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

Prognostic significance of dobutamine stress echocardiography in patients with chronic kidney disease and known or suspected coronary artery disease: a 5-year follow-up study

Dobutamine stress echocardiography (DSE) is an effective noninvasive modality for evaluating coronary artery disease (CAD), with high accuracy. However, data on the prognostic value of DSE in patients with chronic kidney disease (CKD) are limited. This study aims to assess the prognostic significance of DSE in patients with CKD and known or suspected CAD. We included consecutive patients with CKD stage 3 or higher and known or suspected CAD who underwent clinically indicated DSE between 2007 and 2017. The primary endpoint was all-cause mortality at 5 years. Univariable and multivariable analyses were conducted to identify predictors of all-cause mortality, with a p value < 0.05 considered statistically significant. A total of 274 patients were included in the study. The mean age was 64.0 ± 13.1 years, with 54% being male and 13.1% having known CAD. Among the patients, 64.6% had advanced CKD (≥ stage 4). Abnormal DSE was observed in 62 patients (22.6%). During a follow-up period of 7.0 ± 3.5 years, 78 patients (28.5%) died. The mortality rate was significantly higher in patients with abnormal DSE compared to those with normal DSE (48.4% vs. 22.6%, p < 0.001). Multivariable analysis identified age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.008-1.05, p = 0.005), New York Heart Association (NYHA) functional class (HR 1.60, 95% CI 1.05-2.43, p = 0.03), and chronotropic index < 0.73 (HR 2.61, 95% CI 1.60-4.25, p < 0.001) as independent predictors of mortality. Conversely, a normal DSE result was found to be a protective factor (HR 0.49, 95% CI 0.30-0.81, p = 0.005). In conclusion, DSE demonstrated significant prognostic value in patients with CKD and known or suspected CAD. Age, NYHA functional class, and a chronotropic index < 0.73 were identified as independent predictors of all-cause mortality.

A Novel Disulfidptosis-Related Diagnostic Gene Signature and Differential Expression Validation in Ischaemic Cardiomyopathy

Ischaemic cardiomyopathy (IC) predominantly arises from prolonged deprivation of oxygen in the coronary arteries, resulting in compromised cardiac contractility or relaxation. This study investigates the role of disulfidptosis-associated genes (DiGs) in IC. Through the analysis of datasets GSE5406 and GSE57338, we explored the association between DiGs and immune characteristics to identify crucial genes contributing to IC development. The support vector machine model emerged as the most effective, identifying key genes such as MYH9, NUBPL, MYL6, MYH10 and NCKAP1. Validation with independent datasets GSE57345, GSE48166 and single-cell GSE145154 further supported these findings, demonstrating high predictive accuracy. Experimental validation in an IC mouse model, using Western blot, immunohistochemistry and RT-qPCR, confirmed the altered expression of these core genes in myocardial ischaemic regions. This research not only elucidates the significance of DiGs in IC but also underscores the diagnostic potential of identified core genes.

Perivascular fat attenuation index (FAI) on computed tomography coronary angiography reclassifies individual cardiovascular risk estimation

Background

The perivascular fat attenuation index (FAI) detects and quantifies coronary inflammation by measuring phenotypic changes in perivascular adipose tissue by using computed tomography coronary angiography images.

Aim

The primary objective of this study was to evaluate the reclassification of cardiovascular (CV) risk after incorporating perivascular FAI assessment in currently used risk score algorithms.

Methods

This was a single-center, retrospective study of 200 patients with suspected coronary artery disease who underwent computed tomography coronary angiography in clinical practice between January 2022 and May 2022. From the patients who met the inclusion criteria, we included 50 patients with the highest CV risk according to the U-prevent calculator score to perform the perivascular FAI analysis. High perivascular FAI was defined as either a FAI-Score of ≥75th percentile in the left anterior descending artery or right coronary artery, or ≥95th percentile in the left circumflex artery.

Results

In 62 % of the patients, there was a reclassification in CV risk after perivascular FAI assessment; individual risk was upgraded in 22 % of patients and in 40 % their risk was downgraded. The presence of any plaque (72.7 % vs. 94.1 %; P = 0.032) and the proportion of patients with moderate-to-high coronary artery calcium score (≥100 Agatston units) was higher in the high perivascular FAI group compared to the low FAI group (76.5 % vs. 36.4 %; P = 0.016). Major adverse cardiac and cerebrovascular events did not differ between both groups.

Conclusion

The findings in this study suggest the potential valuable role of perivascular FAI assessment in individual CV risk prediction for patients with documented or suspected coronary artery disease.

Beta-Blocker Therapy After Myocardial Infarction

Historical data strongly supported the benefits of beta-blocker therapy following a myocardial infarction (MI) for its efficacy in reducing mortality and morbidity. However, in the context of the progressive evolution of treatment strategies for MI patients, the apparent benefit of beta-blocker therapy is becoming less clear. In particular, its effectiveness in patients with preserved left ventricular ejection fraction is currently being challenged. Consequently, contemporary guidelines are now varying in their recommendations regarding the role of beta-blocker therapy in post-MI patients. This review aims to summarize and compare the largest and most influential studies from the prereperfusion era to modern practice regarding different health outcomes while highlighting the need for further research to clarify beta-blocker therapy's place in contemporary post-MI management.

Study of fluoroscopic landmarks in IVUS guided zero contrast PCI - A single centre experience

INTRODUCTION

Contrast induced nephropathy is third most common cause of renal insufficiency following percutaneous coronary angioplasty (PCI) and patients with preexisting renal dysfunction are even at a higher risk for poor outcomes. With the advent of intravascular imaging, safety and efficacy of angioplasty can be improved significantly in these patients.

