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

Effectiveness of home-based cardiac rehabilitation interventions delivered via mHealth technologies: a systematic review and meta-analysis

BACKGROUND

Centre-based cardiac rehabilitation (CBCR) is underused due to low referral rates, accessibility barriers, and socioeconomic constraints. mHealth technologies have the potential to address some of these challenges through remote delivery of home-based cardiac rehabilitation (HBCR). This study aims to assess the effects of mHealth HBCR interventions compared with usual care and CBCR in patients with heart disease.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials of mHealth HBCR interventions. Four electronic databases (MEDLINE, CENTRAL, CINAHL, and Embase) were searched from inception to March 31, 2023, with no restrictions on language or publication type. Eligible studies were randomised controlled trials of adult patients (age ≥18 years) with heart disease, comparing mHealth interventions with usual care or CBCR. The primary outcome of interest was aerobic exercise capacity, assessed with VO2 peak or 6-min walk test (6MWT). Quality of evidence was assessed using the GRADE system. This review was registered with PROSPERO, CRD42024544087.

FINDINGS

Our search yielded 9164 references, of which 135 were retained for full-text review. 13 randomised controlled trials met eligibility criteria and were included in the systematic review, involving 1508 adults with myocardial infarction, angina pectoris, or heart failure, or who had undergone revascularisation. Intervention duration ranged from 6 weeks to 24 weeks. Random-effects meta-analysis showed that, compared with usual care, mHealth HBCR significantly improved 6MWT (mean difference 24·74, 95% CI 9·88-39·60; 532 patients) and VO2 peak (1·77, 1·19-2·35; 359 patients). No significant differences were found between mHealth HBCR and CBCR. Quality of evidence ranged from low to very low across outcomes due to risk of bias and imprecision (small sample size).

INTERPRETATION

mHealth HBCR could improve access and health outcomes in patients who are unable to attend CBCR. Further research is needed to build a robust evidence base on the clinical effectiveness and cost-effectiveness of mHealth HBCR, particularly in comparison with CBCR, to inform clinical practice and policy.

FUNDING

None.

Endothelial Cell-Derived Extracellular Vesicles Allow to Differentiate Between Various Endotypes of INOCA: A Multicentre, Prospective, Cohort Study

Ischemia and non-obstructive coronary artery disease (INOCA) might be due to coronary microvascular dysfunction (CMD), vasospastic angina (VSA) or both. We compared plasma concentration of various extracellular vesicles (EVs) in patients with different INOCA endotypes. Patients were divided into those with INOCA (CMD, VSA, mixed CMD + VSA) and non-anginal chest pain. Plasma concentrations of EVs were measured using flow cytometry. Out of 96 patients included, 34 had CMD (35%), 15 VSA (16%), 24 mixed endotype (25%) and 23 non-anginal chest pain (24%). Patients with INOCA had lower ratio of endothelial EVs (CD144 +) to total EVs, compared to patients with non-anginal pain (p = 0.027). Patients with mixed endotype had lower ratio of endothelial EVs (CD144 +) to total EVs, compared to CMD (p = 0.008), VSA (p = 0.014) and non-anginal pain (p < 0.001). Decreased ratio of endothelial EVs (CD144 +) to total EVs might serve as a "circulating footprint" of the mixed INOCA endotype.

Deep Learning-based Quantitative CT Myocardial Perfusion Imaging and Risk Stratification of Coronary Artery Disease

Background Precise assessment of myocardial ischemia burden and cardiovascular risk stratification based on dynamic CT myocardial perfusion imaging (MPI) is lacking. Purpose To develop and validate a deep learning (DL) model for automated quantification of myocardial blood flow (MBF) and ischemic myocardial volume (IMV) percentage and to explore the prognostic value for major adverse cardiovascular events (MACE). Materials and Methods This multicenter study comprised three cohorts of patients with clinically indicated CT MPI and coronary CT angiography (CCTA). Cohorts 1 and 2 were retrospective cohorts (May 2021 to June 2023 and January 2018 to December 2022, respectively). Cohort 3 was prospectively included (November 2016 to December 2021). The DL model was developed in cohort 1 (training set: 211 patients, validation set: 57 patients, test set: 90 patients). The diagnostic performance of MBF derived from the DL model (MBFDL) for myocardial ischemia was evaluated in cohort 2 based on the area under the receiver operating characteristic curve (AUC). The prognostic value of the DL model-derived IMV percentage was assessed in cohort 3 using multivariable Cox regression analyses. Results Across three cohorts, 1108 patients (mean age: 61 years ± 12 [SD]; 667 men) were included. MBFDL showed excellent agreement with manual measurements in the test set (segment-level intraclass correlation coefficient = 0.928; 95% CI: 0.921, 0.935). MBFDL showed higher diagnostic performance (vessel-based AUC: 0.97) over CT-derived fractional flow reserve (FFR) (vessel-based AUC: 0.87; P = .006) and CCTA-derived diameter stenosis (vessel-based AUC: 0.79; P < .001) for hemodynamically significant lesions, compared with invasive FFR. Over a mean follow-up of 39 months, MACE occurred in 94 (14.2%) of 660 patients. IMV percentage was an independent predictor of MACE (hazard ratio = 1.12, P = .003), with incremental prognostic value (C index: 0.86; 95% CI: 0.84, 0.88) over conventional risk factors and CCTA parameters (C index: 0.84; 95% CI: 0.82, 0.86; P = .02). Conclusion A DL model enabled automated CT MBF quantification and accurate diagnosis of myocardial ischemia. DL model-derived IMV percentage was an independent predictor of MACE and mildly improved cardiovascular risk stratification. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Zhu and Xu in this issue.

Patient-centric no-option refractory angina management: establishing comprehensive angina relief (CARE) clinics

INTRODUCTION

Refractory angina (RA) is a debilitating condition characterized by persistent angina despite optimized medical therapy and limited options for further revascularization, leading to diminished quality of life and increased healthcare utilization. The RA patient population is rapidly expanding with significant unmet needs. Specialty clinics should be developed to focus on the long-term efficacy and safety of clinically available and novel treatment strategies, emphasizing quality of life.

AREAS COVERED

Patient-focused Comprehensive Angina Relief (CARE) clinics can enhance care and outcomes by providing individualized management for complex RA. This review summarizes peer-reviewed articles from PubMed and trial data from ClinicalTrials.gov. We discuss the epidemiology and pathophysiology of RA, introduce standardized tools for evaluating angina and psychosocial factors, and address symptom management. We also review treatment options such as risk factor modification, medication, and complex revascularization. Additionally, we explore emerging therapies, including coronary sinus occlusion, regenerative therapy, and neuromodulation for 'no-option' RA.

EXPERT OPINION

In the next five years, patients with refractory chest pain with or without coronary artery disease will increasingly be referred to specialty clinics for follow-up. Conducting more randomized control clinical trials with larger population subsets will bring novel therapies to the forefront.

Performance of 3-T Nonenhanced Whole-Heart bSSFP Coronary MR Angiography: A Comparison with 3-T Modified Dixon Water-Fat Separation Sequence

Purpose To compare the performance of improved nonenhanced whole-heart balanced steady-state free precession (bSSFP) coronary MR angiography (CMRA) with that of the modified Dixon (mDixon) water-fat separation method at 3-T imaging. Materials and Methods From September 2023 to December 2023, patients with suspected coronary artery disease who underwent bSSFP and mDixon CMRA after coronary CT angiography (CCTA) were consecutively recruited. The two sequences' acquisition success rates, subjective image quality scores, objective image quality measurements, and diagnostic performance for coronary stenosis with CCTA as the reference standard were analyzed. Results Sixty-two participants completed two CMRA sequences. Data from 49 participants (30 male and 19 female participants; mean age, 62 years ± 10 [SD]) were ultimately analyzed. The acquisition success rates, overall subjective image quality scores, apparent signal-to-noise ratios, and contrast-to-noise ratios of bSSFP and mDixon were significantly different: 93.5% versus 80.6% (P = .021), 5 versus 4 (P < .001), 33.4 ± 10.6 versus 20.7 ± 7.5 (P < .001), and 14.9 ± 6.2 versus 7.0 ± 3.1 (P < .001), respectively. The sensitivity and specificity of bSSFP in predicting stenosis greater than or equal to 50% were 94.7% (95% CI: 71.9, 99.7) and 96.7% (95% CI: 80.9, 99.8) per participant, 95.8% (95% CI: 76.9, 99.8) and 96.7% (95% CI: 91.3, 98.9) per vessel, and 96.6% (95% CI: 80.4, 99.8) and 99.0% (95% CI: 97.3, 99.7) per segment, respectively. Conclusion Compared with the mDixon water-fat separation method, the improved nonenhanced whole-heart bSSFP sequence performed excellently at 3-T imaging. Nonenhanced bSSFP CMRA sequences at 3-T imaging may be recommended for broader clinical applications. Keywords: Coronary Arteries, Imaging Sequences, Comparative Studies, Technology Assessment, Cardiac, MR Angiography, Coronary Angiography, MRI, Image Quality Enhancement Supplemental material is available for this article. © RSNA, 2025.

Predicting the need for calcium modification techniques using computed tomography coronary angiography

Calcified coronary arteries pose a challenge to percutaneous coronary intervention (PCI). Calcium modification techniques (CMTs) increase procedural length, complexity and risk. Computed tomography coronary angiography (CTCA) is well suited to calcium identification and quantification and may offer valuable pre-procedural information. We hypothesised that CTCA could predict cases where CMT would be required during PCI. A single centre retrospective review (2021/2022) of consecutive patients who underwent PCI with a preceding CTCA demonstrating a calcified lesion in a major epicardial vessel. Blinded to the PCI strategy CTCA images were re-reviewed and calcium thickness, length, density and circumferential arc quantified. Receiver operating characteristic (ROC) curve for CMT defined optimum cut-off values. Calcium density (> 1000 HU) and calcific arc (> 180°) were proposed as a calcium planning score (CPSCTCA), with 1 point assigned per criteria met. 76 PCI procedures were included (72 patients). CMT was used in 53% at the discretion of the operator. Calcific arc, density, length and thickness had an area under the curve (AUC) of 0.74, 0.7, 0.67 and 0.63 respectively. There was a step-wise increase in the proportion of cases requiring CMT with increasing CPSCTCA. 0 vs. 1 point; OR 9 (1.1-82, p =.04), RR 5 (0.8-36, p =.09), 1 vs. 2 points; OR 3.2 (1.1-9.3, p =.03), RR 1.6 (1-2.3, p =.04), 0 vs. 2 points; OR 30 (3.3-272, p =.003), RR of 8 (1.3-54, p =.03). The incorporation of CTCA measured calcium density > 1000 HU and calcium arc > 180° into a calcium planning score may help with predicting the need for CMT at the time of PCI.

