thromboembolic events in the course of left ventricular thrombus, the pandemic necessitated the refinement of existing management strategies.

CASE PRESENTATION

In this paper, we present two White male patients of Central European (Polish) descent (50 and 64 years old) who, although reported to have had acute ST-elevation myocardial infarction, turned out to be ST-elevation myocardial infarction latecomers. In both cases, we were dealing with the presence of left ventricular thrombus and complications related to the central nervous system. On the basis of these two patients, we discuss the role of revascularization in latecomer ST-elevation myocardial infarction patients. We present the position of direct oral anticoagulants in the left ventricular thrombus treatment and show that, in limited cases of a huge thrombus, cardiac surgery is a treatment of choice.

CONCLUSIONS

As left ventricular thrombus is still relatively common in ST-elevation myocardial infarction latecomers, we present the current state of knowledge on this topic, emphasizing the need for further research in this area.

Association of epicardial fat volume with the severity of coronary artery disease: a preliminary study on risk prediction of obstructive coronary heart disease

BACKGROUND

We aimed to explore the correlation between epicardial fat volume (EFV) and the severity of coronary atherosclerotic artery disease (CAD), evaluate the predictive value of EFV for obstructive CAD, and provide prediction for the selection of clinical treatment schemes for CAD.

METHODS

A total of 203 patients undergoing chest computed tomography (CT) and Coronary Artery Angiography (CAG) were included in this retrospective study. The severity of coronary stenosis and SYNTAX score were evaluated by CAG images. There were 141 patients in obstructive CAD group which was defined as coronary stenosis severity ≥ 70% and 62 patients in non obstructive CAD group.

RESULTS

Multivariate logistic regression analysis showed that after adjusting for confounding factors, EFV (OR, 1.008; 95% CI, 1.000-1.016; p = 0.039) was an independent risk factor for obstructive CAD. Spearman correlation analysis showed a significant positive correlation between EFV and SYNTAX score, as well as the number of coronary lesions (r = 0.157, p = 0.026; r = 0.231, p = 0.002). The EFV of males was significantly higher than that of females (p < 0.001). EFV was significantly positively correlated with intrathoracic fat volume (IFV) (p < 0.001).

CONCLUSIONS

EFV maybe an independent risk factor for obstructive CAD. Quantitative measurement of EFV by QCT can predict the severity of CAD. EFV was significantly correlated with IFV, but not with BMI.

CLINICAL TRIAL NUMBER

Not applicable.

Coronary Computed Angiography and Coronary Artery Calcium Score for Preoperative Cardiovascular Risk Stratification in Patients Undergoing Noncardiac Surgery

Perioperative and long-term postoperative major adverse cardiovascular events (MACE) are a leading cause of morbidity and mortality in patients undergoing noncardiac surgery. In selected high-risk patients, when information about cardiovascular status may influence surgical decisions, preoperative risk stratification is reasonable, with stress imaging being the preferred method. Coronary computed angiography (CCTA) and coronary artery calcium score (CACS) offer direct anatomical assessment of atherosclerotic coronary arteries and help gauge the extent and severity of coronary artery disease. Strong evidence supports that CCTA and CACS, either alone or in combination, are reliable methods for assessing the risk of both perioperative and long-term postoperative MACE, often demonstrating equal or superior prognostic performance compared to traditional imaging tools. Moreover, integrating CCTA or CACS into standard preoperative imaging protocols further enhances perioperative risk prediction and improves the ability to accurately stratify patients. Future research is needed to better define the role of CCTA and CACS in preoperative cardiovascular risk evaluation of patients undergoing noncardiac surgery.

First-pass perfusion imaging using cardiovascular magnetic resonance in patients with various cardiac implantable electronic devices

AIMS

The number of patients with cardiac implantable electronic devices (CIEDs) is increasing. However, there is limited experience regarding vasodilator-stress cardiovascular magnetic resonance (CMR) and resulting device artifacts on perfusion images. The aim of this study was to determine CMR image quality in patients with different CIED types for CMR-based perfusion stress testing.

METHODS AND RESULTS

A total of 156 patients with active CIEDs underwent CMR on a 1.5-Tesla scanner. Both conventional steady-state-free-precession (SSFP) and modified spoiled gradient-echo (sGE) protocols under stress and resting conditions were used to evaluate image artifacts in a 16-segment segment model of the heart. The study group comprised 39% conventional pacemaker (PM), 4% cardiac resynchronization therapy-pacemaker (CRT-P), 38% conventional implantable cardioverter-defibrillator (ICD), 6% cardiac resynchronization therapy-ICD (CRT-D), and 13% subcutaneous ICD (S-ICD) patients. PM-carriers showed only minor image artifacts in both perfusion protocols. Artifacts caused by ICDs were predominantly located in the left-ventricular (LV) inferolateral and anterior segments. S-ICDs showed the highest extent of artifacts with an anterolateral accentuation. The artifact extent was significantly reduced when sGE-based perfusion was used compared to SSFP-based sequences. 69% of the patients received a stress-perfusion protocol, and elective coronary angiography confirmed the presence of coronary stenosis in three cases. No major safety-relevant issues occurred.

CONCLUSION

Myocardial perfusion imaging by CMR is safe and feasible with moderate-to-high image quality in patients with all types of CIEDs, including non-conditional devices, ICDs, and S-ICDs. A sGE-based perfusion protocol should be preferred in patients with left-sided ICDs, CRT-Ds, or S-ICDs.

Incremental diagnostic value of coronary computed tomography angiography derived fractional flow reserve to detect ischemia

Over the past decade, coronary computed tomographic angiography (CCTA) has been the most robust non-invasive method for evaluating significant coronary stenosis. Thanks to new technologies, it is now possible to determine the fractional flow reserve (FFR) non-invasively using computed tomographic (CT) images. The aim of this work was to evaluate the incremental diagnostic value of CT-derived FFR for ischemia detection. In this retrospective monocentric study, we investigated 421 patients who underwent CCTA and subsequent ischemia testing between 04/2009 and 06/2020. Endpoint was ischemia on a coronary vessel level assessed by CMR (n = 20), SPECT (n = 225), invasive angiography (stenosis ≥ 90%; n = 80) or invasive FFR (positive if ≤ 0.8; n = 96). CT-FFR was derived from CCTA images by a machine learning (ML) based software prototype. Patients averaged 66.5 [58.2-73.6] years of age and 72.7% (n = 306) were male. Overall, 52.5% (n = 221) had hypertension and 67.9% (n = 286) had hypercholesteremia. Logistic regression analysis on a per vessel base showed that the diagnostic model with CT-FFR plus CCTA had significantly better-fit criteria than the diagnostic model with CCTA alone (log-likelihood χ2 230.21 vs. 192.17; p for difference < 0.001). In particular, the area under curve (AUC) by receiver operating characteristics curve (ROC) analysis for CT-FFR plus CCTA (0.87) demonstrated greater discrimination of hemodynamic ischemia compared to CCTA alone (0.83; p for difference < 0.0001). Combined CCTA and CT-FFR have improved diagnostic accuracy compared to CCTA alone in detecting ischemia on the coronary vessel level and thus could reduce the use of invasive coronary angiography in the future.