MATERIAL AND METHODS

This observational prospective study included 72 consecutive patients with CKD(eGFR ≤45 ml/min/m2) and established CAD who underwent absolute zero contrast PCI at a single tertiary center.PCI was planned in patients with significant stenosis and indications for revascularization.All Procedures were performed under dry fluoroscopy and IVUS guidance without use of any contrast.Informed consent, clinical,procedural and follow-up data was collected and analysed.

RESULTS

Total 72 patients (90 vessels) with median age of 63 years and eGFR (34.1 ml/min/1.73 m2) underwent zero contrast PCI. Procedure was performed by Femoral (45.6 %)and radial (54.4%) route. Total 11 patients (15.3%) underwent left main stenting. Fluoroscopic landmarks such as side-branch wiring (71.1%),floating wire in aorta (22.2 %), calcifications (21.1%), bony landmarks such as ribs or vertebrae (45.5%) and Sternal wires/clips (6.6%) were used in addition to IVUS to enable more accurate placement of stent.Technical and procedural success were achieved in 91.1% and 97.2% of patients.One patient died in hospital due to non-cardiac cause and one patient required hemodialysis.Post procedure at 48 hrs, there was no deterioration of renal function.On 3 months followup, there was no significant major adverse cardiovascular events (MACE).

CONCLUSION

Our study shows that with the help of fluoroscopy landmarks and intravascular imaging, zero contrast PCI can be performed safely with good clinical outcomes in patients at risk of nephropathy.

Safety of Vericiguat in Patients with Coronary Artery Disease: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to investigate the safety of vericiguat in patients with coronary artery disease.

METHODS

We conducted a comprehensive literature review of the PubMed, ClinicalTrials.gov, and Cochrane Library databases up to 27 March 2024. We included studies that compared vericiguat with placebo in patients with coronary artery disease. Clinical data were extracted, and adverse events were analyzed using Review Manager software (version 5.4) after conducting a quality assessment of the enrolled studies.

RESULTS

Three randomized controlled trials involving 151 patients were included in this meta-analysis. Compared with the placebo group, vericiguat treatment resulted in a decrease in systolic blood pressure by 1.4-10 mmHg and diastolic blood pressure by 0.4-6 mmHg, along with an increase in heart rate by 1.8-7 bpm, all of which are clinically insignificant. Vericiguat treatment demonstrated no significant serious adverse events [odds ratio (OR) = 1.97; 95% confidence interval (CI) = 0.39-9.91; P = 0.41]. However, a significant difference in adverse events between the two groups was noted (OR = 4.04; 95% CI = 2.17-7.52; P < 0.001).

CONCLUSION

This meta-analysis suggests that vericiguat is a safe drug for use in patients with coronary artery disease; however, further clinical trials are needed to validate these findings.

REGISTRATION

The study protocol has been prospectively registered in PROSPERO (CRD42024528105).

Streamlined Clinical Management Pathways May Reduce Major Amputations in Patients with Chronic Limb Threatening Ischaemia: A Prospective Cohort Study with Historical Controls

OBJECTIVE

Patient characteristics and patterns of disease in chronic limb threatening ischaemia (CLTI) have markedly changed in recent years. Urgent specialist referral and timely revascularisation are recommended in international guidelines. UK guidelines now recommend revascularisation within five days of referral for inpatients and two weeks in outpatients. This study compared the contemporary one year major amputation incidence in patients with CLTI with a historical cohort at a single UK centre.

METHODS

This was a single centre, observational cohort study with historical controls. A prospective cohort was recruited between May 2019 and March 2022. A historical cohort presenting between 2013 and 2015 inclusive was retrospectively identified. Significant changes in management pathways, including establishing a rapid access limb salvage clinic, occurred between these periods, aiming to expedite time from referral to revascularisation. The one year primary outcome was major amputation, and the secondary outcome was death. Major amputation was analysed by Fine-Gray competing risks models (death as the competing risk), presented as subdistribution hazard ratios (SHRs). One year mortality was analysed by Cox regression, presented as hazard ratios. Analyses were adjusted for propensity score.

RESULTS

A total of 928 patients were included (432 prospective and 496 historical). Proportions of patients presenting with tissue loss (72.2% vs. 71.6%; p = .090) were similar in both cohorts. At one year, 48 patients (11.1%) in the prospective cohort and 124 patients (25.0%) in the historical cohort had undergone a major amputation (p < .001). Risk of major amputation was 57.0% lower in the prospective cohort compared with the historical cohort after adjustment for propensity score (SHR 0.43, 95% confidence interval 0.29 - 0.63; p < .001).

CONCLUSION

An encouraging reduction in major amputation incidence was observed after improvements to CLTI management pathways, but residual confounding is likely. The generalisability of these results is uncertain.

Prevalence and Clinical Parameters Associated With Chronic Total Occlusions in Patients With Chronic Coronary Syndromes: Insights From a Nationwide Registry

Background and Aims

The prevalence of coronary chronic total occlusions (CTO) among patients with chronic coronary syndrome (CCS) and their associations with clinical factors have received limited study. We analyzed a national database registry to determine the prevalence, location, and parameters associated with coronary CTOs.

Methods

We identified all CCS patients without prior coronary artery bypass graft surgery (CABG) who underwent coronary angiography in the Persian CardioVascular Disease Registry (PCVDR). We compared the baseline demographics and characteristics of patients with vs. without at least one CTO lesion. We used logistic regression analysis to identify parameters associated with coronary CTOs.