Deep learning reconstruction algorithm and high-concentration contrast medium: feasibility of a double-low protocol in coronary computed tomography angiography

OBJECTIVE

To evaluate radiation dose and image quality of a double-low CCTA protocol reconstructed utilizing high-strength deep learning image reconstructions (DLIR-H) compared to standard adaptive statistical iterative reconstruction (ASiR-V) protocol in non-obese patients.

MATERIALS AND METHODS

From June to October 2022, consecutive patients, undergoing clinically indicated CCTA, with BMI < 30 kg/m2 were prospectively included and randomly assigned into three groups: group A (100 kVp, ASiR-V 50%, iodine delivery rate [IDR] = 1.8 g/s), group B (80 kVp, DLIR-H, IDR = 1.4 g/s), and group C (80 kVp, DLIR-H, IDR = 1.2 g/s). High-concentration contrast medium was administered. Image quality analysis was evaluated by two radiologists. Radiation and contrast dose, and objective and subjective image quality were compared across the three groups.

RESULTS

The final population consisted of 255 patients (64 ± 10 years, 161 men), 85 per group. Group B yielded 42% radiation dose reduction (2.36 ± 0.9 mSv) compared to group A (4.07 ± 1.2 mSv; p < 0.001) and achieved a higher signal-to-noise ratio (30.5 ± 11.5), contrast-to-noise-ratio (27.8 ± 11), and subjective image quality (Likert scale score: 4, interquartile range: 3-4) compared to group A and group C (all p ≤ 0.001). Contrast medium dose in group C (44.8 ± 4.4 mL) was lower than group A (57.7 ± 6.2 mL) and B (50.4 ± 4.3 mL), all the comparisons were statistically different (all p < 0.001).

CONCLUSION

DLIR-H combined with 80-kVp CCTA with an IDR 1.4 significantly reduces radiation and contrast medium exposure while improving image quality compared to conventional 100-kVp with 1.8 IDR protocol in non-obese patients.

CLINICAL RELEVANCE STATEMENT

Low radiation and low contrast medium dose coronary CT angiography protocol is feasible with high-strength deep learning reconstruction and high-concentration contrast medium without compromising image quality.

KEY POINTS

Minimizing the radiation and contrast medium dose while maintaining CT image quality is highly desirable. High-strength deep learning iterative reconstruction protocol yielded 42% radiation dose reduction compared to conventional protocol. "Double-low" coronary CTA is feasible with high-strength deep learning reconstruction without compromising image quality in non-obese patients.

Indobufen-based dual antiplatelet therapy in patients with multivessel coronary disease undergoing drug-eluting stent implantation insight from the OPTION trial

BACKGROUND

It remains unclear whether indobufen-based dual antiplatelet therapy (DAPT) preserves ischemic protection while limiting bleeding risk in patients with multivessel coronary disease (MVD). This study aimed to investigate the efficacy and safety of indobufen-based DAPT in patients with MVD.

METHODS

Patients in the OPTION trial were stratified based on the presence of MVD. We compared the ischemic and bleeding risks of indobufen-based DAPT (indobufen 100mg twice a day plus clopidogrel 75 mg/d for 12 months) vs conventional DAPT (aspirin 100 mg/d plus clopidogrel 75 mg/d for 12 months) in patients with and without MVD, using landmarks at 6 months and 1-year post-percutaneous coronary intervention (PCI).

RESULTS

Patients with MVD tended to be older and contained a higher prevalence of high-risk features. Compared with patients without MVD, those with MVD were at higher risk for net adverse clinical events and ischemic events. The risk of ischemic events between indobufen-based DAPT vs conventional DAPT was similar either in patients with MVD or without MVD during the first and second 6 months. During the first 6 months, indobufen-based DAPT decreased the risk of bleeding events consistently in patients with and without MVD. Of note, during the second 6 months, indobufen-based DAPT continually decreased the risk of bleeding events in patients with MVD but not in those without MVD.

CONCLUSIONS

In patients with MVD, indobufen plus clopidogrel DAPT compared to aspirin plus clopidogrel DAPT could reduce the risk of bleeding events while preserving ischemic protection during both the first and second 6 months post-PCI. Indobufen presents an effective option for patients with MVD, especially those at high ischemic risk requiring DAPT beyond 6 months post-PCI.

TRIAL REGISTRATION

The trial was registered at www.chictr.org. A Randomized Controlled Trial of Indobufen vs Aspirin after Coronary Drug-eluting Stent Implantation: the OPTION Trial (ChiCTR-IIR-17013505).

Value of upfront coronary computed tomography angiography in patients with non-ST-segment elevation acute coronary syndrome

This study aimed to evaluate the diagnostic performance of coronary computed tomography angiography (CCTA) in ruling out coronary artery stenosis ≥ 70% across all segments and its role in providing preprocedural guidance for chronic total occlusion (CTO) management in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). This study was a post hoc analysis of a prospective, multicenter cohort comprising 347 patients with NSTE-ACS. All patients underwent CCTA immediately after being diagnosed with NSTE-ACS, followed by invasive coronary angiography (ICA) within 1 day. The diagnostic performance of CCTA in ruling out obstructive coronary stenosis was assessed using negative predictive value (NPV). Additionally, segments distal to CTO were analyzed to compare the detection capabilities of CCTA and ICA. The NPV of CCTA for ruling out coronary stenosis ≥ 70% was robust, ranging from 94.7 to 100.0% across the 18-segment model at the segment level, and 25.9% of patients had no significant stenosis and could have avoided unnecessary ICA based on CCTA findings. CCTA identified 71.0% of segments distal to CTO, significantly higher than ICA (48.8%, P < 0.001). 25.1% of patients had CTO, where CCTA provided valuable preprocedural guidance for revascularization. CCTA demonstrated high diagnostic accuracy in ruling out significant stenosis and provided critical information for CTO revascularization, highlighting its potential as a triaging and planning tool in NSTE-ACS.

Comparative evaluation of a novel [18F] F-Labeled PET tracer XTR004 against [13N] ammonia in myocardial perfusion imaging for coronary artery disease

AIMS

This study aimed to evaluate image quality, myocardial perfusion, and diagnostic performance of a novel [18F]F-labeled PET tracer, XTR004 PET, myocardial perfusion imaging (MPI) compared with [13N]Ammonia (NH3) PET MPI.

METHODS AND RESULTS

Forty-seven patients with suspected or known coronary artery disease (CAD) were prospectively enrolled to undergo one-day rest/ATP-stress XTR004 and NH3 electrocardiograph-gated PET imaging within 2 weeks. Among them, twenty-six patients underwent invasive coronary angiography (ICA), and nineteen were identified with flow-limited CAD (stenosis ≥ 70%). Image quality (excellent/good/average) and certainty of interpretation were evaluated by two independent, blinded readers. Despite a higher liver uptake, XTR004 achieved good to excellent image quality in 83% of cases, comparable to 95.7% of NH3(P = 0.091). Additionally, the diagnostic certainty, measured as the percentage of cases with definitely abnormal or normal interpretations, was similar between XTR004 and NH3, with results of 87.2% and 89.2%, respectively. The sensitivity and specificity levels of XTR004 and NH3 MPI were similar (79% vs. 79%, 86% vs. 71%, P = 1.00). Linear regression of rest/stress myocardial perfusion in 17 segments revealed the linear slope close to unity with excellent R2 value (rest: slope = 0.954-1.074, R2 = 0.990-0.997; stress: slope = 0.951-1.082, R2 = 0.971-0.996). XTR004 was tolerated well by all patients. No adverse events were reported.

CONCLUSION

XTR004 PET MPI demonstrated promising image quality, diagnostic certainty and myocardial perfusion characteristics comparable to NH3 PET MPI. Future research should concentrate on the quantitative analysis of myocardial blood flow to explore the clinical implications of XTR004 PET MPI.

Expanding interpretability through complexity reduction in machine learning-based modelling of cardiovascular disease: A myocardial perfusion imaging PET/CT prognostic study

BACKGROUND

Machine learning-based analysis can be used in myocardial perfusion imaging data to improve risk stratification and the prediction of major adverse cardiovascular events for patients with suspected or established coronary artery disease. We present a new machine learning approach for the identification of patients who develop major adverse cardiovascular events. The new method is robust against the deleterious effect of outliers in the training set stratification and training process.

METHODS

The proposed sum-of-sigmoids model is obtained by averaging the contributions of various input variables in an ensemble of XGBoost models. To illustrate its performance, we have applied it to predict major adverse cardiovascular events from advanced imaging data extracted from rest and adenosine stress 13N-ammonia positron emission tomography myocardial perfusion imaging polar maps. There were 1185 individual studies performed, and the event occurrence was tracked over a follow-up period of 2 years.

RESULTS

The sum-of-sigmoids model achieved a prediction accuracy of .83 on the test set, matching the performance of significantly more complex and less interpretable models (whose accuracies were .83-.84).

CONCLUSION

The sum-of-sigmoids model is interpretable and simple, while achieving similar prediction accuracy to significantly more complex machine learning models in the considered prediction task. It should be suitable for applications such as automated clinical risk stratification, where clear and explicit justification of the classification procedure is highly pertinent.

Perioperative Antithrombotic Strategies in Vascular Surgery: A Survey in Germany

Background and Aims

The variety of modern antithrombotic medications complicates the choice of individual perioperative therapy in vascular surgery, especially when more than one antithrombotic option is possible. The aim of this study was to determine the perioperative and periinterventional setting concerning antithrombotics in vascular surgery in Germany.

Methods

This article is based on a survey from year 2018 of heads of German vascular surgical departments or units regarding their experience with different anticoagulants. The survey asked for the frequency and time of preoperative pausing of the antithrombotics before various vascular operations or interventions.

Results

The evaluable response rate was 52% (169/324). Acetylsalicylic acid was discontinued before open aortic surgery in 9% (15/169) of respondents. Clopidogrel was paused in 65% (107/169) before open aortic surgery, in 25% (41/169) before vascular surgery (like carotid endarterectomy, endovascular aortic repair, or operations on peripheral arteries), and in 11% (18/169) before peripheral percutaneous interventions. Discontinuation of vitamin K antagonists or direct oral anticoagulants (took place before conventional operations in 99.4%; oral anticoagulation was continued for peripheral percutaneous interventions in only 6% (8/169). Management was heterogeneous with regard to the timing of the perioperative medication pause. Clopidogrel was not discontinued according to time specifications in 8%; ticagrelor in 75%; rivaroxaban in 23%; and dabigatran in 29%, compared to the recommendations of the industrial information sheets.