Bi-variational physics-informed operator network for fractional flow reserve curve assessment from coronary angiography

The coronary angiography-derived fractional flow reserve (FFR) curve, referred to as the Angio-FFR curve, is crucial for guiding percutaneous coronary intervention (PCI). The invasive FFR is the diagnostic gold standard for determining functional significance and is recommended to complement coronary angiography. The invasive FFR curve can quantitatively define disease patterns. The Angio-FFR curve further overcomes the limitation of invasive FFR measurement and thus emerges as a promising approach. However, the Angio-FFR curve computation suffers from a lack of satisfactory trade-off between accuracy and efficiency. In this paper, we propose a bi-variational physics-informed neural operator (BVPINO) for FFR curve assessment from coronary angiography. Our BVPINO combines with the variational mechanism to guide the basis function learning and residual evaluation. Extensive experiments involving coronary angiographies of 215 vessels from 184 subjects demonstrate the optimal balance of BVPINO between effectiveness and efficiency, compared with computational-based models and other machine/deep learning-based models. The results also provide high agreement and correlation between the distal FFR predictions of BVPINO and the invasive FFR measurements. Besides, we discuss the Angio-FFR curve assessment for a novel gradient-based index. A series of case studies demonstrate the effectiveness and superiority of BVPINO for predicting the FFR curve along the coronary artery centerline.

Inflammatory Markers and Saphenous Vein Graft Stenosis: Insights into the Use of Glucose-to-Lymphocyte Ratio as a Prognostic Marker

Background: Coronary artery bypass grafting (CABG) for the treatment of ischemic heart disease is still considered an effective treatment option to improve clinical outcomes and reduce mortality. However, the patency rates of saphenous vein grafts (SVGs) are significantly lower compared to those of arterial grafts. Atherosclerosis has emerged as one of the main causes of SVG stenosis (SVGS), especially stenoses that develop after one year. In this study, we aimed to investigate the association of glucose-to-lymphocyte ratio (GLR), a novel inflammatory biomarker, with LVG patency status in patients undergoing CABG surgery. Methods: A total of 778 patients who were diagnosed with chronic coronary syndromes (CCS) according to the 2019 ESC guidelines for the diagnosis and treatment of CCS; had undergone CABG more than one year previously; and had at least one SVG used during surgery were included in this study. GLR was calculated as blood glucose level (mg/dL) divided by lymphocyte count (K/uL). Results: SVGS was detected in 341 patients, while SVGs were intact in 437 patients. Patients with SVGS had a higher prevalence of diabetes mellitus (DM) (p = 0.002) and significantly higher blood glucose levels (p < 0.001). In addition, the interval between CABG operation and coronary angiography (CAG) was longer in the SVGS group (p < 0.001). Neutrophil levels were higher, and lymphocyte levels were lower in this group (p = 0.010 and p = 0.034, respectively). Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), glucose/lymphocyte ratio (GLR) and high-sensitivity C-reactive protein (CRP) levels were significantly higher in patients with SVGS (p < 0.001 for all). According to multivariate logistic regression analysis, DM, CRP level, time since CABG, and GLR were identified as independent predictors of SVGS (p = 0.004, p = 0.048, p < 0.001, and p < 0.001, respectively). ROC analysis showed that SVGS could be predicted with 75.8% sensitivity and 68.6% specificity when the cut-off value for GLR was >315.5 (area under the curve [AUC]: 0.801, 95% CI: 0.765-0.837, p < 0.001). Conclusions: Higher GLR levels are associated with SVGS in patients with coronary artery disease.

Evaluation of Secondary Prevention Knowledge in Patients with Coronary Artery Disease

Background and Objectives: Most patients with cardiovascular disease have limited health literacy and knowledge. The promotion of knowledge among patients with coronary artery disease is an integral part of health maintenance and the minimisation of secondary cardiac events. The aim of this study was to map the percent proportion of answers and scores obtained from them in the studied domains. Materials and Methods: In this cross-sectional study, a Coronary Artery Disease Education Questionnaire (CADE-Q II) was used to verify knowledge gaps in the five studied domains. In total, 253 patients with coronary artery disease completed the CADE-Q II, which targeted five domains: health status, risk factors, exercise, nutrition and psychosocial risk. Data were collected between June 2021 and November 2024. Results: An analysis of the data found a total mean CADE-Q II score of 61.05 ± 11.42 SD out of 93 points. Our research showed that the total mean score of a group of patients corresponded to an acceptable level of knowledge. Patients in the cohort provided a total of 7843 responses for the five study domains. In total, 46.8% of patients scored all answers correctly in terms of risk factors, 49.0% in terms of nutrition, 53.1% in terms of health status, 64.4% in terms of psychosocial risk, and 65.0% in terms of exercise. Conclusions: The use of the CADE-Q II questionnaire, with its focus on the studied domains, verifies patient knowledge and provides a foundation for education, the provision of effective information and the promotion of secondary prevention knowledge.

Association of Glymphatic System Dysfunction with Cardiac Injury and Cognitive Impairment in Heart Failure: A Multimodal MRI Study

RATIONALE AND OBJECTIVES

Glymphatic dysfunction, a critical pathway to cognitive impairment, remains underexplored in heart failure (HF). This study investigated glymphatic dysfunction in patients with HF and the relationship between cardiac injury and cognitive performance.

METHODS

46 HF patients and 39 age- and sex-matched healthy controls (HCs) underwent brain MR to assess glymphatic markers: choroid plexus (CP) volume, perivascular space (PVS) score, white matter fractional free water (FW), diffusivity along perivascular spaces (ALPS), blood-oxygen-level-dependent (BOLD) signals, and cerebrospinal fluid (CSF) coupling. Group differences were analyzed, and same-day cardiac MR in HF patients assessed cardiac injury markers. Correlation, regression, and mediation analyses explored associations between glymphatic markers, cardiac injury markers, and cognition.

RESULTS

Patients with HF exhibited significantly higher CP volume, PVS scores, and FW, alongside a lower mean ALPS index and BOLD-CSF coupling than HCs (all P<0.05). Montreal Cognitive Assessment (MoCA) score correlated positively with the mean ALPS index (r=0.479, Padjust=0.014) and inversely with basal ganglia PVS score (r=-0.462, Padjust=0.033) and BOLD-CSF coupling (r=-0.398, Padjust=0.043). Among cardiac MRI parameters, stroke volume (SV) and SV index (SVI) correlated significantly with the mean ALPS index (r=0.419, Padjust=0.020; r=0.448, Padjust=0.014). Mediation analysis showed that the mean ALPS index mediated the correlation between SV/SVI and MoCA scores.

CONCLUSION

Patients with HF exhibit glymphatic dysfunction, with the mean ALPS index closely correlated to cardiac function and cognition. Cardiac injury-related glymphatic dysfunction in patients with HF may link to cognitive impairment.