Results

Among the 40,161 patients with CCS who underwent coronary angiography between March 2019 and December 2023, 6805 (17.86%) had at least one CTO. CTO patients were significantly older (64.43 ± 8.96 years vs. 62.64 ± 9.54 years, p < 0.001) and more likely to be men (75.3% vs. 54.4%, p < 0.001). The left anterior descending artery (70.4%) and right coronary artery (16.5%) were the most common CTO lesion locations. Older age (adjusted odds ratio [aOR] 95% confidence intervals [CI] 1.024 (1.021-1.028), male gender (aOR 2.865 (2.685-3.058), any smoking (aOR 1.256 (1.145-1.378), diabetes mellitus (aOR 1.372 (1.288-1.460), and dyslipidemia (aOR 1.166 (1.096-1.239) were independently associated with the presence of a CTO.

Conclusion

Approximately 1 in 5 CCS patients without prior CABG undergoing coronary angiography in this national database registry had a CTO. Advanced age, male gender, history of smoking, diabetes mellitus, and dyslipidemia were associated with higher likelihood of coronary CTOs.

Routine stress testing in diabetic patients after coronary intervention: a systematic review and meta-analysis

BACKGROUND

Stress testing is a widely used non-invasive tool in patients with angina, but its role in diabetic patients after coronary intervention remains uncertain. This review evaluates its impact in this population.

GOALS

We aimed to perform a systematic review and meta-analysis of studies assessing death, MACE, ischemia and repeated revascularization in diabetic patients post-coronary intervention.

METHODS

We searched PubMed, Embase, and Cochrane for RCTs and cohort studies on diabetic patients post-revascularization reporting MI and cardiovascular death, ischemia, repeat revascularization, and pooled hazard ratios for mortality or MI. Statistical analysis used RStudio and RevMan, with heterogeneity assessed via I² statistics.

RESULTS

We included 14,461 patients from 15 studies (14 observational cohorts, 1 RCT), all with diabetes and prior revascularization. Follow-up ranged from 1 to 5.2 years, with a mean age of 60.8 ± 9.5 years, and 75 % male. MI and cardiovascular death occurred in 11.24 % (95 % CI: 7.35-15.79 %; p < 0.01, Figure 2), ischemia in 36.07 % (95 % CI: 30.26-42.08 %; p < 0.01, Figure 3), and repeated revascularization in 15.65 % (95 % CI: 6.65-27.64 %; p < 0.01, Figure 4). For mortality or MI, the pooled hazard ratio was 1.28 (95 % CI: 1.02-1.61, Figure 5), suggesting a modest benefit of standard care over routine stress testing.

CONCLUSION

Routine stress testing in diabetic patients after coronary intervention may not significantly impact outcomes. Further controlled studies are needed to clarify its clinical benefit.

Prediction of obstructive coronary artery disease using coronary calcification and epicardial adipose tissue assessments from CT calcium scoring scans

BACKGROUND

Low-cost/no-cost non-contrast CT calcium scoring (CTCS) exams can provide direct evidence of coronary atherosclerosis. In this study, using features from CTCS images, we developed a novel machine learning model to predict obstructive coronary artery disease (CAD), as defined by the coronary artery disease-reporting and data system (CAD-RADS).

METHODS

This study analyzed 1324 patients from the SCOT-HEART trial who underwent both CTCS and CT angiography. Obstructive CAD was defined as CAD-RADS 4A-5, while CAD-RADS 0-3 were considered non-obstructive CAD. We analyzed clinical, Agatston-score-derived, and epicardial fat-omics features to predict obstructive CAD. The most predictive features were selected using elastic net logistic regression and used to train a CatBoost model. Model performance was evaluated using 1000 repeated five-fold cross-validation and survival analyses to predict major adverse cardiovascular event (MACE) and revascularization. Generalizability was assessed using an external validation set of 2316 patients for survival predictions.

RESULTS

Among the 1324 patients, obstructive CAD was identified in 334 patients (25.2 ​%). Elastic net regression identified the top 14 features (5 clinical, 2 Agatston-score-derived, and 7 fat-omics). The proposed method achieved excellent performance for classifying obstructive CAD, with an AUC of 90.1 ​± ​0.9 ​% and sensitivity/specificity/accuracy of 83.5 ​± ​5.5 ​%/93.7 ​± ​1.9 ​%/82.4 ​± ​2.0 ​%. The inclusion of Agatston-score-derived and fat-omics features significantly improved classification performance. Survival analyses showed that both actual and predicted obstructive CAD significantly differentiated patients who experienced MACE and revascularization.

CONCLUSIONS

We developed a novel machine learning model to predict obstructive CAD from non-contrast CTCS scans. Our findings highlight the potential clinical benefits of CTCS imaging in identifying patients likely to benefit from advanced imaging.

Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis

OBJECTIVES

Screening for obstructive coronary artery disease (CAD) with coronary computed tomography angiography (CCTA) could prevent unnecessary invasive coronary angiography (ICA) procedures during work-up for trans-catheter aortic valve implantation (TAVI). CT-derived fractional flow reserve (CT-FFR) improves CCTA accuracy in chest pain patients. However, its reliability in the TAVI population is unknown. This systematic review and meta-analysis assesses CCTA and CT-FFR in TAVI candidates.

METHODS

PubMed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.