Conclusion

The perioperative antithrombotic therapy in German vascular surgery clinics is not uniform and does not correspond to the current specialist recommendations in a notable proportion of clinics.

[Vaccination and cardiovascular diseases]

Respiratory tract infections with influenza, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and respiratory syncytial (RS) viruses and pneumococci as well as endogenous reactivation of varicella zoster viruses presenting as herpes zoster, are associated with adverse cardiovascular outcomes, such as myocardial infarction or hospitalization for heart failure. Effective prevention of these events, particularly through influenza and pneumococcal vaccination, is well established and cost-effective. Despite guideline recommendations to vaccinate older patients and people at risk, vaccination rates in these population groups remain suboptimal and below average in international comparison. This article sheds light on the association of vaccine preventable diseases with cardiovascular complications and demonstrates the protective effect of the respective vaccinations. Additionally, recommendations on the practical approach to vaccinating high-risk patients are given.

Diagnosing and treating stable angina: a contemporary approach for practicing physicians

Longer life expectancy and advancements in coronary artery disease management have improved life expectancy and survival, increasing the prevalence of chronic coronary syndromes (CCS). Angina is a common symptom in patients with CCS but remains underdiagnosed and undertreated. Contemporary guidelines provide detailed information on diagnosing and treating angina based on evidence and expert consensus; however, their extensive nature may hinder uptake by non-specialists. This review presents a practical approach to diagnosing stable angina, followed by the three pillars of CCS management: 1) healthy lifestyle including appropriate exercise, diet, and avoiding toxic habits; 2) optimal medical therapy, including treatment recommended to prevent cardiovascular events and drugs for the control of myocardial ischemia and angina tailored to the patient's comorbidities; and 3) myocardial revascularization when indicated. This approach may be useful for practicing physicians but is not intended to substitute more detailed and authoritative documents. Checklists are proposed to help focus patient-physician interactions and make follow-up visits more efficient. This approach seeks to increase the proportion of correct angina diagnoses and patients receiving evidence-based treatments, emphasizing the importance of patient education, managing residual angina, and reducing cardiovascular risk. We include reference to the recently published 2024 ESC guidelines on chronic coronary syndromes.

Role of CT and CMR in the Management of Chronic Coronary Syndrome

Chronic coronary syndrome (CCS), encompassing a wide range of phenotypes and clinical scenarios, remains the leading global cause of disability and premature death. Advanced non-invasive imaging modalities, such as coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR), play a pivotal role in enhancing diagnostic accuracy and guiding tailored management strategies for CCS patients. CCTA offers detailed insights into the presence, extent, and severity of coronary atherosclerotic plaques. In addition to detecting coronary stenoses, it enables the characterization of plaque phenotypes and the evaluation of additional prognostic biomarkers, such as perivascular adipose tissue (PVAT) attenuation, allowing for more comprehensive risk stratification. Recent technological advancements have further expanded CCTA's capabilities, enabling the integration of anatomical assessment with hemodynamic evaluation through non-invasive fractional flow reserve computation (FFR-CT) or stress myocardial perfusion analysis. With its superior three-dimensional spatial resolution, CCTA enhances pre-procedural planning for complex coronary revascularization, enabling the selection of optimal interventional strategies and improving patient selection. CMR is considered the gold standard for functional assessment of cardiac function, myocardial viability, quantitative flow evaluation, and tissue characterization, offering excellent soft-tissue contrast. CMR perfusion imaging can accurately assess myocardial ischemia, quantify myocardial blood flow (MBF), and detect microvascular dysfunction, thanks to its high temporal and spatial resolution with the advantage of no radiation exposure. This review highlights the evolving role of CCTA and CMR in managing patients with CCS, focusing on their current applications according to the most recent 2024 ESC guidelines, prognostic value, and recent technological advancements.

Guideline-Directed Medical Therapy and Outcomes in the ISCHEMIA Trial

BACKGROUND

Guideline-directed medical therapy (GDMT) with multiple risk factor goals is recommended for patients with chronic coronary disease (CCD), yet achieving all GDMT goals is uncommon. The relative importance of these goals and timing of their attainment on cardiovascular events is uncertain.

OBJECTIVES

This study aims to describe the relationship between achieving specific GDMT goals, when they are achieved, and clinical outcomes.

METHODS

This was an observational study of participants with CCD in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. The primary outcome was cardiovascular (CV) death or myocardial infarction (MI). GDMT goals were systolic blood pressure (SBP) <130 mm Hg, low-density lipoprotein cholesterol <70 mg/dL, not smoking, and antiplatelet therapy. Frequency of GDMT goals met at baseline and during follow-up is described. Bayesian joint modeling for longitudinal goal status and time-to-event analyses characterized the relative importance of specific GDMT goal attainment and timing with CV death/MI.

RESULTS

All 5,179 ISCHEMIA participants were included. Among 4,914 participants with complete data on all 4 GDMT goals at baseline, 386 (9%), 2,073 (42%), 1,843 (38%), and 612 (12%) met 0-1, 2, 3, and 4 GDMT goals, respectively. The 4-year cumulative event rate for CV death/MI was highest for participants who attained no GDMT goals (24.5%; 95% credible interval [CrI]: 13.5%-42.2%) and lowest for those who attained all goals at baseline and remained at goal during follow-up (8.7%; 95% CrI: 6.7%-10.9%). SBP goal attainment was associated with a significant absolute event reduction in CV death/MI (-5.1%; 95% CrI: -11.3% to -1.0%), followed by antiplatelet therapy (-11.2%; 95% CrI: -29.1% to 0.8%), achieving low-density lipoprotein cholesterol <70 mg/dL (-2.0%; 95% CrI: -6.0% to 2.4%), and not smoking (-1.7%; 95% CrI: -9.3% to 4.2%). Ten millimeters of mercury lower SBP during follow-up was associated with 10% relative risk reduction of CV death/MI (RR [relative risk] = 0.90; 95% CrI: 0.82-0.98), after adjusting for other GDMT goals and baseline characteristics.

CONCLUSIONS

Among participants with CCD, early attainment and maintenance of GDMT goals, especially SBP, were associated with fewer cardiovascular events. Compared with no GDMT goals at target, having all 4 GDMT goals at target at baseline was associated with an absolute 16% fewer CV deaths and MIs. (ISCHEMIA [International Study of Comparative Health Effectiveness With Medical and Invasive Approaches]; NCT01471522).

AI-based detection and classification of anomalous aortic origin of coronary arteries using coronary CT angiography images

Anomalous aortic origin of the coronary artery (AAOCA) is a rare cardiac condition that can lead to ischemia or sudden cardiac death, yet it is often overlooked or falsely classified in routine coronary CT angiography (CCTA). Here, we developed, validated, externally tested, and clinically evaluated a fully automated artificial intelligence (AI)-based tool for detecting and classifying AAOCA in 3D-CCTA images. The discriminatory performance of the different models achieved an AUC ≥ 0.99, with sensitivity and specificity ranging 0.95-0.99 across all internal and external testing datasets. Here, we present an AI-based model that enables fully automated and accurate detection and classification of AAOCA, with the potential for seamless integration into clinical workflows. The tool can deliver real-time alerts for potentially high-risk AAOCA anatomies, while also enabling the analysis of large 3D-CCTA cohorts. This will support a deeper understanding of the risks associated with this rare condition and contribute to improving its future management.

Chronic coronary syndrome in Africa: current management and service challenges, and opportunities for optimizing patient care

African populations have traditionally been considered at relatively low risk of cardiovascular diseases (CVD), such as chronic coronary syndrome (CCS), but this is rapidly changing in association with ageing populations, uncontrolled urbanization and lack of control of classical CV risk factors. In sub-Saharan Africa, CVD deaths have increased by more than 50% in the past three decades. For CCS care, limited availability of clinical expertise, diagnostic facilities, and access to optimal medical therapy (OMT), lack or inadequate reimbursement of healthcare costs, and scarcity of universal health coverage (UHC) are major challenges. Cardiologists from 11 African countries, meeting through the AFEX: ACT ON Angina programme, with the endorsement of the World Heart Federation, identified the need to: engage clinicians, patients, and the media to raise awareness of CCS and angina, and encourage lifestyle modification and risk factor control, as well as early referral of high-risk individuals; develop care pathways to address growing demand, including cross-border and online collaboration where local expertise is unavailable; optimize the use of treatment budgets by adapting and implementing international guidelines according to local priorities, and avoiding prescription of nonevidence-based medicines; initiate collaborative research into the nature of CCS in African countries and potential differences in risk factors, presentation, and treatment response compared with Europe and North America whose experience forms the basis of international guidelines. A roadmap is proposed to guide future developments in CCS care and support best practices across Africa.

Deep learning-quantified body composition from positron emission tomography/computed tomography and cardiovascular outcomes: a multicentre study

BACKGROUND AND AIMS

Positron emission tomography (PET)/computed tomography (CT) myocardial perfusion imaging (MPI) is a vital diagnostic tool, especially in patients with cardiometabolic syndrome. Low-dose CT scans are routinely performed with PET for attenuation correction and potentially contain valuable data about body tissue composition. Deep learning and image processing were combined to automatically quantify skeletal muscle (SM), bone and adipose tissue from these scans and then evaluate their associations with death or myocardial infarction (MI).

METHODS

In PET MPI from three sites, deep learning quantified SM, bone, epicardial adipose tissue (EAT), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and intermuscular adipose tissue (IMAT). Sex-specific thresholds for abnormal values were established. Associations with death or MI were evaluated using unadjusted and multivariable models adjusted for clinical and imaging factors.

RESULTS

This study included 10 085 patients, with median age 68 (interquartile range 59-76) and 5767 (57%) male. Body tissue segmentations were completed in 102 ± 4 s. Higher VAT density was associated with an increased risk of death or MI in both unadjusted [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.37-1.43] and adjusted (HR 1.24, 95% CI 1.19-1.28) analyses, with similar findings for IMAT, SAT, and EAT. Patients with elevated VAT density and reduced myocardial flow reserve had a significantly increased risk of death or MI (adjusted HR 2.49, 95% CI 2.23-2.77).

CONCLUSIONS

Volumetric body tissue composition can be obtained rapidly and automatically from standard cardiac PET/CT. This new information provides a detailed, quantitative assessment of sarcopenia and cardiometabolic health for physicians.