Metabolomic profiling in heart failure as a new tool for diagnosis and phenotyping

Classifying heart failure (HF) by stages and ejection fraction (EF) remains a debated topic in cardiology. Metabolomic profiling (MP) offers a means to identify unique pathophysiological changes across different phenotypes, presenting a promising approach for the diagnosis and prognosis of HF, as well as for the development of targeted therapies. In our study, MP was performed on 408 HF patients (54.9% male). The mean ages of patients were 62 [53;68], 67 [65;74], 68 [61;72], and 69 [65;73] years for stages A, B, C, and D, respectively. This study demonstrates high accuracy in HF stage classification, distinguishing Stage A from Stage B with an AUC ROC of 0.91 and Stage B from Stage C with an AUC ROC of 0.97, by integrating chromatography-mass spectrometry data through multiparametric machine learning models. The observed metabolic similarities between HF with mildly reduced EF and HF with reduced EF phenotypes (AUC ROC 0.96) once again highlight the fundamental differences at the cellular and molecular levels between HF with preserved EF and HF with EF < 50%. Hierarchical clustering based on MP identified four distinct HF phenotypes and 26 key metabolites, including metabolites of tryptophan catabolism, glutamine, riboflavin, norepinephrine, serine, and long- and medium-chain acylcarnitines. The average follow-up period was 542.37 [16;1271] days. A downward change in the trajectory of EF [HR 3,008, 95% CI 1,035 to 8,743, p = 0,043] and metabolomic cluster 3 [HR 2,880; 95% CI 1,062 to 7,810, p = 0,0376] were associated with increased risk of all-cause mortality. MP can refine HF phenotyping and deepen the understanding of its underlying mechanisms. Metabolomic analysis illuminates the biochemical landscape of HF, aiding in its classification and suggesting new therapeutic pathways.

Model to predict the risk of cardiac death based on clinical characteristics and Gated-SPECT parameters

BACKGROUND

Coronary artery disease is a complex, multifactorial process with high prevalence and morbidity-mortality. Single photon emission computed tomography (SPECT) myocardial perfusion imaging synchronized with the electrocardiogram (gated-SPECT) is a non-invasive imaging technique that has demonstrated high sensitivity and specificity for diagnosis and staging. To better predict the risk of adverse events, it is necessary to analyze the simultaneous behavior of clinical elements and diagnostic tests, a type of study that is scarce in the current literature. This research evaluated the relationship between clinical characteristics and gated-SPECT myocardial perfusion parameters with progression to cardiac death; subsequently, a model was built to predict the risk of such an outcome.

METHODS

An observational, longitudinal, and retrospective study was conducted with 2 230 patients who underwent this test due to suspected coronary artery disease. Clinical characteristics, test parameters, and progression to cardiac death were collected and the relationships between them were studied. A logistic regression model was built to study the relationships between the variables and their influence on the probability of progression to cardiac death.

RESULTS

Clinical characteristics associated with a higher probability of cardiac death were male sex (OR = 5.104, p = 0.004), peripheral arterial disease (OR = 7.175, p < 0.001), and diabetes mellitus (OR = 3.159, p = 0.013). The gated-SPECT parameters associated with a higher risk of this outcome were VTS ≥70 ml (OR = 12.257, p < 0.001), EF < 50% (OR = 10.757, p < 0.001), VTD ≥140 ml (OR = 8.884, p < 0.001), ventricular dilation (OR = 8.959, p < 0.001), and reversible defects (OR = 7.454, p = 0.001). Fixed defects, parietal motility abnormalities, the presence of both reversible and fixed defects, and the hyperdynamic gated state were also associated with a higher risk of cardiac death but with lower ORs. The logistic regression model showed good overall performance and high ability to determine progression to cardiac death, close to perfect predictive capacity (AUC = 0.9656).

Enhancing the diagnostic specificity of exercise ECG testing in obstructive coronary artery disease: the role of the Selvester QRS score

BACKGROUND

Exercise ECG testing is a widely used, noninvasive tool for detecting obstructive coronary artery disease (OCAD). However, its diagnostic performance is often limited by low specificity, leading to false-positive results and unnecessary invasive procedures.

OBJECTIVE

This study aims to assess the potential of combining the Selvester QRS score with exercise ECG to enhance diagnostic specificity for OCAD in patients with suspected stable angina.

METHODS

This retrospective study included 203 patients who presented with chest pain, underwent exercise ECG and were assessed for OCAD by coronary angiography or computed tomography angiography. Receiver operating characteristic analysis identified the optimal Selvester QRS score cutoff and assessed the diagnostic performance of exercise ECG and the combined model. Multivariable logistic regression was performed in the exercise ECG positive and negative groups.

RESULTS

Of the 203 patients, 116 were diagnosed with OCAD. The optimal Selvester QRS score cutoff was ≥3, with a sensitivity of 83.6% and a specificity of 93.1%. The combination of a positive exercise ECG and a Selvester QRS score ≥3 achieved the highest specificity (98.9%). Regression analyses showed that Selvester QRS score ≥3 was an independent predictor of OCAD, even in patients with negative exercise ECG results (adjusted odds ratio: 7.018; P < 0.001).

CONCLUSION

The Selvester QRS score can improve the specificity of the exercise ECG in detecting OCAD in patients with suspected stable angina. This approach has the potential to reduce false positives and unnecessary invasive procedures by improving risk stratification.

Implementation of a national AI technology program on cardiovascular outcomes and the health system

Coronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause (n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93-1.08), P = 0.97) or cardiovascular mortality (n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85-1.08), P = 0.48), while reducing invasive coronary angiograms (n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90-0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years.

Plasma metabolites, systolic blood pressure, lifestyle, and stroke risk: A prospective cohort study

BACKGROUND

To estimate the associations of stroke risk with plasma metabolites, metabolic risk score (MRS), the combinations of MRS with hypertension or lifestyle, and lifestyle-related metabolic signature. To assess the improvement of the stroke risk prediction model through the incorporation of MRS.

METHODS

A total of 77,315 participants from the UK Biobank were included in this study. Xgboost and LASSO-Cox regression were used to select metabolites and construct MRS. Elastic net regression was utilized to construct the lifestyle-related metabolic signature. Multivariate Cox regression was used to estimate the associations between metabolites, MRS, the combinations of MRS with hypertension or lifestyle, lifestyle-related metabolic signature, and stroke risk.

RESULTS

We identified 48, 63, 39, and 4 metabolites associated with the risk of stroke, ischemic stroke (IS), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH), respectively. High MRS significantly increased the risk of stroke (HR = 2.65 (95% confidence interval (CI): 2.09-3.35)), IS (HR = 2.45 (95% CI: 1.89-3.17)), ICH (HR = 2.74 (95% CI: 1.55-4.85)), and SAH (HR = 4.64 (95% CI: 2.25-9.56)). In the combination analyses, compared with normal systolic blood pressure (SBP) and low MRS, normal/high SBP, and high MRS significantly increased stroke risk (HR = 5.80 (95% CI: 2.75-12.27)/6.37 (95% CI: 3.22-12.62)). A favorable/unfavorable lifestyle and high MRS also significantly increased stroke risk (HR = 2.38 (95% CI: 1.73-3.28)/3.86 (95% CI: 2.63-5.67)) compared with a favorable lifestyle and low MRS. Incorporating MRS into the 15-year stroke and IS risk prediction model increased the areas under the curves (AUCs) from 0.746 to 0.766 and from 0.771 to 0.811, respectively. The metabolic signature was correlated with adherence to a healthy lifestyle (r = 0.414; P = 2.22e-16) and inversely associated with stroke risk (HR = 0.80 (95% CI: 0.73-0.86)).

CONCLUSIONS

Various metabolites and MRS were significantly associated with the risk of stroke, IS, ICH, and SAH. Individuals with a high MRS may face an elevated stroke risk among populations with high SBP or unhealthy lifestyle, even those with normal SBP or healthy lifestyle. MRS provided modest improvement to the stroke risk prediction model. The lifestyle-related metabolic signature could reduce 20% stroke risk.