RESULTS

Thirty-four articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 7235 and 1269 patients, respectively. Reference standard was mostly anatomical severity of CAD. At patient level, pooled CCTA sensitivity was 94.0% and specificity 72.4%. CT-FFR sensitivity was 93.2% and specificity 70.3% with substantial variation between studies. However, in studies that compared both, CT-FFR performed better than CCTA. Sensitivity of CCTA versus CT-FFR was 74.9% versus 83.9%, and specificity was 65.5% versus 89.8%.

CONCLUSIONS

Negative CCTA accurately rules out CAD in the TAVI population. CCTA could lead to significant reduction in pre-TAVI ICA, but false positives remain high. Diagnostic accuracy of CT-FFR was comparable to that of CCTA in our meta-analyses, but in studies performing a direct comparison, CT-FFR performed better than CCTA. However, as most studies were small and used CT-FFR software exclusively available for research, a large study on CT-FFR in TAVI work-up using commercially available CT-FFR software would be appropriate before considering routine implementation.

KEY POINTS

Question Coronary artery disease (CAD) screening with invasive coronary angiography before trans-catheter aortic valve implantation (TAVI) is often retrospectively unnecessary, revealing no obstructive CAD. Findings Coronary CTA ruled out CAD in approximately half of TAVI candidates. CT-derived fractional flow reserve (CT-FFR) performed similarly overall but better than coronary CTA in direct comparison. Clinical relevance Addition of coronary CTA to TAVI planning-CT to screen for obstructive CAD could reduce negative invasive coronary angiographies in TAVI work-up. CT-FFR could reduce false-positive coronary CTA results, improving its gatekeeper function in this population, but more data is necessary.

Automated classification of coronary LEsions fRom coronary computed Tomography angiography scans with an updated deep learning model: ALERT study

OBJECTIVES

The use of deep learning models for quantitative measurements on coronary computed tomography angiography (CCTA) may reduce inter-reader variability and increase efficiency in clinical reporting. This study aimed to investigate the diagnostic performance of a recently updated deep learning model (CorEx-2.0) for quantifying coronary stenosis, compared separately with two expert CCTA readers as references.

METHODS

This single-center retrospective study included 50 patients that underwent CCTA to rule out obstructive coronary artery disease between 2017-2022. Two expert CCTA readers and CorEx-2.0 independently assessed all 150 vessels using Coronary Artery Disease-Reporting and Data System (CAD-RADS). Inter-reader agreement analysis and diagnostic performance of CorEx-2.0, compared with each expert reader as references, were evaluated using percent agreement, Cohen's kappa for the binary CAD-RADS classification (CAD-RADS 0-3 versus 4-5) at patient level, and linearly weighted kappa for the 6-group CAD-RADS classification at vessel level.

RESULTS

Overall, 50 patients and 150 vessels were evaluated. Inter-reader agreement using the binary classification at patient level was 91.8% (45/49) with a Cohen's kappa of 0.80. For the 6-group classification at vessel level, inter-reader agreement was 67.6% (100/148) with a linearly weighted kappa of 0.77. CorEx-2.0 showed 100% sensitivity for detecting CAD-RADS ≥ 4 and kappa values of 0.86 versus both readers using the binary classification at patient level. For the 6-group classification at vessel level, CorEx-2.0 demonstrated weighted kappa values of 0.71 versus reader 1 and 0.73 versus reader 2.

CONCLUSION

CorEx-2.0 identified all patients with severe stenosis (CAD-RADS ≥ 4) compared with expert readers and approached expert reader performance at vessel level (weighted kappa > 0.70).

KEY POINTS

Question Can deep learning models improve objectivity in coronary stenosis grading and reporting as coronary CT angiography (CTA) workloads rise? Findings The deep learning model (CorEx-2.0) identified all patients with severe stenoses when compared with expert readers and approached expert reader performance at vessel level. Clinical relevance CorEx-2.0 is a reliable tool for identifying patients with severe stenoses (≥ 70%), underscoring the potential of using this deep learning model to prioritize coronary CTA reading by flagging patients at risk of severe obstructive coronary artery disease.

Effects of Cardiovascular Rehabilitation on Myocardial Perfusion and Functional Exercise Capacity in Patients With Stable Coronary Artery Disease and Myocardial Ischemia

PURPOSE

Myocardial ischemia is prevalent in chronic heart diseases. Cardiac rehabilitation (CR) offers non-pharmacological benefits to reduce hospitalization and mortality, yet its impact on coronary vascular changes remains unclear. We assessed the effects of CR on myocardial perfusion and exercise capacity in patients with stable coronary artery disease and exercise-induced ischemia.

METHODS

We conducted a retrospective observational study in individuals with stable coronary artery disease and myocardial ischemia enrolled in a CR program. Inclusion criteria required a minimum of 3 months of supervised CR and cardiac single-photon emission computed tomography (SPECT) imaging before and after the program. Blinded analysis and interpretation of the SPECT studies was carried out by nuclear cardiologists. The primary outcome was a change in myocardial perfusion via SPECT analysis. Secondary outcomes included changes in exercise capacity, electrocardiographic changes during treadmill stress tests, and evaluation of adverse effects during training. Cinecoronariographies reports were collected for further cardiac status assessment.

RESULTS

Of 394 patients, 22 with myocardial ischemia were analyzed (96% males, 61.5 ± 9.5 yr). Number of CR sessions ranged from 42 to 73. Stress-induced ischemia significantly decreased (P = .019), with improvements in exercise capacity, including absolute peak oxygen uptake (mL/min, P = .027), relative oxygen uptake (mL/kg/min, P = .044), maximum metabolic equivalent of task (P = .019), and exercise duration (P < .001). No adverse events occurred.