Results from Cardiovascular Examination Do Not Predict Cerebrovascular Macroangiopathy: Data from a Prospective, Bicentric Cohort Study

Background: There is a large overlap in the risk profiles and pathophysiologies of coronary artery disease (CAD) and cerebrovascular macroangiopathy. Therefore, this study aimed to analyse whether findings in CAD examination by coronary angiography or cardio-computer tomography (cardio-CT) are predictive of cerebrovascular macroangiopathy. Methods: Our study was a prospective, bicentric, cross-sectional cohort study. A total of 191 patients without earlier CAD diagnosis who underwent a cardio-CT scan or coronary angiography for the screening of CAD during clinical routine were serially included. Two groups were formed based on the criterion of CAD (yes/no), and both were subsequently examined using sonography of the carotids. The CAD scores Syntax score I, Agatston equivalent score, and CAD-RADS score as well as AHA classification were determined. In cerebrovascular examinations, plaques and stenoses of the internal carotid artery (ICA) and the intima-media thickness (IMT) of the common carotid artery were analysed. Demographic and medical data such as the presence of arterial hypertension, diabetes mellitus, obesity, nicotine abuse, and dyslipidaemia were documented. The primary endpoint was the nominal association between CAD and ICA stenosis controlled for age and gender; secondary endpoints were correlations between ICA stenoses and CAD scores. Results: Of the 191 serially recruited patients (58% male, 65 ± 11 yrs.), 101 fulfilled CAD criteria; 90 did not. Of all patients, 137 had ICA plaques, and 11 thereof had an ICA stenosis ≥ 50%. No association was found between CAD and ICA stenosis (Wald = 0.24; p = 0.624). Accordingly, there was no association between IMT and Syntax score I (Wald = 0.38; p = 0.706), Agatston equivalent score (Wald = 0.89; p = 0.380), CAD-RADS score (Wald = 0.90; p = 0.377), or AHA classification (Wald = 0.21; p = 0.837). Common cardiovascular risk factors, i.e., arterial hypertension (Wald = 4.47; p = 0.034), diabetes mellitus (Wald = 7.61; p = 0.006), and nicotine abuse (Wald = 0.83; p = 0.028), were associated with newly diagnosed CAD but not with ICA plaques, stenosis, or increased IMT. Conclusions: In our cohort, newly diagnosed CAD was associated with typical risk factors. However, neither CAD nor these risk factors were associated with cerebrovascular disease. This suggests that in patients without prior CAD diagnosis, findings from CAD examinations might not be reliably predictive of cerebrovascular disease.

Prognostic Impact of Chronic Kidney Disease After Percutaneous Coronary Intervention with Drug-Coated Balloons

Background: A drug-coated balloon (DCB) is an emerging treatment technology for percutaneous coronary intervention (PCI). However, the prognostic factors of PCI with a DCB remain fully determined. Chronic kidney disease (CKD) is an independent predictor of adverse outcomes in patients with coronary artery disease (CAD) who underwent PCI. The aim of this present study was to clarify the impact of CKD on prognosis in CAD patients who underwent PCI with a DCB. Methods: We enrolled 252 consecutive patients with CAD who underwent PCI with a DCB from 2015 to 2023. The endpoints of this study were composite events including all-cause death, myocardial infarction, target vessel revascularization, stroke, and major bleeding. Results: The prevalence rate of CKD was 48%. Patients with CKD were older and had higher prevalence of hypertension and diabetes mellitus than those without. Kaplan-Meier analysis revealed a significantly higher composite event rate in patients with CKD (log-rank test, p = 0.003). In the multivariate Cox proportional hazards analysis, CKD was independently associated with composite events after adjusting for confounding factors (adjusted hazard ratio 1.985, 95% confidence intervals 1.157-3.406, p = 0.013), mainly driven by all-cause deaths. Conclusions: CKD was associated with unfavorable outcomes in CAD patients who underwent PCI with a DCB.

Chinese Guidelines for the Diagnosis and Treatment of Heart Failure 2024

In the past 6 years, significant breakthroughs have been achieved in the treatment of heart failure (HF), especially in drug therapy. The classification of chronic HF and the treatment methods for HF and its complications are also constantly being updated. In order to apply these results to the diagnosis and treatment of patients with HF in China and further improve the level of diagnosis and treatment of HF in China, the HF Group of Chinese Society of Cardiology, Chinese Medical Association, Chinese College of Cardiovascular Physician, Chinese HF Association of Chinese Medical Doctor Association, and Editorial Board of Chinese Journal of Cardiology have organized an expert group and update the consensus and evidence-based treatment methods in the field of HF based on the latest clinical research findings at home and abroad, combined with the national conditions and clinical practice in China, and referring to the latest foreign HF guidelines while maintaining the basic framework of the 2018 Chinese Guidelines for Diagnosis and Treatment of HF.

Prognostic value of left atrioventricular coupling index in heart failure

AIMS

To investigate the distribution of left atrioventricular coupling index (LACI) among patients with heart failure and left ventricular ejection fraction (LVEF) < 50% and to explore its association with the combined endpoint of all-cause death or HF hospitalization at long-term follow-up.

METHODS AND RESULTS

Patients with HF and LVEF < 50% undergoing cardiac magnetic resonance were evaluated. Patients with atrial fibrillation or flutter were excluded. Left atrioventricular coupling index was measured as the ratio between the left atrial (LA) and the LV end-diastolic volumes. Patient population was divided according to LACI tertiles and followed up. Total of 478 patients (mean age 62 ± 12 years, 78% male) were included. The median value of LACI was 27.1% (interquartile range 19.9-34.5). Patients within the worst LACI tertile (≥30.9%) showed smaller LV volumes and larger LA volumes as compared with patients in the first or second tertile (LACI 6.2-22.2 and LACI 22.3-30.9, respectively). Left atrioventricular coupling index was significantly associated with the combined endpoint [hazard ratio (HR) 1.87, P = 0.01]. After adjusting for sex, age, ischaemic HF aetiology, LVEF, LA reservoir strain, diabetes mellitus, LV scar, mitral regurgitation, and LVEDVi, LACI remained significantly associated with the combined endpoint (HR 1.77, P = 0.02). Patients with the highest LACI values had worse outcomes compared with patients in first and second tertiles (HR 1.69, P = 0.02 and HR 1.77, P = 0.02, respectively).

CONCLUSION

In patients with HF and LVEF <50%, LACI is independently associated with adverse events. Patients with most impaired left atrioventricular coupling have the worst clinical outcomes.

Highlights of the Cardiovascular Magnetic Resonance 2024 Conference: the first joint European Association of Cardiovascular Imaging, European Society of Cardiovascular Radiology, and Society for Cardiovascular Magnetic Resonance conference

Cardiovascular Magnetic Resonance 2024 Conference (CMR2024) convened in London, UK, from 24 to 26 January 2024 and brought together 2705 learners and renowned cardiac imaging professionals to discuss and learn about the latest advancements. Organized by the Society for Cardiovascular Magnetic Resonance (SCMR) and the European Association of Cardiovascular Imaging (EACVI), in collaboration with the European Society of Cardiovascular Radiology (ESCR), CMR2024 was the largest international cardiac magnetic resonance conference to date. This conference underscored the collaboration between cardiologists, radiologists, scientists, and technologists by bringing together three major societies-SCMR, EACVI, and ESCR. Innovative session formats like 'Shark Tank' and 'Workflow, Innovations & Patients' facilitated expert opinion and practical experiences sharing in a 'TED-talk style'. With over 1168 abstract submissions and 75% acceptance rate, the programme featured multiple Early Career Award sessions, oral scientific sessions, oral case sessions, and rapid-fire sessions, all categorized by topic. Highlights included patient- and physician-centred imaging sessions, sharing referring physicians' and patients' insights of incremental value of cardiovascular magnetic resonance (CMR) in patient's management. The programme offered invited lectures in eight parallel tracks with three plenary and two keynote speakers. In addition, the interactive workshops and panel discussions provided a platform for knowledge exchange, support, and collaboration. A great emphasis was placed on collaboration between radiologists, cardiologists, scientists, and technologists, showcasing an ideal cardiac imaging marriage as a model for enhanced patient care around the globe. The event also featured exhibitions of the latest CMR technology and software, offering attendees a glimpse into the future cardiac imaging. CMR2024 emerged as a remarkable scientific, educational, and networking event, inspiring attendees to learn and collaborate within the global CMR community.

Kinesiophobia in patients with coronary heart disease: a Rodgers' evolutionary concept analysis

Introduction

Research on kinesiophobia in coronary heart disease is increasing, but existing studies primarily adopt concepts from the chronic pain domain, neglecting the specific characteristics of coronary heart disease patients. This gap limits effective identification and management.

Objective

This study aims to clarify the concept of kinesiophobia in coronary heart disease using Rodgers' evolutionary concept analysis.

Methodology

Rodgers' evolutionary concept analysis method was applied to review the literature. A comprehensive search was conducted in PubMed, Web of Science, PsycINFO, CINAHL, Cochrane Library, Embase, Scopus, ProQuest, OVID, CNKI, Wanfang Data, CBM, and VIP Database (up to June 30, 2024). Inclusion criteria: Studies on coronary heart disease patients, addressing the concept's attributes, antecedents, and consequences, published in English or Chinese. Exclusion criteria: Unavailable full text, gray literature, non-peer-reviewed texts, and study protocols.

Results

A total of 31 articles were included. The attributes of kinesiophobia in coronary heart disease patients were identified as self-symptomatic distress, complex emotional responses, subjective avoidance behavior with personality tendencies, and misperceptions with negative reactions. Antecedents included sociodemographic, disease-related, and psychological factors. Consequences encompassed reduced participation in cardiac rehabilitation, decreased functional capacity, increased major adverse cardiac events, and lower quality of life.

Conclusion

In this study, we found that kinesiophobia in patients with coronary heart disease is a subjective avoidance behavior that includes both "fear of pain or weakness" and "fear of cardiac events" based on personality tendencies, driven by complex emotional responses and misperceptions based on their own symptomatic disturbances, and presents an excessive and irrational fear of movement. This analysis highlights the need for early identification and multidisciplinary interventions tailored to this population. It also provides a foundation for developing more specific and objective assessment tools.

Homogeneity of the Coronary Microcirculation in Angina with Non-Obstructive Coronary Artery Disease

AIMS

The homogeneity of coronary microcirculatory dysfunction (CMD) across different myocardial territories in angina with non-obstructive coronary artery disease (ANOCA) patients is scarcely explored. This study investigates the variability in microvascular resistance reserve (MRR) across the 3 main perfusion territories of the coronary circulation to investigate the homogeneity or dishomogeneity of microcirculatory function.