Clinical impact of air pollution on SPECT myocardial perfusion imaging

BACKGROUND

Air pollution contributes to cardiovascular morbimortality. Air pollution effects on cardiovascular function assessed from non-invasive and invasive imaging have been reported but never on myocardial perfusion. This study aimed to characterize relations of air pollution exposure to myocardial perfusion imaging (MPI).

METHODS

Patients referred to SPECT (single-photon emission computed tomography) MPI were prospectively enrolled between 2017 and 2020. Myocardial ischemia was assessed from the SPECT. Moderate-to-severe ischemia was defined as a > 10 % ischemic myocardium. Exposures to particulate matter (PM2.5 and PM10) and NO2 at the home address were characterized via a 10-meter resolution air pollutant-dispersion model and air quality monitoring system data. Associations of exposures with scintigraphy parameters were assessed through multivariable regressions, and potential modifying effects by sex and BMI were investigated.

RESULTS

A total of 1,585 participants were prospectively included (mean age 67.7 ± 11.6 years, 63.3 % male); 148 (9.3 %) patients presented a moderate-to-severe ischemia. In multivariate analysis, the odds of moderate-to-severe ischemia was increased, with adjusted odds-ratio (ORa) of 1.39 [95 % confidence interval (95 % CI): 1.07-1.80; p = 0.013], 1.33 (95 % CI: 1.01-1.75; p = 0.042), and 1.22 (95 % CI: 0.96-1.57; p = 0.10) for each increase of one Interquartile Range (IQR) in PM2.5, PM10 and NO2 exposure, respectively (IQR equal to 3.3, 4.3 and 10.0 µg/m3, respectively). With further adjustment for cardiometabolic diseases and symptoms, only the association with PM2.5 remained statistically significant: ORa 1.34 (95 % CI: 1.03-1.75, p = 0.031) for each one-IQR increase. Associations with PM10 and PM2.5 tended to be stronger in women (interaction p-value equal to 0.11 and 0.077, respectively).

CONCLUSION

We provide new insights into a mechanism by which particulate air pollution may influence cardiovascular risk. Exposure to PM was associated with moderate-to-severe ischemia, particularly in women.

Future of factor XI inhibitors in cardiovascular practice

Anticoagulation is indicated for treatment and prevention of arterial and venous thrombosis. Targeting different steps of the coagulation process, currently available anticoagulants entail an increased risk of bleeding, which detrimentally impacts on prognosis and hinders the administration of an effective antithrombotic regimen. Factor XI (FXI) inhibition has emerged as a strategy to uncouple prevention of thrombosis from bleeding. Indeed, while FXI is crucial for the amplification phase in pathological thrombosis, it is ancillary in physiological hemostasis. A comprehensive search in several scientific databases has been performed to identify relevant studies in the field. In addition, ongoing trials have been searched for in proper datasets to provide an updated and comprehensive assessment of the current state of investigations on FXI inhibition. Many compounds have been tested to inhibit FXI at different stages (i.e., synthesis, activation, or interactions with target molecules and coagulation factors). These include antisense oligonucleotides, monoclonal antibodies, small molecules, natural peptides and aptamers. In phase 2 studies, FXI inhibitors reduced thrombotic complications without any corresponding increase in bleeding. FXI inhibitors were noninferior and potentially superior to low-molecular-weight heparin in orthopedic surgery and reduced bleeding compared to apixaban in patients with atrial fibrillation. FXI inhibition is also under testing in other conditions, including end-stage renal disease, cancer, or noncardioembolic stroke. FXI inhibition represents a promising and rapidly emerging approach for a number of clinical indications. This article reviews the rationale, evidence, pharmacology, and future applications of FXI inhibition.

Elevated lipoprotein(a) levels are independently associated with the presence of significant coronary stenosis in de-novo patients with stable chest pain

BACKGROUND

The role of lipoprotein(a) (Lp(a)) in the risk-assessment of patients with de-novo stable chest pain is sparsely investigated. We assessed the association between Lp(a) concentration and the presence of coronary stenosis on coronary computed tomography (CT) angiography in a broad population of patients referred with stable chest pain.

METHODS

Lp(a) measurements and coronary CT angiography were performed in 4,346 patients with stable chest pain and no previous history of coronary artery disease. The patients were included in the trial program, the Danish study of Non-Invasive testing in Coronary artery disease, Dan-NICAD. The prevalence and odds ratios for stenosis were calculated comparing normal Lp(a) (< 20 nmol/l) with moderately elevated (20 to <125 nmol/l), high (125 to <200 nmol/l), and very high (≥200 nmol/l) Lp(a) concentrations in both univariate and multivariate analyses.

RESULTS

In total, 2,418 (55.6%), 1,276 (29.4%), 425 (9.8%), and 227 (5.2%) patients had normal, moderately elevated, high, and very high Lp(a) levels, respectively. The prevalences of coronary stenosis increased with increasing Lp(a) concentration (n = 569 (23.5%), n = 328 (25.7%), n = 129 (30.4%), and n = 77 (33.9%) in patients with normal, moderately elevated, high, and very high Lp(a), respectively). Likewise, the prevalence of patients with multivessel disease increased with increasing Lp(a) concentration (n = 252 (10.4%), n = 149 (11.7%), n = 61 (14.4%), and n = 41 (18.1%) in patients with normal, moderately elevated, high, and very high Lp(a), respectively). In an unadjusted model, odds ratios for stenosis increased with increasing Lp(a) concentrations odds ratio 95% CI: 1.12 (0.96-1.31), 1.42 (1.13-1.77), and 1.67 (1.24-2.22) for moderately elevated, high, and very high Lp(a) versus normal Lp(a), respectively). Adjustment for age, sex, and cardiovascular risk factors did not affect the association.

CONCLUSIONS

In stable, symptomatic patients without established coronary artery disease, Lp(a) levels are positively associated with the presence of coronary stenosis on coronary CT angiography. These findings may warrant using Lp(a) in the diagnostic management of patient with suspected coronary artery disease.

TRIAL REGISTRATION

The 3 studies within the Dan-NICAD program are registered on ClinicalTrials.gov: Dan-NICAD, NCT02264717, https://clinicaltrials.gov/study/NCT02264717?term=dan-nicad&rank=1. Dan-NICAD 2, NCT03481712, https://clinicaltrials.gov/study/NCT03481712?term=dan-nicad&rank=3. Dan-NICAD 3, NCT04707859, https://clinicaltrials.gov/study/NCT04707859?term=dan-nicad&rank=2.

Telemedicine-supported lifestyle intervention for glycemic control in patients with CHD and T2DM: multicenter, randomized controlled trial

Patients with coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM) have a substantially increased risk for major cardiovascular events and mortality. Increasing physical activity and improving a healthy diet may effectively reduce cardiovascular risk factors; however, the effects are often transient. In a multicenter, 1:1 randomized controlled trial including 502 patients with combined CHD and T2DM (68 ± 8 years; 84% men), we assessed the effects of a home-based telemedicine-supported lifestyle intervention (exercise training, nutritional recommendations and health literacy training) with regular individualized feedback versus usual care. The study met its primary endpoint of reduced glycated hemoglobin after 6 months in favor of the lifestyle intervention group (mean between-group difference in the complete-case analysis (n = 197 and n = 193), -0.13% (95% confidence interval, -0.25 to -0.01), P = 0.04). When individualized feedback and health literacy training were discontinued after 6 months (while other telemedicine tools were maintained), no statistically significant between-group differences were observed at 12 months. At 12 months, 31 patients (6.2%) had a major adverse cardiovascular event (lifestyle intervention, n = 20 (8.0%); usual care, n = 11 (4.4%); P = 0.15), with the main reason being hospitalization for angina or revascularization (lifestyle intervention, n = 15; usual care, n = 8). There were five deaths (lifestyle intervention, n = 2; usual care, n = 3), none of which were categorized as related to the intervention. However, three events that resulted in hospitalization were categorized as potentially related to the intervention (decompensation of heart failure, vertebral disc prolapse and inguinal hernia). In conclusion, a home-based lifestyle intervention with telemedicine support showed modest effects in patients with CHD and T2DM. ClinicalTrials.gov registration: NCT03835923 .