CONCLUSION

After a structured CR program of at least 3 months in patients with stable coronary artery disease and exercise-induced ischemia, there was a notable reduction in stress-induced ischemia and enhancements in exercise capacity, highlighting the safety and efficacy of CR in improving myocardial perfusion and exercise tolerance.

Myocardial Strain Imaging: Theory, Current Practice, and the Future

Myocardial strain imaging by echocardiography or cardiac magnetic resonance (CMR) is a powerful method to diagnose cardiac disease. Strain imaging provides measures of myocardial shortening, thickening, and lengthening and can be applied to any cardiac chamber. Left ventricular (LV) global longitudinal strain by speckle-tracking echocardiography is the most widely used clinical strain parameter. Several CMR-based modalities are available and are ready to be implemented clinically. Clinical applications of strain include global longitudinal strain as a more sensitive method than ejection fraction for diagnosing mild systolic dysfunction. This applies to patients suspected of having heart failure with normal LV ejection fraction, to early systolic dysfunction in valvular disease, and when monitoring myocardial function during cancer chemotherapy. Segmental LV strain maps provide diagnostic clues in specific cardiomyopathies, when evaluating LV dyssynchrony and ischemic dysfunction. Strain imaging is a promising modality to quantify right ventricular function. Left atrial strain may be used to evaluate LV diastolic function and filling pressure.

Incremental prognostic value of pericoronary adipose tissue attenuation beyond conventional features in patients with nonobstructive coronary artery disease

BACKGROUND AND AIMS

It remains uncertain whether pericoronary adipose tissue attenuation (PCATa) is associated with clinical outcome in patients with nonobstructive coronary artery disease (CAD). We aim to investigate the incremental prognostic value of PCATa beyond clinical and coronary computed tomographic angiography (CCTA) features in patients with nonobstructive CAD.

METHODS

Consecutive patients with chest pain suspected of CAD referred for CCTA from January 2017 to December 2018 were prospectively included. Multivariable Cox proportional hazard regression analysis was employed to identify the predictive factors for major adverse cardiovascular events (MACE), while the receiver operating characteristics (ROC) curve was utilized to assess the discriminatory capacity of PCATa. Kaplan-Meier curves were ultilized to visually represent event-free survival and were compared using Log-rank tests among groups stratified by high-risk plaque (HRP) and PCATa.

RESULTS

Of the 1614 patients (mean age 59.0 years, 55.6 % male) with nonobstructive CAD, 68 (4.2 %) suffered MACE during a median follow-up of 28.6 months. After multivariable adjustment, PCATa was identified as an independent predictor (HR: 1.060, 95%CI: 1.025-1.096, p = 0.001). The inclusion of PCATa significantly enhanced the discrimination capacity [AUC:0.72 (0.66-0.78), p = 0.041] and risk reclassification (NRI = 1.99, p < 0.001; IDI = 0.93, p < 0.001) beyond the influence of clinical and CCTA factors. In the presence of HRP, a higher PCATa was found to be associated with a relatively higher risk of MACE compared to a lower PCATa (HR: 2.45, 95%CI: 1.09-5.52, p = 0.031).

CONCLUSIONS

PCATa is positively correlated with adverse outcome in patients with nonobstructive CAD, and it offers incremental predictive value beyond clinical variables and CCTA characteristics.

Indobufen versus aspirin in patients with indication for antiplatelet therapy: A systematic review and meta-analysis

INTRODUCTION

Aspirin is commonly recommended for individuals who have experienced stroke or myocardial infarction (MI). Indobufen, a cyclooxygenase-1 inhibitor, has been studied as a potential alternative. We conducted a meta-analysis and trial sequential analysis (TSA) to compare indobufen with aspirin in patients requiring antiplatelet therapy.

METHODS

We searched PubMed, Scopus, and Cochrane Central for studies that compared indobufen and aspirin antiplatelet therapies. We focused on efficacy outcomes, such as composite vascular events, MI, and ischemic stroke, and safety outcomes, such as major bleeding and any bleeding. Heterogeneity was assessed using I2 statistics, and our analysis followed the PRISMA guidelines.

RESULTS

The review included 5 studies with 11,943 patients (indobufen n = 5952, 49.84 %), three involving post-MI and two involving post-stroke patients. No significant differences were found between the groups in composite vascular events at 90 days (RR 0.84; 95 % CI 0.46-1.53; p = 0.560; I2 = 53 %) and 1-year (RR 1.13; 95 % CI 0.99-1.29; p = 0.08; I2 = 0 %). MI (RR 0.73; 95 % CI 0.43-1.22; p = 0.22; I2 = 0 %), ischemic stroke (RR 1.16; 95 % CI 0.99-1.37; p = 0.06; I2 = 0 %), and cardiovascular death (RR 1.35; 95 % CI 0.80-2.26; p = 0.257; I2 = 0 %) at 1-year also showed no significant differences. Major bleeding at 1 year (RR 0.73; 95 % CI 0.41-1.31; p = 0.297; I2 = 64 %) was comparable, but any bleeding at 1 year showed a significant difference (RR 0.65; 95 % CI 0.43-0.98; p = 0.03; I2 = 87 %) favoring indobufen. Subgroup analysis of RCTs showed marginally significant increased risk regarding ischemic stroke with indobufen (RR 1.18; 95 % CI 1.00-1.39; p = 0.05).