METHODS AND RESULTS

This post-hoc analysis of the PACIFIC trials included symptomatic ANOCA patients with [15O]H2O positron emission tomography (PET) and three-vessel invasive fractional flow reserve (FFR). MRR was computed in the three main coronary branches by integrating PET-derived coronary flow reserve and invasive FFR. A total of 155 patients (50% male, age 59 ± 10 years) and 465 vessels (MRR: 3.92 ± 1.21) were included. There were no significant differences in MRR among the three coronary branches. Correlations in MRR among the three coronary branches were good (r = 0.76 to 0.86). The mean difference between MRR measurements in different arteries was small (2.4 to 7.5%), without any consistent directional bias. The overall intraclass correlation coefficient for absolute agreement was 0.80 (95% CI: 0.74-0.85), indicating good single-measure reliability. Approximately 80% (123/155) of patients showed diagnostic concordance of CMD (MRR ≤3.0) across the three vessels.

CONCLUSION

In most ANOCA patients, microvascular function is homogeneously distributed across the three major coronary territories. Single-artery testing may suffice in many cases, aligning with guidelines. However, some patients exhibit notable inter-territorial variation, suggesting that multivessel evaluation may be prudent in borderline scenarios.

Multimodal prediction of major adverse cardiovascular events in hypertensive patients with coronary artery disease: integrating pericoronary fat radiomics, CT-FFR, and clinicoradiological features

PURPOSE

People with both hypertension and coronary artery disease (CAD) are at a significantly increased risk of major adverse cardiovascular events (MACEs). This study aimed to develop and validate a combination model that integrates radiomics features of pericoronary adipose tissue (PCAT), CT-derived fractional flow reserve (CT-FFR), and clinicoradiological features, which improves MACE prediction within two years.

MATERIALS AND METHODS

Coronary-computed tomography angiography data were gathered from 237 patients diagnosed with hypertension and CAD. These patients were randomly categorized into training and testing cohorts at a 7:3 ratio (165:72). The least absolute shrinkage and selection operator logistic regression and linear discriminant analysis method were used to select optimal radiomics characteristics. The predictive performance of the combination model was assessed through receiver operating characteristic curve analysis and validated via calibration, decision, and clinical impact curves.

RESULTS

The results reveal that the combination model (Radiomics.

CLINICAL

Imaging) improves the discriminatory ability for predicting MACE. Its predictive efficacy is comparable to that of the Radiomics.Imaging model in both the training (0.886 vs. 0.872) and testing cohorts (0.786 vs. 0.815), but the combination model exhibits significantly improved specificity, accuracy, and precision. Decision and clinical impact curves further confirm the use of the combination prediction model in clinical practice.

CONCLUSIONS

The combination prediction model, which incorporates clinicoradiological features, CT-FFR, and radiomics features of PCAT, is a potential biomarker for predicting MACE in people with hypertension and CAD.

Inflammatory and Fibrosis Parameters Predicting CPET Performance in Males with Recent Elective PCI for Chronic Coronary Syndrome

Functional capacity (FC), ideally determined by a cardiopulmonary exercise test (CPET), is a valuable prognostic marker in chronic coronary syndrome (CCS). As CPET has limited availability, biomarkers of inflammation and/or fibrosis could help predict diminished FC. Our objective was to assess the value of galectin-3 (gal-3) and that of three inflammatory markers easily obtained from a complete blood count (NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio) and MLR (monocyte-to-lymphocyte ratio) in predicting diminished FC in males with recent elective percutaneous coronary intervention (PCI) for CCS. Our prospective study enrolled 90 males who had undergone elective PCI in the previous 3 months (mean age 60.39 ± 10.39 years) referred to a cardiovascular rehabilitation (CR) clinic between February 2023 and December 2024. All subjects received clinical examination, a cardiopulmonary stress test, transthoracic echocardiography and bloodwork. Based on percentage of predicted oxygen uptake (%VO2max), patients were classified in two subgroups-impaired FC (≤70%, n = 50) and preserved FC (>70%, n = 40). NLR, PLR and gal-3 were elevated in patients with poor FC and were significant predictors of diminished FC in multivariate analysis. PLR, NLR and gal-3 could guide referrals for CR for high-risk males with recent elective PCI.

Comparison of P2Y12 inhibitors and aspirin in secondary prevention of coronary events: a meta-analysis of RCTs

OBJECTIVE

This systematic review and meta-analysis compared the efficacy and safety of P2Y12 inhibitors versus aspirin monotherapy for secondary prevention in patients with coronary heart disease (CAD), providing evidence for clinical decision-making.

METHODS

Following the PRISMA and AMSTAR2 guidelines, a comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing P2Y12 inhibitors and aspirin monotherapy in CAD patients. The inclusion criteria focused on RCTs comparing P2Y12 inhibitors (clopidogrel, ticagrelor, and prasugrel) with aspirin. Studies that were non-randomized, did not focus on monotherapies with these agents, involved patients under 18 years old, or included non-CAD patients were excluded. The primary outcomes included myocardial infarction (MI) and stroke, while secondary outcomes comprised gastrointestinal complications, major bleeding, and mortality. The Cochrane Risk of Bias tool was used to assess the risk of bias. A random-effects model was applied to calculate risk ratios (RR) with 95% confidence intervals (CI), and sensitivity analyses were conducted to evaluate the robustness of the findings.

RESULTS

A total of 31,956 patients were included in the meta-analysis. P2Y12 inhibitors significantly reduced the risk of myocardial infarction (RR: 0.77, 95% CI: 0.67 to 0.89, I² = 0%, P < 0.001) and hemorrhagic stroke risk (RR: 0.53, 95% CI: 0.30 to 0.92, I² = 20.2%, P = 0.025). No statistically significant difference was observed in major bleeding (RR: 0.96, 95% CI: 0.71 to 1.30, I² = 63.8%, P = 0.814) or all-cause mortality (RR: 0.99, 95% CI: 0.85 to 1.15, I² = 30.3%, P = 0.877). Heterogeneity was assessed, and sensitivity analysis confirmed the robustness of the primary findings.

CONCLUSIONS

Compared with aspirin, P2Y12 inhibitors reduce risk of myocardial infarction and hemorrhagic stroke in the secondary prevention of CAD. However, there is no significant differences in major bleeding or all-cause mortality. Further research, including subgroup analyses and studies in diverse populations, is needed to validate these findings and explore genetic factors that may influence treatment outcomes.

Impact of anti-inflammatory diets on cardiovascular disease risk factors: a systematic review and meta-analysis

Introduction

Chronic inflammation, via multiple pathways, influences blood pressure and lipid profiles, serving as a significant risk factor for the onset of cardiovascular disease (CVD). Anti-inflammatory dietary patterns may ameliorate CVD risk factors through the modulation of inflammatory mediators and metabolic factors, potentially leading to improved cardiovascular outcomes. Current findings regarding the relationship between dietary habits and CVD risk factors, such as blood pressure and lipid levels, exhibit considerable variability. We performed a comprehensive systematic review and meta-analysis to explore the possible association between anti-inflammatory dietary patterns (such as the Mediterranean diet, DASH diet, Nordic diet, Ketogenic diet, and Vegetarian diet) and CVD risk factors.

Methods

We conducted a comprehensive search across five databases: PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure (CNKI). Ultimately, we identified 18 eligible randomized controlled trials (including randomized crossover trials), which were subjected to meta-analysis utilizing RevMan 5 and Stata 18.

Results

A comprehensive meta-analysis of these studies conducted based on random effects model indicated that, in comparison to an Omnivorous diet, interventions centered on anti-inflammatory diets were linked to significant reductions in Systolic Blood Pressure (SBP) (MD: -3.99, 95% CI: -6.01 to -1.97; p = 0.0001), Diastolic Blood Pressure (DBP) (MD: -1.81, 95% CI: -2.73 to -0.88; p = 0.0001), Low Density Lipoprotein Cholesterol (LDL-C) (SMD: -0.23, 95% CI: -0.39 to -0.07; p = 0.004), Total Cholesterol (TC) (SMD: -0.31, 95% CI: -0.43 to -0.18; p < 0.00001) and High-sensitivity C-reactive Protein (hs-CRP) (SMD: -0.16, 95% CI: -0.31 to -0.00; p = 0.04). No notable correlations were identified between High Density Lipoprotein Cholesterol (HDL-C) and Triglycerides (TG).

Discussion

The findings indicate that anti-inflammatory diets may lower serum hs-CRP levels and positively influence the reduction of CVD risk factors, such as blood pressure and lipid profiles, thereby contributing to the prevention and progression of cardiovascular conditions. Most of the outcome indicators had low heterogeneity; sensitivity analyses were subsequently conducted on outcome measures demonstrating substantial heterogeneity, revealing that the findings remained consistent.

Inflammation and platelet hyperresponsiveness in coronary artery disease and the influence of Talin-1/αIIbβ3-mediated bidirectional signaling pathway

Background

While platelet hyperreactivity constitutes an independent risk factor for major adverse cardiovascular events (MACEs) in coronary artery disease, its molecular underpinnings remain poorly characterized. Recent advances in transcriptomic profiling have revealed potential associations with specific RNA signatures. Through systematic bioinformatics analysis of differential gene expression patterns and pathway activation in CHD patients, this study aims to elucidate key molecular regulators of platelet hyperactivity, establishing a theoretical framework for developing precision therapeutic strategies to mitigate post-CHD complications.

Methods

This randomized controlled study included 16 CHD patients and 16 healthy controls. Inflammation markers, platelet aggregation function, and CD62p levels were assessed using flow cytometry. Mitochondrial morphology and organelles were observed using scanning electron microscopy and transmission electron microscopy. Genes related to symptom alteration between CHD patients and healthy controls were identified using the criteria of p < 0.05. The molecular correlations of these genes were analyzed using a comprehensive perspective that included Gene Ontology (GO) biological process and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Western blot and correlation analyses were also conducted to validate the expression and diagnostic value of the DEGs.

Results

CHD patients exhibited alterations in platelet organelles ultrastructure, heightened platelet activation and aggregation, and disturbance of the inflammatory equilibrium. RNA sequencing demonstrated distinct changes in the gene expression profiles of circulating platelets from CHD patients. The increase in platelet activation and aggregation could be partially associated with the upregulation of the Talin-1 and αIIbβ3 proteins expression.

Conclusion

Abnormal transcription and platelet activation occur after CHD onset, and upregulation of the Talin-1/αIIbβ3-mediated bidirectional signaling pathway are the primary pathological features.

Clinical Trial Registration

https://www.chictr.org.cn/, identifier ChiCTR2100041998.