Effects of β-Blockers on the Outcomes in Patients With Pulmonary Arterial Hypertension Stratified by the Presence of Comorbid Conditions: A Multicenter Prospective Cohort Study: The Database of Pulmonary Hypertension in the Polish Population (BNP-PL)

BACKGROUND

Current guidelines do not recommend β-blockers in pulmonary arterial hypertension (PAH) unless indicated by comorbidities. However, the evidence regarding the role of β-blockers in PAH is contradictory.

RESEARCH QUESTION

What are the effects of β-blockers on clinical outcomes in patients newly diagnosed with PAH, and how do these outcomes differ based on the presence of cardiovascular comorbidities that are standard indications for β-blocker use?

STUDY DESIGN AND METHODS

We analyzed data from 806 patients newly diagnosed with PAH enrolled prospectively in the Database of Pulmonary Hypertension in the Polish Population (BNP-PL). The end points were all-cause mortality and a composite of hospitalization due to right-sided heart failure, syncope, or death. Indications for β-blocker use included hypertension, significant arrhythmia, and coronary artery disease. Propensity score matching was used to form a control group based on age, PAH mortality risk variables, and initially introduced PAH-specific therapy.

RESULTS

Of the 806 patients, 469 (58.2%) received β-blockers at the time of PAH diagnosis. In propensity score matching, β-blocker treatment showed a higher incidence of the composite end point (hazard ratio, 1.44; 95% CI, 1.04-1.99; P = .03) and had a neutral impact on mortality (hazard ratio, 1.22; 95% CI, 0.87-1.72; P = .25). When stratified according to the presence of comorbidities, β-blockers showed adverse effects on the composite end point in patients without comorbidities and a neutral effect in patients with at least one comorbidity.

INTERPRETATION

Our results indicate that β-blockers pose significant risks in patients with PAH, especially in patients without coexisting systemic hypertension, coronary artery disease, or arrhythmia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03959748; URL: www.

CLINICALTRIALS

gov.

Optimizing Coronary CT Image Reconstruction With Deep Learning for Improved Quality: A Retrospective Study

OBJECTIVE

To evaluate the impact of deep learning image reconstruction on image quality in CCTA compared with adaptive statistical iterative reconstruction (ASIR).

MATERIALS AND METHODS

CCTA data sets from 100 consecutive patients with suspected CAD were acquired with a Revolution Apex 256-row CT scanner, reconstructed with ASIR-V and DLIR-H, and subsequently analyzed. Image noise, SNR, and CNR in five regions of interest (25 mm) were calculated and t tested. The normality of quantitative variables was assessed using the Shapiro-Wilk test. For non-normally distributed data, the Mann-Whitney U test was applied. The concordance of HU values within specific ROIs was analyzed with Bland-Altman plots. Correlation between ASIR-V and DLIR-H was conducted using the Spearman rank correlation test.Subjective image analysis was conducted using a 5-point scale to evaluate noise level, vascular enhancement smoothness, artifact reduction, and diagnostic confidence. Intraclass correlation (ICC) was used to assess the reliability and consistency of subjective ratings among the reader.

RESULTS

DLIR-H significantly reduced image noise across all ROIs (from 15% to 41%, all P<0.05), compared with ASIR-V. Mean SNR (ASIR-V vs. DLIR-H) were septum=4.3±1.7 versus 6.4±2.2; cavity of the left ventricle=24.3±8.3 versus 36.6±11.7; CNR: septum=8.2±2.5 versus 12.4±3.5; cavity of left ventricle= 28.2±9.1 versus 42.5±13.0. Spearman rank correlation ranged from 0.64 to 0.79 (P<0.05). Bland-Altman analysis showed good agreement between ASIR-V and DLIR-H, with no discernible patterns. Subjectively, DLIR-H significantly outperformed ASIR-V across all evaluated criteria (all P<0.05). ICC values indicated strong agreement among readers, demonstrating excellent reliability for most criteria and good reliability for vascular enhancement smoothness.

CONCLUSIONS

DLIR-H significantly improved CCTA image quality compared with ASIR-V, which contributes to a more accurate diagnosis in patients with suspected CAD.

Epidemiology of Ischemic Heart Disease Burden Attributable to High Temperature in Asia From GBD 2021

BACKGROUND

Ischemic heart disease (IHD) posed the highest global disease burden in 2021, with regional disparities in Asia. Moreover, climate change is exacerbating population exposure to high temperatures (Hi-Tem).

OBJECTIVES

This study aimed to systematically assess the burden of IHD attributed to Hi-Tem in Asia, considering geographic and demographic factors.

METHODS

The Global Burden of Disease Study 2021 tools evaluated the IHD burden from Hi-Tem in Asia, and decomposition analysis was conducted to further explore the potential burden drivers.

RESULTS

Asia witnessed a significant increase in IHD burden caused by Hi-Tem, with 88,450 (95% UI: 15,815-188,816) deaths and 2,112,025.42 (95% UI: 456,758.65-4,325,643.47) disability-adjusted life years in 2021. Over the past 3 decades, the burden increased annually by 1.63% (95% CI: 1.25%-2.01%) in age-standardized mortality rate and by 1.60% (95% CI: 1.21%-1.99%) in age-standardized rate of disability-adjusted life years. Notably, South Asia bore the heaviest burden, whereas high-income Asia Pacific had the lightest. Men and older persons consistently faced a higher IHD burden from Hi-Tem. Despite generally balanced contributions from population growth, aging, and epidemiological changes, regional disparities may persist.

CONCLUSIONS

Our study provides a comprehensive overview of the demographic and geographic characteristics of the IHD burden attributable to Hi-Tem in Asia from 1990 to 2021. In summary, Asia's IHD burden caused by Hi-Tem rose significantly, with the greater impact on men and older populations.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Cardiac fibroblast-derived mitochondria-enriched sEVs regulate tissue inflammation and ventricular remodeling post-myocardial infarction through NLRP3 pathway

Resident cardiac fibroblasts (CFs) play crucial roles in sensing injury signals and regulating inflammatory responses post-myocardial infarction (MI). Damaged mitochondria can be transferred extracellularly via various mechanisms, including extracellular vesicles (EVs). In this study, we aimed to investigate whether CFs could transfer damaged mitochondrial components via small EVs (sEVs) and elucidate their role in regulating inflammatory responses post-MI. Left anterior descending coronary artery ligation was performed in mice. Mitochondrial components in sEVs were detected using nanoflow cytometry. Differential protein expression in sEVs from normoxia and normoglycemia CFs (CFs-Nor-sEVs) and CFs post oxygen-glucose deprivation (CFs-OGD-sEVs) was identified using label-free proteomics. CFs-sEVs were co-cultured with mouse bone marrow-derived macrophages (BMDMs) to assess macrophage inflammatory responses. Effects of intramyocardial injection of CFs-sEVs were assessed in MI mice in the absence or presence of NLRP3 inhibitor CY-09. Results demonstrated that mitochondrial components were detected in CFs-derived sEVs post-MI. Damaged mitochondrial components were enriched in CFs-OGD-sEVs (CFs-mt-sEVs), which promoted pro-inflammatory phenotype activation of BMDMs in vitro. Myocardial injection of CFs-mt-sEVs enhanced tissue inflammation, aggravated cardiac dysfunction, and exacerbated maladaptive ventricular remodeling post-MI in vivo. Mechanistically, above effects were achieved via activation of NLRP3 and above effects could be reversed by NLRP3 inhibitor CY-09. This study indicates that CFs could transfer damaged mitochondrial components via the sEVs post-MI, promote macrophage inflammatory activation and exacerbate maladaptive ventricular remodeling post MI by activating NLRP3. Our findings highlight the potential therapeutic effects of inhibiting CFs-mt-sEVs and NLRP3 to improve cardiac function and attenuate ventricular remodeling post-MI.