CONCLUSION

The efficacy and safety of antiplatelet therapy with indobufen were comparable to those of aspirin alone. Therefore, indobufen can be considered as a suitable alternative for patients who are intolerant or hypersensitive to aspirin. Nevertheless, additional trials involving larger populations are required to establish their clinical applicability.

A new business paradigm to make coronary CT angiography (CCTA) accessible to all

Recently, the Centers for Medicare and Medicaid proposed a classification change that, if enacted, could double reimbursement for coronary CT angiography (CCTA) in the U.S. [1]. With this comes the potential to realistically build an economically viable and sustainable model to deliver cardiac CT outside of major urban (hospital and private practice) and academic centers. The value of CCTA in reducing cardiovascular morbidity and mortality has been demonstrated in large, randomized control trials and real-world studies, but access to CCTA in rural, socially deprived, and low-resource settings (including poorer urban areas with a lack of specialist equipment and specialty-based services) remains a significant challenge. This paper discusses the end-to-end business aspects required to deliver a sustainable cardiac CT service in these areas, exploring technologist-delivered services, with remote support from physicians, and the potential to leverage developing artificial intelligence (AI) decision aid tools and mobile scanners.

Noninvasive machine-learning models for the detection of lesion-specific ischemia in patients with stable angina with intermediate stenosis severity on coronary CT angiography

This study proposed noninvasive machine-learning models for the detection of lesion-specific ischemia (LSI) in patients with stable angina with intermediate stenosis severity based on coronary computed tomography (CT) angiography. This single-center retrospective study analyzed 76 patients (99 vessels) with stable angina who underwent coronary CT angiography (CCTA) and had intermediate stenosis severity (40-69%) on invasive coronary angiography. LSI, defined as a resting full-cycle ratio < 0.86 or fractional flow reserve ≤ 0.80, was determined in 40 patients (46 vessels) using a hybrid resting full-cycle ratio-fractional flow reserve strategy. The resting full-cycle ratio and/or fractional flow reserve were measured using invasive coronary angiography as references for functional severity indices of coronary stenosis in the machine-learning models. LSI detection models were constructed using noninvasive machine-learning models that predicted the resting full-cycle ratio and fractional flow reserve by feeding machine-learning models with image features extracted from CCTA. The diagnostic performance of the proposed LSI detection models was assessed using a nested 10-fold cross-validation test. The LSI detection models with the highest diagnostic performance achieved an accuracy of 0.88 (95% CI: 0.81, 0.94), sensitivity of 0.78 (95% CI: 0.70, 0.86) and specificity of 0.96 (95% CI: 0.92, 1.00) on a vessel basis and 0.88 (95% CI: 0.81, 0.95), 0.80 (95% CI: 0.70, 0.86) and 0.97 (95% CI: 0.92, 1.00), respectively, on a patient basis. These findings suggest that LSI detection models with features extracted from CCTA can noninvasively detect LSI in patients with stable angina with intermediate stenosis severity.

State of the art of CT myocardial perfusion

Coronary computed tomography angiography (CCTA) is a powerful tool to rule out coronary artery disease (CAD). In the last decade, myocardial perfusion CT (CTP) technique has been developed for the evaluation of myocardial ischemia, thereby increasing positive predictive value for diagnosis of obstructive CAD. A diagnostic strategy combining CCTA and perfusion acquisitions provides both anatomical coronary evaluation and functional evaluation of the stenosis, increasing the specificity and the positive predictive value of cardiac CT. This could improve risk stratification and guide revascularization procedures, reducing unnecessary diagnostic procedures in invasive coronary angiography. Two different acquisitions protocol have been developed for CTP. Static CTP allows a qualitative or semiquantitative evaluation of myocardial perfusion using a single scan during the first pass of iodinated contrast material in the myocardium. Dynamic CTP is capable of a quantitative evaluation of perfusion through multiple acquisitions, providing direct measure of the myocardial blood flow. For both, CTP acquisition hyperemia is reached using stressor agents such as adenosine or regadenoson. CTP in addition to CCTA acquisition shows good diagnostic accuracy compared to invasive fractional flow reserve (FFR). Furthermore, the evaluation of late iodine enhancement (LIE) could be performed allowing the detection of myocardial infarction.

Unlocking the Potential of the HEART Pathway: Predicting MACE and Facilitating Nurse-Physician Collaboration in Chest Pain Unit

BACKGROUND AND OBJECTIVE

The HEART pathway serves as a tool for predicting major adverse cardiac events (MACE) among patients presenting with acute chest pain, aiding in the early discharge of low-risk patients and reducing unnecessary cardiac investigations. This study aimed to evaluate physician-nurse reliability of the HEART pathway and investigate the efficacy of HEART pathway to predict 3-month MACE in patients with acute chest pain.

METHODS

We conducted a prospective study on 97 patients experiencing acute chest pain. A team of 3 professionals, a nurse, a cardiology resident, and a cardiology attending physician, performed risk stratification. We assessed interrater reliability among the raters as well as explored 3-month MACE outcomes.

RESULTS

Excellent pairwise agreements were found between the raters. Overall agreement among raters was excellent, with an intraclass correlation coefficient of 0.84 (95% confidence interval: 0.73-0.97). The HEART pathway score exhibited strong predictive power (area under curve: 0.85) for 3-month MACE. At a cutoff score of 4, sensitivity, specificity, and negative predictive values were 87.5%, 58.9%, and 95.8%, respectively.