The Role of Dietary Education in Cardiac Rehabilitation

Cardiovascular disease remains a leading cause of death globally; however, most cases could be prevented by addressing modifiable risk factors, such as unhealthy lifestyle factors, including diet. These aspects are also crucial in secondary prevention. Cardiac rehabilitation programs are vital in improving cardiovascular outcomes, and apart from recommended pharmacotherapy, they focus on lifestyle modifications, including exercise, a healthy diet, and smoking cessation. The aim of this review was to summarize the evidence on the role of dietary education in cardiac rehabilitation programs. The available data show that nutritional recommendations play an important role in cardiac rehabilitation programs, with the Mediterranean diet being widely recommended for its cardiovascular benefits. Adherence to dietary recommendations in the course of cardiac rehabilitation has been linked to improved metabolic and cardiovascular outcomes; however, further studies with long-term follow-up are needed. Moreover, while challenges in following dietary recommendations exist, individualized care and support are essential for successful outcomes in cardiac rehabilitation programs. Including dietary education is an important part of cardiac rehabilitation after myocardial infarction; however, more studies are needed to investigate the role of individualized dietary support and personalized education in cardiac rehabilitation.

Deep learning analysis of exercise stress electrocardiography for identification of significant coronary artery disease

Background

The diagnostic power of exercise stress electrocardiography (ExECG) remains limited. We aimed to construct an artificial intelligence (AI)-based method to enhance ExECG performance to identify patients with significant coronary artery disease (CAD).

Methods

We retrospectively collected 818 patients who underwent both ExECG and coronary angiography (CAG) within 6 months. The mean age was 57.0 ± 10.1 years, and 614 (75%) were male patients. Significant coronary artery disease was seen in 369 (43.8%) CAG reports. We also included 197 individuals with normal ExECG and low risk of CAD. A convolutional recurrent neural network algorithm, integrating electrocardiographic (ECG) signals and features from ExECG reports, was developed to predict the risk of significant CAD. We also investigated the optimal number of inputted ECG signal slices and features and the weighting of features for model performance.

Results

Using the data of patients undergoing CAG for training and test sets, our algorithm had an area under the curve, sensitivity, and specificity of 0.74, 0.86, and 0.47, respectively, which increased to 0.83, 0.89, and 0.60, respectively, after enrolling 197 subjects with low risk of CAD. Three ECG signal slices and 12 features yielded optimal performance metrics. The principal predictive feature variables were sex, maximum heart rate, and ST/HR index. Our model generated results within one minute after completing ExECG.

Conclusion

The multimodal AI algorithm, leveraging deep learning techniques, efficiently and accurately identifies patients with significant CAD using ExECG data, aiding clinical screening in both symptomatic and asymptomatic patients. Nevertheless, the specificity remains moderate (0.60), suggesting a potential for false positives and highlighting the need for further investigation.

Cancer-Therapy-Related Cardiac Dysfunction: Latest Advances in Prevention and Treatment

The increasing efficacy of cancer therapies has significantly improved survival rates, but it has also highlighted the prevalence of cancer-therapy-related cardiac dysfunction (CTRCD). This review provides a comprehensive overview of the identification, monitoring, and management of CTRCD, a condition resulting from several treatments, such as anthracyclines, HER2-targeted therapies, target therapies, and radiotherapy. The paper includes a discussion of the mechanisms of CTRCD associated with various cancer treatments. Early detection through serum biomarkers and advanced imaging techniques is crucial for effective monitoring and risk stratification. Preventive strategies include pharmacological interventions such as ACE inhibitors/angiotensin receptor blockers, beta-blockers, and statins. Additionally, novel agents like sacubitril/valsartan, sodium-glucose co-transporter type 2 inhibitors, and vericiguat show promise in managing left ventricular dysfunction. Lifestyle modifications, including structured exercise programs and optimized nutritional strategies, further contribute to cardioprotection. The latest treatments for both asymptomatic and symptomatic CTRCD across its various stages are also discussed. Emerging technologies, including genomics, artificial intelligence, novel biomarkers, and gene therapy, are paving the way for personalized approaches to CTRCD prevention and treatment. These advancements hold great promise for improving long-term outcomes in cancer patients by minimizing cardiovascular complications.

Characteristics and clinical impact of coronary computed tomography angiography following exercise stress testing for evaluating coronary artery disease

Exercise stress testing (EST) remains effective in assessing coronary artery disease (CAD), especially in developing countries, while coronary computed tomography angiography (CCTA) is being increasingly utilized. However, limited data exist on whether CCTA following EST can affect diagnosis or treatment. This study aimed to characterize patients who underwent CCTA following EST and evaluate its clinical impact. Consecutive patients who underwent CCTA after EST for CAD assessment between 2014 and 2021 were included in the study. CCTA results were categorized as obstructive CAD, nonobstructive CAD, and normal. Clinical and EST characteristics were compared among groups. Multivariable logistic regression analysis was used to identify independent predictors of obstructive CAD. The diagnostic impact and therapeutic consequences of CCTA were assessed at the subsequent clinic visits. A total of 209 patients (64% male, age 60 ± 10 years) with 26% known CAD were included. The most common indication for CCTA was an inconclusive EST (31%). CCTA revealed obstructive CAD in 53 patients, nonobstructive CAD in 111 patients, and normal results in 45 patients. Multivariable analysis identified hyperlipidemia (odds ratio 3.60, 95% confidence interval 1.27-10.22, P = .01) and the Duke Treadmill Score (odds ratio 0.86, 95% confidence interval 0.80-0.92, P < .001) as independent predictors of obstructive CAD. CCTA had a diagnostic impact on 69% of all patients (76% for patients with no known CAD and 50% for patients with known CAD), including the exclusion of obstructive CAD in patients with a positive EST; the diagnosis of obstructive CAD, nonobstructive CAD, or normal CCTA in patients with an inconclusive EST; and the diagnosis of both obstructive and nonobstructive CAD in patients with a negative EST. Therapeutically, CCTA led to medication changes in 38% of patients, while 24% underwent invasive procedures. In conclusion, among patients undergoing CCTA following EST for CAD assessment, hyperlipidemia and the Duke Treadmill Score were identified as independent predictors of obstructive CAD. CCTA also had significant diagnostic and therapeutic impacts in this population.

Long-term clinical significance of the presence of puff-chandelier ruptures detected by non-obstructive aortic angioscopy

Although studies have reported various patterns of atherosclerotic aortic plaques (AAPs) detected by non-obstructive aortic angioscopy (NOA), the long-term outcomes associated with AAPs such as puff-chandelier rupture atheromatous plaque (PCR), remain unclear. This study investigated the long-term prognostic significance of AAPs detected by NOA in patients who underwent percutaneous coronary intervention (PCI). This retrospective multicenter cohort study included 167 patients who underwent PCI and NOA. The association between AAPs and the incidence of major adverse cardiac events (MACE) were assessed. MACE was categorized into: MACE1, including cardiac death, myocardial infarction, stroke, and ischemia-driven unplanned revascularization; and MACE2, including cardiac death, myocardial infarction, and stroke. There were no NOA-related complications. Of all AAPs, only PCR showed a significant prognostic value during the follow-up period (mean follow-up period: 6.3 years [range 5.9-6.6]). In multivariable Cox proportional hazards analysis, PCR was an independent predictor of MACE (MACE1; HR 1.91, 95% CI 1.04-3.49, P = 0.04, MACE2; hazard ratio [HR] 4.52, 95% confidence interval [CI] 1.23-16.57, P = 0.02). Kaplan-Meier analysis revealed that PCR was significantly associated with MACE. NOA during PCI is safe and feasible. Detecting PCR by NOA may provide reliable information for identifying patients at high risk of subsequent long-term adverse events after PCI.

Dynamic handgrip exercise for the detection of myocardial ischemia using fast Strain-ENCoded cardiovascular magnetic resonance

BACKGROUND

Previous data suggest dynamic handgrip exercise (DHE) as a potential physiological, needle-free stressor feasible for cardiovascular magnetic resonance (CMR) examinations. DHE-fast Strain-ENCoded imaging (fSENC) is potentially cost-saving, ultra-fast and avoids pharmacological side effects thereby targeting the drawbacks of conventional pharmacological stress CMR.

OBJECTIVES

To assess the diagnostic accuracy of DHE-fSENC for detecting ischemia-related wall motion abnormalities in suspected obstructive coronary artery disease (CAD).

METHODS

Patients with known or suspected obstructive CAD referred for CMR stress testing were prospectively enrolled. Diagnostic accuracy was assessed in comparison to pharmacological stress CMR and in a subgroup, compared to invasive coronary angiography (ICA). The CMR protocol was extended by both-handed DHE with 80 repetitions per minute over 2 min followed by fSENC short-axis acquisition before pharmacological stress testing. Stress-induced impairment of regional longitudinal strain was graded suspicious for obstructive CAD.

RESULTS

Two-hundred sixty individuals with cardiovascular high-risk profile (64±13years, 75% male) were enrolled. DHE-fSENC provided a sensitivity of 79% (95% CI: 64-89) and specificity of 87% (95% CI 82-91) compared to pharmacological stress CMR. In a subgroup of 105 patients with recent ICA, high diagnostic accuracy was found for the detection of obstructive CAD (sensitivity 82% [95% CI: 67-92], specificity 89% [95% CI: 78-95]). Exam duration of DHE-fSENC was significantly reduced compared to conventional CMR stress protocols (DHE-fSENC 207±69 s vs. adenosine-perfusion 287±82 s vs. dobutamine-cine 1132±294 s, all p<0.001).

CONCLUSION

DHE-fSENC allows for a reliable and fast detection of obstructive CAD, thereby expanding the applicability of needle-free CMR stress testing.

High-Throughput Screening for Prescribing Cascades Among Real-World Angiotensin-II Receptor Blockers (ARBs) Initiators

Objective

Angiotensin-II Receptor Blockers (ARBs) are commonly prescribed; however, their adverse events may prompt new drug prescription(s), known as prescribing cascades. We aimed to identify potential ARB-induced prescribing cascades using high-throughput sequence symmetry analysis.

Methods

Using claims data from a national sample of Medicare beneficiaries (2011-2020), we identified new ARB users aged ≥66 years with continuous enrollment ≥360 days before and ≥180 days after ARB initiation. We screened for initiation of 446 other (non-antihypertensive) 'marker' drug classes within ±90 days of ARB initiation, generating sequence ratios (SRs) reflecting proportions of ARB users starting the marker class after versus before ARB initiation. Adjusted SRs (aSRs) accounted for prescribing trends over time, and for significant aSRs, we calculated the naturalistic number needed to harm (NNTH); significant signals were reviewed by clinical experts for plausibility.