Resource Efficient Screening for Primary Prevention of Coronary Heart Disease: A Proof-of-Concept Test in the MESA Cohort

BACKGROUND

The best use of cardiac imaging to guide preventive coronary heart disease (CHD) treatment is debated. Current guidelines recommend the pooled cohort equation, followed by computed tomography for coronary artery calcification (CAC) assessment. We evaluated if this approach could be simplified using a self-report risk algorithm instead of the pooled cohort equation.

METHODS

A gradient boosting machine model was trained on self-reported factors to calculate the probability of a high CAC score (≥100). This model was part of a self-report-based CHD preventive strategy with 3 steps: (1) calculate the probability of having a high CAC; (2) perform computed tomography for high-risk individuals; and (3) assign treatment eligibility with lipid-lowering therapy if CAC score exceeds a designated threshold. This strategy was tested using data from the MESA (Multi-Ethnic Study of Atherosclerosis) cohort (n=4564) and compared with guidelines recommending CAC scanning for intermediate-risk individuals (pooled cohort equation, 7.5% to <20%) by evaluating CHD events over 10-year follow-up in the group defined as treatment eligible by either strategy.

RESULTS

The pooled cohort equation identified 33% of the MESA population as eligible for a CAC scan and 19% as treatment eligible, capturing 48% of all CHD events (103 of 216). The self-report strategy identified 56% of CHD events (120 of 216; P=0.02) with the same number of CAC scans and treatments but required health care visits for only 33% of the population.

CONCLUSIONS

A self-report screening strategy, combined with CAC scoring, is more resource efficient and better discriminates high-risk individuals suitable for lipid-lowering therapy compared with current guidelines.

Prognostic impact of hypertension and diabetes in patients with cardiac amyloidosis

BACKGROUND

Hypertension and diabetes may increase the risk of adverse events in the general population and patients with cardiomyopathies, however, their role in patients with cardiac amyloidosis (CA) is still unclarified.

AIMS

to evaluate the effect on phenotype and clinical outcomes of hypertension and diabetes in patients with CA.

METHODS

Data from 5 Italian Amyloidosis Referral Centres were used to describe clinical characteristics and outcomes of patients with CA based on the presence of a history of hypertension and diabetes.

RESULTS

The study includes 887 patients with CA (311 light chain CA, 87 hereditary transthyretin CA, 489 wild-type transthyretin CA). Median age was 75 years (67-81), and 692 (78 %) were men. Five hundred-seven (57 %) patients had hypertension, 127 (14 %) had diabetes. In multivariable linear regression analysis, hypertension was associated with an increased interventricular septal thickness (coefficient 0.63,95 % CI 0.2-1.06), and augmented E/e' ratio (1.92,95 % CI 0.55-3.29). On Cox regression, diabetes was independently associated with death and heart failure hospitalizations (HR 1.45,95 % CI 1.05-1.99, p = 0.02).

CONCLUSIONS

Patients with hypertension present a more severe phenotype with increased LV wall thickness and more severe diastolic dysfunction compared to non-hypertensive. The presence of diabetes in this cohort is associated with an increased risk of adverse outcomes.

Combined assessment of fractional flow reserve, resting full-cycle ratio, and resting ratio of distal coronary to aortic pressure for clinical outcomes

BACKGROUND

Fractional flow reserve (FFR) and non-hyperemic indices are invasive standards for evaluating functional significance of coronary stenosis. However, data are limited about outcomes in vessels with concordant and discordant physiological results, particularly with a ratio of distal coronary to aortic pressure (Pd/Pa) at rest.

METHODS

This was a single-center, retrospective, observational study. Coronary physiological indices including FFR, resting full-cycle ratio (RFR), and resting Pd/Pa were invasively evaluated in vessels with intermediate coronary artery stenosis. FFR ≤0.80, RFR ≤0.89, and resting Pd/Pa ≤0.92 were considered physiologically positive. Vessels were divided into three groups according to the results of FFR, RFR, and resting Pd/Pa: concordant positive (all positive for FFR, RFR, and resting Pd/Pa), concordant negative (all negative for FFR, RFR, and resting Pd/Pa), and discordant groups. The primary endpoint was target vessel failure (TVF) defined as a composite of cardiac death and target vessel myocardial infarction and unplanned revascularization.

RESULTS

Of 987 vessels included, 311 (31.5 %), 263 (26.6 %), and 413 (41.9 %) were in the concordant positive, discordant, and concordant negative groups. During a median follow-up period of 417 (208-756) days, TVF occurred more frequently in the concordant positive group, followed by the discordant and concordant negative groups (7.7 % vs. 4.6 % vs. 2.4 %, p = 0.004). TVF increasingly accrued during long-term follow-up, while discordant results of RFR and resting Pd/Pa did not result in worse outcomes compared with negative RFR and resting Pd/Pa.

CONCLUSION

The combined assessment of FFR with RFR and resting Pd/Pa stratified TVF risks in vessels with intermediate coronary stenosis.

The interaction of lipomatous hypertrophy of the interatrial septum with pericardial adipose tissue biomarkers by computed tomography

OBJECTIVE

Novel pericardial adipose tissue imaging biomarkers are currently under investigation for cardiovascular risk stratification. However, a specific compartment of the epicardial adipose tissue (EAT), lipomatous hypertrophy of the interatrial septum (LHIS), is included in the pericardial fat volume (PCFV) quantification software. Our aim was to evaluate LHIS by computed tomography angiography (CTA), to elaborate differences to other pericardial adipose tissue components (EAT) and paracardial adipose tissue (PAT), and to compare CT with [18F]FDG-PET.

MATERIALS AND METHODS

Of 6983 patients screened who underwent coronary CTA for clinical indications, 190 patients with LHIS were finally included (age 62.8 years ± 9.6, 31.6% females, BMI 28.5 kg/cm2 ± 4.7) in our retrospective cohort study. CT images were quantified for LHIS, EAT, and PAT density (HU), and total PCFV, with and without LHIS, was calculated. CT was compared with [18F]FDG-PET if available.