CONCLUSIONS

The HEART pathway score effectively predicts 3-month MACE in patients with acute nontraumatic chest pain. Moreover, the high agreement among the attending physician, the resident physician, and the nurse suggests that nurses could use this tool, potentially reducing the workload on physicians.

Absence of long-term incremental prognostic value of inducible wall motion abnormalities on dipyridamole stress CMR in patients with suspected or known coronary artery disease

OBJECTIVES

This single-center retrospective study evaluated the long-term (~5 years) prognostic value of dipyridamole stress cardiac magnetic resonance (CMR) in patients with known or suspected coronary artery disease (CAD), assessing the impact of both key phases of the ischemic cascade (perfusion and wall motion).

MATERIAL AND METHODS

We considered 322 consecutive patients who underwent dipyridamole stress CMR. Abnormal wall motion at rest and after dipyridamole, perfusion at stress and at rest, and late gadolinium enhancement (LGE) were analyzed. End-points were non-fatal myocardial infarction, unplanned late revascularization (60 days after CMR), and cardiac death.

RESULTS

Forty-four patients were excluded because they underwent early revascularization (within 60 days after stress CMR), leading to a final population of 278 patients (73 females, 62.42 ± 10.50 years). A positive stress CMR was found in 78 (28.1%) patients; 50 patients had a reversible stress perfusion defect in at least one myocardial segment and 28 had a reversible stress perfusion defect plus worsening of stress wall motion in comparison with the rest. During a mean follow-up time of 59.34 ± 31.72 months, 37 (13.3%) cardiac events were recorded: 10 cardiac deaths, one non-fatal myocardial infarction, and 26 late revascularization after unstable angina or myocardial infarction. According to the Cox regression analysis, age, diabetes mellitus, previous revascularization, left ventricular ejection fraction (LVEF), reversible perfusion and perfusion + motion defect, and LGE were significant univariate prognosticators. The presence of associated wall motion abnormality (WMA) did not provide additional prognostic stratification in comparison to the only perfusion defect. In the multivariate Cox regression, the independent predictive factors were diabetes (hazard-ratio-HR = 5.64, p < 0.0001), reversible perfusion defect and reversible perfusion + motion defect vs normal stress CMR (HR = 6.43, p < 0.0001, and HR = 4.57, p = 0.004; respectively), and LVEF (HR = 0.96, p = 0.010).

CONCLUSION

A positive dipyridamole stress CMR predicted a higher long-term risk of cardiovascular events, but the presence of inducible WMA did not show any additional prognostic value over the reversible perfusion defect.

KEY POINTS

Question The long-term incremental prognostic value of inducible wall motion abnormalities by stress cardiac MR in patients with known or suspected CAD requires investigation. Findings The presence of inducible wall motion abnormalities did not offer additional prognostic value in comparison to the only reversible perfusion defect. Clinical relevance Independent from the presence of wall motion abnormalities, more aggressive management may be appropriate in patients with reversible perfusion defects to reduce the long-term risk of cardiovascular events.

Design and rationale of the South-East Netherlands Heart Registry (ZON-HR)

INTRODUCTION

In patients undergoing percutaneous coronary intervention (PCI), personalised medicine is key to the secondary prevention of ischaemic and bleeding events. To provide an extensive overview of the quality of secondary prevention and of personalised medicine, a consortium in the southeastern region of the Netherlands has created a PCI registry: the South-East Netherlands Heart Registry (Zuid-Oost Nederland Hart Registratie, ZON-HR).

AIM

To visualise and improve personalised secondary prevention post-PCI, focussing on key elements such as antiplatelet treatment, cholesterol management and comorbidities such as diabetes mellitus.

DESIGN AND POPULATION

A prospective multicentre registry of all consecutive patients undergoing PCI at 4 participating PCI centres and 3 referral centres.

TREATMENT

Interventional procedures and concomitant pharmaceutical treatment are performed in accordance with the guidelines. The ZON-HR promotes risk stratification after PCI using a simplified protocol for a personalised antiplatelet strategy.

DATA COLLECTION AND QUALITY

Demographics, laboratory values, baseline procedural characteristics and pharmaceutical treatment data are collected. Outcomes include thromboembolic and bleeding complications and medication changes. Data are pseudonymised, and a clinical event committee will review 20% of the adverse events (randomly selected).

STRENGTHS AND WEAKNESSES

This registry represents the entire PCI population and visualises gaps in secondary prevention. Weaknesses are the collection of outcomes and medication changes using mostly patient-reported outcomes.

CONCLUSION

The ZON-HR is a comprehensive PCI registry that provides baseline and follow-up data of a large PCI cohort in the southeastern region of the Netherlands. The ZON-HR aims to improve secondary prevention after PCI and augment personalised treatment that focusses on key elements of secondary prevention.

Urinary albumin-to-creatinine ratio as an independent predictor of long-term mortality in atherosclerotic cardiovascular disease patients: A propensity score-matched study: UACR and Long-term Mortality in ASCVD

BACKGROUND AND AIMS

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of mortality, and while the association between the urinary albumin-to-creatinine ratio (UACR) and cardiovascular risk is recognized, the specific impact of UACR on the long-term survival of ASCVD patients remains not fully understood. The aim of this study is to investigate the influence of UACR on the long-term risk of all-cause mortality in patients with ASCVD.