Results

We identified 320,663 ARB initiators (mean ± SD age 76.0 ± 7.2 years; 62.5% female; 91.5% with hypertension). Of the 446 marker classes evaluated, 17 signals were significant, and three (18%) were classified as potential prescribing cascades after clinical review. The strongest signals ranked by the lowest NNTH included benzodiazepine derivatives (NNTH 2130, 95% CI 1437-4525), adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (NNTH 2656, 95% CI 1585-10074), and other antianemic preparations (NNTH 9416, 95% CI 6606-23784). The strongest signals ranked by highest aSR included other antianemic preparations (aSR 1.7, 95% CI 1.19-2.41), benzodiazepine derivatives (aSR 1.18, 95% CI 1.08-1.3), and adrenergics in combination with anticholinergics, including triple combinations with corticosteroids (aSR 1.12, 95% CI 1.03-1.22).

Conclusion

The identified prescribing cascade signals reflected known and possibly under-recognized ARB adverse events in this Medicare cohort. These hypothesis-generating findings require further investigation to determine the extent and impact of these prescribing cascades on patient outcomes.

Accuracy of instantaneous wave-free ratio and fractional flow reserve derived from single coronary angiographic projections

BACKGROUND

Angiography-derived fractional flow reserve (FFR) software has been developed using pressure wire based FFR as the reference, however most software requires 2 angiographic views ≥25 degrees apart limiting their clinical utility. This study aims to validate in a prospective multi-center registry the diagnostic performance of a novel angiography derived instantaneous wave-free ratio (Angio-iFR, Royal Philips, Amsterdam) with pressure wire-based iFR as reference.

METHODS

Coronary angiograms were obtained from patients with coronary artery lesions of between 40% and 90% severity and both iFR and FFR measurements. The pressure wire's position was documented during contrast injection in 2 angiographic views. Angio-iFR/FFR was computed at this exact position by independent corelab analysts blinded to physiological data. The primary end point was the sensitivity and specificity of the Angio-iFR compared to the corresponding invasively measured iFR values. The study was powered to meet prespecified performance goals for sensitivity (75%) and specificity (80%).

RESULTS

A total of 441 patients were enrolled in 32 centers in Europe, Japan, and the United States. Paired Angio-iFR and wire-iFR were available in 398 vessels. The mean iFR was 0.90 (standard deviation: 0.11) with 31.9% of vessels having an iFR≤0.89. Angio-iFR software showed excellent feasibility (97%), and a median analysis time of 55 s. The per-vessel sensitivity and specificity of Angio-iFR was 77% (95% confidence interval [CI]: 69%-84%) and 49% (95% CI: 41%-54%) respectively, which fell below the performance goals.

CONCLUSIONS

Angio-iFR did not achieve prespecified diagnostic performance against pressure wire-based iFR. Further software refinements are warranted.

TRIAL REGISTRATION

Radiographic Imaging Validation and EvALuation for Angio iFR (ReVEAL iFR), NCT0385750, https://clinicaltrials.gov/study/NCT03857503.

MicroRNA-143-3p and miR-452-5p: A Fingerprint for the Diagnosis of Aortic Stenosis in the Geriatric Population

Background/Objectives: Aortic stenosis (AS) is the most common valvular pathology in the geriatric population and is the primary cause of valve replacement. However, misdiagnoses and delays in treatment are common due to comorbidities, frailty, and sedentary lifestyles among elderly individuals. MicroRNAs (miRNAs) are highly conserved molecular regulators involved in various cellular processes and have gained recognition as reliable biomarkers in cardiovascular diseases. In the present study, we evaluated plasma miRNAs as potential biomarkers for the early diagnosis of AS in the geriatric population to identify early therapeutic strategies. Methods: This prospective, case-control study included 87 individuals over 75 years of age. The participants were divided into AS (n = 58) and control (n = 29) groups. Results: Fifty-four miRNAs were differentially expressed between patients with AS and controls. Among those genes, 29 were upregulated and 25 were downregulated in patients with AS relative to controls. We selected seven candidate genes (miR-185-5p, miR-143-3p, miR-370-3p, let-7d-3p, miR-452-5p, miR-6787-3p, and miR-21-3p) for experimental validation by qRT-PCR. Only miR-143-3p and miR-452-5p were significantly upregulated in the plasma of patients with AS compared with controls. We developed a multiparametric model by combining the two-miRNA signature with echocardiographic parameters (left ventricular ejection fraction, stroke volume, and global longitudinal strain) to increase diagnostic power; this model yielded sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) values of 78.2%, 70.7%, and 0.837, respectively. Conclusions: In clinical practice, the use of a multiparametric model involving this set of miRNAs combined with echocardiographic variables may improve the accuracy of AS diagnosis and risk stratification.

High Sensitivity Cardiac Troponin T Versus Cardiac Troponin I on Prediction of Significant Coronary Artery Disease in Patients Hospitalized Due to Symptomatic Atrial Fibrillation

Background/Objectives: Patients with atrial fibrillation (AF) often have symptoms and risk factors similar to those of patients with coronary artery disease (CAD). However, the clinical criteria for identifying AF patients who would benefit from coronary angiography (CA) remain vague. We evaluated the predictive value of cardiac troponin I (cTnI), high-sensitivity cardiac troponin T (hs-cTnT), and various clinical parameters for detecting significant coronary artery stenosis. Methods: We retrospectively analyzed symptomatic AF patients admitted to the University Hospital Bonn emergency department between 2015 and 2019 undergoing CA. Out of 183 AF patients, 93 were screened with cTnI and 90 with hs-cTnT. Results: A total of 47 out of 183 (26%) AF patients were diagnosed with significant coronary artery stenosis. The sensitivity for detecting CAD requiring intervention was 62.5% [95% CI, 40.6-81.2%] for cTnI and 100% [95% CI, 85.2-100%] for hs-cTnT. Median hs-cTnT concentrations were significantly higher in the "Revascularization-group" than in the "Non-Revascularization-group" (30.05 ng/L [95% CI, 26.5-54.8 ng/L], 23 patients vs. 15.3 ng/L [95% CI, 12.7-22.5 ng/L], 67 patients, p < 0.001). The calculated regression model that includes age, history of CAD, and hs-cTnT showed the best pretest performance with an AUC of 0.83, p = 0.008. Poor performance was observed for cTnI (AUC of 0.63, p = 0.098). Conclusions: This study demonstrates that the hs-cTnT assay is superior to the contemporary cTnI assay in predicting significant CAD requiring revascularization in patients hospitalized with AF. Older age, pre-existing CAD, impaired renal function, and a higher hs-cTnT cut-off showed the highest pretest probability of relevant CAD in patients hospitalized for AF.

Ultra-processed foods and coronary artery disease severity: a cross-sectional study of at-risk normal-weight and overweight patients undergoing elective angiography

INTRODUCTION

There is growing interest in the connection between ultra-processed food (UPF) and cardiovascular diseases. This study explores how UPF intake relates to the severity of coronary artery disease (CAD) in at-risk patients undergoing elective angiography.

METHODS

Data covering demographic, and clinical details, and dietary intakes (using a validated food frequency questionnaire) were gathered from the Nutrition Heshmat Registry (NUTHER) in Rasht, Iran. UPF consumption was evaluated using the NOVA food classification system, with the exception of core grain foods. The study comprised 1,015 participants, who were classified based on the severity of CAD using the Gensini score (severe-CAD = Gensini score ≥ 60). Logistic regression was used to analyze the odd ratio (OR) and 95%confidence interval (95%CI) for severe-CAD across UPF quartiles (percentage of energy), and for each 10% increase in UPF intake. Restricted cubic spline (RCS) regression was employed to explore nonlinear relationships between UPF and severe-CAD.

RESULTS

Following controlling for potential confounders, normal-weight participants in the highest quartile of UPF exhibited about 5 times greater odds of severe-CAD than those in the lowest category (OR(95%CI): 5.01 (1.89, 13.29); P-for-trend = 0.002). Overweight/obese participants in the higher UPF quartiles had approximately 2-3.5 times greater odds for severe-CAD than those in the 1st quartile (ORs (95%CIs): 3rd quartile 1.91 (1.14, 3.21); and 4th quartile: 3.53 (2.07, 5.99); P-for-trend < 0.001). Each 10% increase in daily energy intake from UPF was associated with about 1.6-2 times increased severe-CAD risk among overweight/obese and normal-weight individuals (ORs (95%CIs) of 1.64 (1.28, 2.11), and 2.24 (1.24, 4.05), respectively). RCS analysis showed an upward trend toward higher UPF intake in relation to increased risk of severe-CAD (P-for-overall-trend < 0.0001; P-for-nonlinearity = 0.005).

CONCLUSION

The findings obtained underscore a direct association between UPF and the risk of CAD progression among at-risk patients, independent of BMI. However, further prospective studies are essential to confirm these results and better understand this relationship.

Built Environment and Cardiovascular Diseases - Insights from a Global Review

PURPOSE OF REVIEW

This narrative review aims to synthesize global literature on the relationship between cardiovascular diseases (CVD) and components of built environment (green spaces, walkability, food environment, accessibility and availability of recreational and healthcare facilities, and effects of air and noise pollution).

RECENT FINDINGS

Increased green space and neighborhood walkability are associated with lower CVD mortality and morbidity; however, benefits have shown differential effects by socioeconomic status (SES). Air pollution is a leading environmental risk factor contributing to CVDs, and it disproportionately impacts low SES populations and women. Findings on relationships between food environment and CVDs are inconsistent and limited. This global review reports on the multifactorial and complex relationship between built environment and higher CVD risk and poor CVD outcomes. Future research can address an unmet need to understand this relationship with further depth and breadth, and to investigate resulting health disparities.

Cardiovascular screening and long-term outcomes in aircraft pilots

BACKGROUND

Pilots face significant occupational risks affecting cardiometabolic health and are subject to regulatory health screenings. Cardiometabolic risk factors, cardiac screening findings and outcomes among pilots have not been well reported.

OBJECTIVES

This study aimed to investigate cardiac evaluations of asymptomatic aircraft pilots and the association between clinical risk factors and outcomes.

METHODS

Asymptomatic aircraft pilots referred for cardiac assessment between January 1991 and May 2023 were studied. Baseline characteristics, cardiac test findings and outcomes were evaluated. Major adverse clinical event (MACE) was defined as death, myocardial infarction, stroke, major arrhythmia, heart failure event or cardiac-related hospitalisation and estimated using Kaplan-Meier methods. Significant valvular disease by echocardiography was defined as stenosis, regurgitation or prolapse of moderate severity or greater. Aortic dilation by transthoracic echocardiogram (TTE) was defined as measuring ≥40 mm in diameter.