RESULTS

CT-density of LHIS was higher (- 22.4 HU ± 22.8) than all other pericardial adipose tissue components: EAT right and left (97.4 HU ± 13 and - 95.1 HU ± 13) PAT right and left (- 107.5 HU ± 13.4 and - 106.3 HU ± 14.5) and PCFV density -83.3 HU ± 5.6 (p < 0.001). There was a mild association between LHIS and PAT right (Beta 0.338, p = 0.006, 95% CI: 0.098-577) and PAT left (Beta 0.249, p = 0.030; 95% CI: 0.024-0.474) but not EAT right (p = 0.325) and left (p = 0.351), and not with total PCFV density (p = 0.164). The segmented LHIS volume comprised 3.01% of the total PCFV, and 4.3% (range, 2.16-11.7%) in those with LHIS > 9 mm. [18F]FDG-PET: LHIS was tracer uptake positive in 83.3% (37.5%: mild and 45.8%: minimal) of 24 patients.

CONCLUSIONS

LHIS is a distinct compartment of PCFV with higher density suggesting brown fat and has no consistent association with EAT, but rather with PAT.

CLINICAL RELEVANCE STATEMENT

LHIS should be recognized as a distinct compartment of the EAT, when using EAT for cardiovascular risk stratification.

KEY POINTS

LHIS is currently included in EAT quantification software. LHIS density is relatively high, it is not associated with EAT, and has a high [18F]FDG-PET positive rate suggesting brown fat. LHIS is a distinct compartment of the EAT, and it may act differently as an imaging biomarker for cardiovascular risk stratification.

CCTA-Guided Selective Invasive Coronary Catheterization: A Strategy to Reduce Contrast Volume and Improve Efficiency

Background: Symptomatic patients with unilateral obstructive coronary artery disease (CAD) identified by coronary computed tomography angiography (CCTA), involving either the right or left coronary artery, typically undergo per-protocol bilateral coronary visualization during invasive coronary angiography (ICA). However, a selective visualization approach may be sufficient. Objectives: The objectives of this study were to assess the accuracy of CCTA in excluding hemodynamically significant coronary stenosis in patients with unilateral CAD and to evaluate whether a CCTA-guided selective ICA strategy can reduce procedure time and contrast agent use. Methods: In this cross-sectional cohort study, 454 patients with clinically suspected stable CAD who underwent CCTA prior to ICA were included. The study population consisted of 190 patients with unilateral obstructive CAD, defined as ≥50% diameter stenosis on CCTA, and an absence of obstructive CAD on the contralateral side. ICA with invasive functional assessment was used as the reference standard. Results: CCTA demonstrated a high accuracy, 97.4% (95% CI: 94-99%), in excluding hemodynamically significant disease in the contralateral arteries without obstructive CAD. Compared to the conventional ICA approach, a CCTA-guided selective visualization strategy resulted in significant reductions in procedure time and contrast agent usage: procedure time and contrast agent usage were reduced by 27% (95% CI: 12.1-47.5%) and 46.8% (95% CI: 27.5-67.0%), respectively. Conclusions: In patients with unilateral obstructive CAD identified by CCTA, a CCTA-guided selective ICA visualization strategy is highly accurate in ruling out hemodynamically significant CAD on the contralateral side. Additionally, this unilateral ICA approach has the potential to reduce both contrast agent usage and procedure time compared to the conventional bilateral visualization strategy.

Carotid intima thickness and elasticity combined with MHR predicting the severity of coronary artery stenosis in patients with premature coronary artery disease

BACKGROUND

Carotid intima thickness (CIT) and hardness coefficient (HC) are sensitive indicators of structural and functional changes in the carotid arteries in the subclinical stage of atherosclerosis. The monocyte to high-density lipoprotein cholesterol ratio (MHR), which is a biomarker of inflammation, has been shown to correlate with cardiovascular disease. The aim of this study was to assess the predictive value of CIT and HC with MHR in determining the severity of coronary artery stenosis in patients with premature coronary artery disease (PCAD).

METHODS

This prospective study included 85 PCAD patients who underwent coronary angiography. Patients were categorized into high-score (42 cases) and low-score (43 cases) groups based on the median Gensini score. Additionally, 41 volunteers matched by body mass index (BMI), age, and gender served as a control group. CIT, carotid media thickness (CMT) and carotid intima-media thickness (CIMT) were measured using a 24 MHz ultra-high frequency ultrasound probe. Diameter (Diam), distance (Dist), pulse wave velocity (PWV), and HC were evaluated through RF-data based quantitative analysis on vessel stiffness. Binary logistic regression identified risk factors influencing the severity of coronary artery stenosis. Receiver operating characteristic curves were plotted to evaluate the diagnostic performance of CIT, HC, and MHR, both individually and in combination, for predicting coronary artery stenosis severity in PCAD patients.

RESULTS

CIT, HC and MHR were significantly higher in the high group than in the low and control groups. CIT (AUC = 0.731, 95%CI: 0.624-0.838, P < 0.001) and HC (AUC = 0.783, 95%CI: 0.683-0.882, P < 0.001) individually demonstrated good diagnostic performance in assessing the severity of coronary artery stenosis, with the combined use of carotid parameters and MHR achieving the highest diagnostic efficacy (AUC = 0.849, 95%CI: 0.770-0.929, P < 0.001).

CONCLUSION

Patients in the high group had elevated CIT, CIT/CMT, and HC compared to those in the low group. Combining CIT and HC with MHR demonstrated high efficacy in predicting coronary artery stenosis severity in PCAD patients.

Comparative effect of aspirin versus clopidogrel monotherapy on incident type 2 diabetes in patients with atherosclerotic cardiovascular diseases: A target trial emulation study

AIMS

To compare the effects of low-dose aspirin and clopidogrel on the risk of incident type 2 diabetes among patients with ASCVD.

METHODS

This target trial emulation study was performed usingthe IQVIA Medical Research Data UK primary care database, including adults with an incident first ASCVD event who initiated low-dose aspirin or clopidogrel between 2004 and 2021. We applied an overlap weighting approach to balance treatment groups. The observational analogues of intention-to-treat and per-protocol effects were estimated using pooled logistic regression.

RESULTS

A total of 111,292 ASCVD patients who initiated aspirin (n = 78,012) or clopidogrel (n = 33,280) were included. In intention-to-treat analyses, aspirin and clopidogrel had similar risks of diabetes (Hazard ratio [HR] 1.02, 95 % Confidence interval [CI] 0.96 to 1.07), cardiovascular events (1.00, 0.95 to 1.05), and bleeding events (1.02, 0.97 to 1.08). In per-protocol analyses, risks remained comparable for diabetes (1.06, 0.97 to 1.15), cardiovascular events (0.96, 0.89 to 1.03), and bleeding events (1.01, 0.92 to 1.10).

CONCLUSIONS

Aspirin and clopidogrel have similar risks of incident diabetes, cardiovascular events, and bleeding events among patients with ASCVD. The choice between these agents may thus be influenced more by factors like cost, patient preference, or tolerance than by clinical outcomes alone.