RESULTS

212 pilots met eligibility criteria for the study. The majority were white (92.9%) and male (91%) with a mean age of 58.5±10.9 years. Mean body mass index was 27.8±4.8 with comorbid hyperlipidaemia (48%), hypertension (32%), prior cancer (27%), sleep apnoea (15%), arrhythmia (12%) and known coronary artery disease (6%). Imaging revealed significant valvular disease (2.4%) and dilated aortas (16%) based on TTEs. Functional cardiac testing performed showed mean functional aerobic capacity of 109±24.6% reaching 11.89±2.65 metabolic equivalents with <8% showing positive findings per EKG or wall motion abnormalities on exercise TTE. Six patients received coronary angiography based on clinical evaluation, with two undergoing percutaneous coronary intervention. Over a 32-year period with a median (range) follow-up of 5.15 (0.1, 31.82) years, MACE incidence was 15%.

CONCLUSIONS

Asymptomatic aircraft pilots have underlying cardiovascular risk factors but good overall functional capacity, long-term outcomes and life expectancy. Prevalence of cardiac structural findings like aortic dilatation warrants increased attention during examination of these patients.

Physical activity, frailty, and kinesiophobia among older adult patients with coronary heart disease in China

BACKGROUND

Physical activity (PA) offers advantages in the secondary prevention of coronary heart disease (CHD). However, in older adults, frailty and kinesiophobia may exert negative influences on PA engagement.

OBJECTIVE

To investigate PA, frailty, and kinesiophobia among older adult patients with CHD in China.

METHODS

This cross-sectional study enrolled older adult patients with CHD in the cardiac outpatient care unit of the *** University. The International Physical Activity Questionnaire, the Frailty Phenotype Scale, and the Tampa Scale of Kinesiophobia were used to evaluate PA, frailty, and kinesiophobia, respectively.

RESULTS

A total of 239 participants (mean age: 72.0 ± 7.5 years, 148 males) were enrolled. The rates of frailty and pre-frailty were 20.5 % and 46.4 %, respectively. The mean kinesiophobia score was 43.13±5.48. The median metabolic equivalent of task of PA was 2784 MET-min/week, and 25.1 % of the patients did not reach the minimum recommended by AHA (150 mins/week). Spearman rank correlation analysis showed that PA was negatively correlated with frailty (r = -0.559, P < 0.001) and kinesiophobia (r = -0.463, P < 0.001). Multivariable logistic regression analysis showed that frailty [OR = 0.412, 95 % confidence interval (CI): 0.304-0.559, P < 0.001] and kinesiophobia (OR=0.936, 95 % CI: 0.879-0.997, P = 0.040) were independently associated with PA after adjustment for age, cardiovascular adverse events, comorbidities, Barthel index, and history of dizziness.

CONCLUSIONS

Older adult patients with CHD had low levels of PA. Frailty and kinesiophobia were independently associated with PA in older adult patients with CHD. Reversing frailty and reducing kinesiophobia in older adult patients with CHD may increase PA levels.

Impact of lipoprotein (a) on coronary atherosclerosis and plaque progression in patients with type 2 diabetes mellitus

OBJECTIVES

To explore the association between baseline Lp (a) levels and high-risk plaques, plaque volume, and plaque progression in patients with diabetes mellitus.

METHODS

Patients with diabetes mellitus and intermediate pretest probability of coronary artery disease (CAD) were prospectively enrolled. All patients underwent baseline coronary computed tomography angiography (CCTA), and patients with recurrent symptoms underwent mid-term follow-up CCTA. Plaque quantification and qualification were performed to compare coronary atherosclerosis features and plaque progression between the elevated and normal Lp (a) groups.

RESULTS

In this study, 1694 subjects (mean age: 62.0 ± 7.0 years; 1031 males) were enrolled for baseline analysis, and 246 subjects with repeat CCTA (mean interval of 2.3 ± 0.74 years) were included for follow-up analysis. The total plaque volume, noncalcified plaque volume, low attenuation plaque (LAP) volume, fibro-fatty plaque volume, and fibrotic plaque volume were higher in the elevated Lp (a) group than in the normal Lp (a) group at baseline (all p < 0.001). At follow-up, the elevated Lp (a) group showed a higher mean annual increase in LAP volume than the normal Lp (a) group (3.03 ± 22.26 mm3 vs -3.09 ± 12.22 mm3; p = 0.011). In multivariate linear regression analysis, elevated Lp (a) levels were associated with accelerated LAP volume progression after adjusting for confounders (Beta = 4.50, 95% confidence interval: 0.06-8.93; p = 0.045).

CONCLUSION

Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up.

KEY POINTS

Question The relationship between Lp (a) levels and coronary artery plaque volume and progression in patients with diabetes mellitus remains unclear. Findings Elevated Lp (a) level was associated with high total coronary plaque volume at baseline and low-attenuation plaque (LAP) volume progression at follow-up. Clinical relevance Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up, which supports the modulation of LAP level to improve prognosis.

Association of P2RY12 Gene Variants and Non-Genetic Factors With Clopidogrel Responsiveness in Vietnamese Patients After Percutaneous Coronary Intervention: A Cross-Sectional Study

BACKGROUND

Clopidogrel response varies significantly among individuals due to multiple influencing factors. This study aimed to investigate the associations between P2RY12 gene variants, non-genetic factors, and platelet aggregation in patients undergoing clopidogrel therapy and percutaneous coronary intervention.

METHODS

We conducted a cross-sectional descriptive study involving 171 patients who successfully underwent coronary artery stenting and were treated with clopidogrel at two military hospitals in Vietnam. Platelet aggregation was assessed using the light transmission aggregometry (LTA) method, with clopidogrel resistance (CR) defined as maximal platelet aggregation > 50%. P2RY12 genetic polymorphisms (C34T-rs6785930 and G52T-rs6809699) were genotyped using Sanger sequencing.

RESULTS

The allele frequencies were 74.56% (C) and 25.44% (T) for P2RY12 C34T, and 88.30% (G) and 11.70% (T) for P2RY12 G52T. Platelet aggregation progressively increased across the GG, GT, and TT genotypes of P2RY12 G52T (p = 0.03), with patients carrying the TT genotype exhibiting significantly higher platelet aggregation compared to other genotypes (p = 0.01). Among non-genetic factors, proton pump inhibitor (PPI) intake was associated with a significant increase in platelet aggregation (p = 0.03). The prevalence of clopidogrel resistance (CR) was 43.86%. Multivariate logistic regression analysis identified the T allele of P2RY12 C34T, reduced estimated glomerular filtration rate (eGFR), and PPI intake as significant risk factors for CR (OR = 2.24, 2.49, 4.01; p = 0.02, 0.049, 0.01, respectively).

CONCLUSIONS

The T allele of P2RY12 C34T was associated with an increased risk of CR. Among non-genetic factors, PPI intake significantly elevated platelet aggregation and, along with reduced eGFR, contributed to a higher risk of CR.

High-Throughput Screening for Prescribing Cascades Among Real-World Angiotensin-Converting Enzyme Inhibitor Initiators

PURPOSE

Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed, but their adverse effects may prompt new drug prescription(s), known as prescribing cascades (PCs). We aimed to identify potential ACEI-induced PCs using high-throughput sequence symmetry analysis.

METHODS

Using claims data from a national sample of Medicare beneficiaries (2011-2020), we identified new ACEI users aged ≥ 66 years with continuous enrollment ≥ 360 days before and ≥ 180 days after ACEI initiation. We screened for initiation of 446 other (non-antihypertensive) "marker" drug classes within ±90 days of ACEI initiation, generating sequence ratios (SRs) reflecting proportions of ACEI users starting the marker class after versus before ACEI initiation. Adjusted SRs (aSRs) accounted for prescribing trends over time. For significant aSRs, we calculated the naturalistic number needed to harm (NNTH), and significant signals underwent clinical review for plausibility.

RESULTS

We identified 308 579 ACEI initiators (mean age 76.1 ± 7.5 years; 59.6% female; 88.6% with hypertension). Of 446 marker classes evaluated, 81 signals were significant, and 42 (52%) classified as potential PCs after clinical review. The strongest signals ranked by lowest NNTH included corticosteroids (NNTH 313; 95% CI, 262-392) and serotonin type 3 (5-HT3) antagonists (NNTH 496; 95% CI, 392-689); the strongest signals ranked by highest aSR included sympathomimetics (aSR, 1.97; 95% CI, 1.10-3.53) and other antianemic preparations (aSR, 1.87; 95% CI, 1.31-2.67).

CONCLUSION

Identified prescribing cascade signals were indicative of known and possibly underrecognized ACEI adverse events in this Medicare cohort. The findings are hypothesis-generating and require further investigation to determine the extent and impact of the identified PCs on health outcomes.

Clinical impact of CCT-FFR as first-strategy in patients with symptomatic stable coronary artery disease: A systematic review and meta-analysis

AIMS

Despite the promising results, the clinical implications of the CCT-FFR is already debated. This metanalysis aimed to determine the potential benefits of incorporating FFRCT into stable CAD management.

METHODS

After searching for studies comparing outcomes of patients with suspected stable CAD who underwent CCT-FFR as a first strategy versus non-urgent cardiovascular testing after a clinical judgment, we calculated odds ratios (ORs) and 95 ​% confidence intervals (CIs) using a random-effects or fixed-effects meta-analysis model depending on heterogeneity significance.

RESULTS

5 studies (3 RCTs and 2 observational studies) globally encompassing 5282 patients (CCT-FFR ​= ​2604 patients, Control Group ​= ​2678 patients) were included in the quantitative analysis. The rates of ICA overall (OR 1.57, 95%CI 1.36-1.81, p value ​< ​0.001) and those without obstructive CAD (OR 6.63, 95%CI 4.79-9.16, p value ​< ​0.001) were reduced in the CCTAFFR group, as compared to the control group. Moreover, CCT-FFR patients underwent coronary revascularization more frequently than patients in the control arm (OR 0.48,CI 0.38-0.62, p value ​< ​0.001). There was no significance difference between the two strategies in terms of 1 year MACE (OR 1.11,CI 0.86-1.44, p value 0.42), nonfatal MI (OR 0.73, CI 0.41-1.33, p value 0.31), all-cause mortality (OR 1.29,CI 0.47-3.54, p value 0.63) and unplanned revascularization for angina (OR 0.99, 95%CI 0.65-1.49, p value 0.95).

CONCLUSIONS

In conclusion, in the management of stable CAD, the use of CCT-FFR was associated with lower overall rates of ICA but higher rates of coronary revascularization with comparable 1-year clinical impact.