Hypertensive Heart Disease in the Nigerian Population: Prevalence, Phenotypes, and Cardiovascular Comorbidities

Objective There is a lack of studies on the phenotyping of hypertensive heart disease (HHD) that examine both left ventricular (LV) structure and function in patients with essential hypertension (HTN) in sub-Saharan Africa. In this study, we investigated the prevalence of HHD, its phenotypic characteristics, and associated cardiovascular (CV) comorbidities by analyzing both LV structure and function. This can significantly enhance the understanding of HHD in the Nigerian population. Methods This cross-sectional study involved 1,799 patients diagnosed with essential HTN, who were recruited from the Federal Medical Centre Abuja Hypertension Registry between 2016 and 2021. HHD was defined as the presence of abnormal LV geometry and/or LV diastolic dysfunction (LVDD), as assessed by echocardiography in accordance with the guidelines set by the American Society of Echocardiography and the European Association of CV Imaging. Abnormal LV geometry was characterized by either concentric remodeling, which is defined as a normal left ventricular mass index (LVMI) with a relative wall thickness (RWT) > 0.42, or left ventricular hypertrophy (LVH), which is indicated by an increased LVMI (> 95 g/m² in women and > 115 g/m² in men) with an RWT > 0.42. Patients with secondary HTN and those with HTN during pregnancy were excluded from the study. Results The mean age of the study participants was 55.3±13.0 years and the majority were female patients (55.9%). The prevalence of HHD, concentric LV remodeling, LVH, and LVDD was 90.8%, 38.2%, 47.4%, and 61.6%, respectively. After multivariate analysis, heart failure (adjusted odds ratio (OR): 9.71, confidence interval (CI) 6.20-15.23, p<0.001), stroke (OR: 1.59, CI 1.01-2.52, p=0.045), LVDD (OR: 2.01, CI 1.61-2.50, p<0.001), and female sex (OR: 1.47, CI 1.20-1.80, p<0.001) were independently and positively associated with LVH. Similarly, LVH (OR: 3.51, CI 2.53-4.87, p<0.001), diabetes mellitus (OR: 1.83, CI 1.37-2.44, p<0.001), concentric LV remodeling (OR: 2.18, CI 1.58-3.01, p<0.001), stroke (OR: 1.87, CI 1.06-3.32, p=0.032), and age ≥60 years (OR: 3.92, CI 3.09-4.96, p<0.001) were independently and positively associated with LVDD. Conclusion Our study showed a high prevalence of HHD with LVH and LVDD as common phenotypes in our hypertensive cohort. These findings suggest that the widespread use of echocardiography should be promoted to aid the early diagnosis of HHD.

Biodistribution, Safety Profile, and Radiation Dosimetry of [18F]SYN2, a PET Cardiac Perfusion Tracer, in Healthy Subjects

A first-in-human phase I clinical study aimed to assess the safety profile, radiation dosimetry, and biodistribution of a potential cardiac PET myocardial perfusion imaging tracer, [18F]SYN2 (18F-labeled acridine derivative), in healthy subjects. Methods: [18F]SYN2 intravenous administration with PET imaging was performed on healthy volunteers, and sequential whole-body imaging was performed over 4 h. Blood and urine samples were collected for up to 240 min. Safety follow-up visits took place at 2, 5, and 14 d after the administration. Results: Ten subjects (8 women and 2 men) completed all study procedures. The mean age was 38.1 ± 8.8 y, and the mean body mass index was 22.7 ± 3.0 kg/m2 The mean administered dose of radioactivity was 258 MBq (range, 246-272 MBq). There were no drug-related adverse events, and the tracer was well tolerated in all subjects. The mean whole-body effective radiation dose for [18F]SYN2 was 0.0195 mSv/MBq. The tracer was rapidly taken up by the myocardial wall and cleared from plasma, leading to good image quality within minutes of tracer injection. Conclusion: On the basis of the safety profile, radiation dosimetry, and biodistribution of [18F]SYN2, it appears to be a promising agent for clinical PET myocardial perfusion imaging and to warrant further clinical studies.

The influence of serum uric acid on coronary atherosclerosis plaque phenotypes by computed tomography angiography: The missing link?

BACKGROUND AND AIMS

The interaction of serum uric acid (SUA) with atherogenesis is incompletely understood. Aim of our study was to investigate the association of SUA levels with coronary plaque composition including high-risk-plaque (HRP) features by coronary computed tomography angiography (CTA) and for the prediction of major adverse cardiac events (MACE).

METHODS AND RESULTS

1242 patients (age 66.17 ± 11.03; 56 % males) referred to coronary CTA were included. SUA>6.5 mg/dl was defined as hyperuricemia. CTA-image analysis included: Coronary stenosis severity (CADRADS), plaque burden (SIS/G-score weighted for non-calcifying plaque), plaques types (1 = calcifying; 2 = mixed (predominantly calcifying); 3 = mixed (predominantly noncalcifying), 4 = noncalcifying."High-risk-plaque"(HRP)-features were quantified: Low-attenuation plaque (LAP) density, Spotty calcification, Napkin-Ring Sign (NRS), Remodeling Index. Coronary Artery Calcium Score (CAC) was measured. Primary outcome was MACE. HRP-features were more prevalent in patients with hyperuricemia (p = 0.005, p = 0.0002, p = 0.0004). SUA level was associated with LAP<30HU (HR:1.23; p = 0.04). Plaque burden and CAC-score were higher in the hyperuricemia group (G-score:p = 0.022 and CAC:p = 0.027). After a mean follow-up of mean 8,32 years, MACE rate was 2.9 %. There was no difference in the MACE rate between subjects with elevated SUA and normals (HR 1.221:95%CI:0.817-2.563; p = 0.597). Low-attenuation-plaque density/LAP<30HU was the strongest prognosticator for MACE (p = 0.033 and p = 0.013); stenosis severity, plaque types and G-score were also predictive, but not SUA, CAC and the other conventional cardiovascular risk factors (except smoking).

CONCLUSION

SUA is associated with HRP-features and coronary plaque burden. Low attenuation plaque is the strongest predictor of MACE, but not SUA level and other major CVRF. CTA imaging biomarkers may improve CV-risk stratification in patients with hyperuricemia.

Association between quality of discharge teaching and self-management in patients after percutaneous coronary intervention: A chain mediation model

AIMS

To examine chain mediating effect of discharge readiness and self-efficacy between quality of discharge teaching and self-management in patients after percutaneous coronary intervention (PCI).

BACKGROUND

Although self-management after PCI has significant benefits in controlling risk factors and delaying disease progression, the status of self-management remains unoptimistic. A large number of studies have explored the close relationship between the quality of discharge teaching and patients self-management, but little is known about the underlying mechanisms.

METHODS

The cross-sectional samples was collected from a tertiary hospital in China. Self-reported questionnaires were used to assess quality of discharge teaching, discharge readiness, self-efficacy and self-management. Pearson correlation analysis and mediation effect analysis were used for statistical analysis.

REPORTING METHOD

The study used the STROBE checklist for reporting.

RESULTS

A total of 198 patients with a mean age of 64.99 ± 11.32 (34-85) were included. The mean score of self-management was 88.41 ± 11.82. Quality of discharge teaching, discharge readiness, self-efficacy and self-management were all positively correlated. Mediation effect analysis showed that the mediating effects of discharge readiness, self-efficacy, discharge readiness and self-efficacy between quality of discharge teaching and self-management were 0.157, 0.177 and 0.049, respectively, accounting for 21.96%, 24.76% and 6.85% of the total effect.

CONCLUSION

The quality of discharge teaching for patients after PCI not only directly affects self-management, but also can indirectly affect self-management through discharge readiness and self-efficacy.

RELEVANCE TO CLINICAL PRACTICE

To improve the life quality of patients after PCI, medical staff should pay attention to the influence of self-management of quality of discharge teaching, and develop intervention strategies based on the path of discharge readiness and self-efficacy.

PATIENT OR PUBLIC CONTRIBUTION

Questionnaires filled out by patients were used to understand the association between quality of discharge teaching, discharge readiness, self-efficacy and self-management.