METHODS

This study included ASCVD patients from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. Mortality outcomes were ascertained by linkage to the National Death Index as of December 31, 2019. UACR risk was stratified into three levels: Group 0 (UACR < 30 mg/g), Group 1 (30-300 mg/g), and Group 2 (>300 mg/g). The primary outcome was all-cause mortality, with cardiovascular mortality as a secondary outcome. Cox proportional hazards, adjusted for demographic factors, traditional cardiovascular risk factors, and secondary prevention medications for ASCVD, were used to analyze the cumulative risk of outcomes. Propensity score matching was employed for risk adjustment, and sensitivity analyses were conducted based on cohorts with chronic coronary syndrome (CCS), stroke, heart failure, and non-heart failure.

RESULTS

Among the 1,737 patients with a median follow-up of 10 years, 1,026 all-cause deaths and 351 cardiovascular deaths were recorded. After full model adjustment, higher UACR levels were associated with increased risks of all-cause mortality (Group 1: hazard ratio (HR), 1.601; 95 % confidence interval (CI), 1.382-1.855; Group 2: HR, 2.378; 95 % CI, 1.884-3.001; both P < 0.001 for trend) and cardiovascular mortality (Group 1: HR, 2.080; 95 % CI, 1.631-2.652; Group 2: HR, 2.883; 95 % CI, 1.951-4.260; both P < 0.001 for trend). Propensity score matching confirmed these findings, showing significantly elevated all-cause mortality risks in high-risk UACR groups (with a cutoff of 30 mg/g: HR, 1.468 (95 %CI, 1.254-1.719), P < 0.001; with a cutoff of 300 mg/g: HR, 1.935 (95 %CI, 1.399-2.675), P < 0.001). All sensitivity analyses were consistent with the results of the overall cohort.

CONCLUSION

UACR is an important prognostic indicator for predicting the long-term outcomes of ASCVD patients, with its impact being independent of eGFR.

Circulating autophagy regulator Rubicon is linked to increased myocardial infarction risk

Background

The identification of new biomarkers that improve existing cardiovascular risk prediction models for acute coronary syndrome is essential for accurately identifying high-risk patients and refining treatment strategies. Autophagy, a vital cellular degradation mechanism, is important for maintaining cardiac health. Dysregulation of autophagy has been described in cardiovascular conditions such as myocardial ischemia-reperfusion injury, a key factor in myocardial infarction (MI). Recently, Rubicon (Run domain Beclin-1-interacting and cysteine-rich domain-containing protein), a key negative regulator of autophagy, has been identified in the modulation of cardiac stress response.

Objectives

This study aimed to explore the relationship between circulating Rubicon levels and MI, and to evaluate the incremental predictive value of Rubicon when integrated into a clinical risk prediction model for MI.

Results

We analyzed plasma Rubicon concentrations in 177 participants, comprising type I MI patients and high-risk control subjects. Our results revealed significantly elevated plasma Rubicon levels in MI patients compared to the control group (126.5 pg/mL vs. 53 pg/mL, p < 0.001). Furthermore, Rubicon levels showed a positive correlation with cardiovascular risk factors such as total cholesterol and LDL cholesterol. Multivariate analysis confirmed that Rubicon levels were independently associated with an increased risk of MI. The inclusion of Rubicon in traditional cardiovascular risk models notably enhanced predictive accuracy for MI, with the area under the curve (AUC) rising from 0.868 to 0.905 (p < 0.001).

Conclusions

These findings suggest that Rubicon is a valuable biomarker associated with MI risk, providing additional predictive value beyond standard cardiovascular risk factors. This highlights the importance of Rubicon's critical role in the pathophysiology of CVD.

The diagnostic value of stress echocardiography with limited myocardial ischemia in high-risk patients

BACKGROUND

The diagnostic value of limited myocardial ischemia in DSE is not well known.

OBJECTIVES

We investigated whether myocardial ischemia during dobutamine stress echocardiography (DSE) in 1 apical segment of any of the ventricular walls of the left ventricle relates to the anatomical and functional stenosis of the suppling coronary artery.

METHODS

Our observational, prospective study enrolled 212 patients, symptomatic or asymptomatic, with newly diagnosed limited myocardial ischemia on DSE. Almost 25% of them had already known CAD, while the rest were divided into low-risk and high-risk groups, integrating 1-2 and ≥3 classical cardiovascular risk factors, respectively. After DSE, all patients underwent invasive coronary angiography (ICA) and were followed up for one year. In coronary arteries distributing ischemic area, the calculated stenosis ≥50% and FFR<0.8 were considered anatomically and functionally significant, respectively. In the latter cases, the patients underwent coronary revascularization.

RESULTS

Significant anatomical and functional stenosis of the supplying coronary artery was common among patients with already known CAD (62.5% and 44.5%, respectively) or those without CAD but a high-risk profile (60.2% and 25.6%, respectively). In logistic regression analysis, CAD revascularization was independently determined by an already known CAD, diabetes mellitus, and high-risk profile. During follow-up, 24 patients experienced ACS or new angina episodes, which were associated with diabetes and smoking in univariate analysis.

CONCLUSION

Limited myocardial ischemia may implicate significant anatomical and functional coronary stenosis among individuals with a history of CAD or those without known CAD but a high-risk profile. The prognostic value of our findings requires further investigation.

Prevalence and risk factors of frailty in older patients with coronary heart disease: A systematic review and meta-analysis

OBJECTIVE

To quantitatively synthesise evidence on the prevalence of and risk factors of frailty in older patients with coronary heart disease.

METHODS

Nine electronic databases were searched from the inception to July 20th 2024. Random-effects model was performed to calculate to estimate the prevalence of frailty in older patients with coronary heart disease. Meta-regression analysis and subgroup analysis were conducted to explore the potential sources of heterogeneity. Sensitivity analysis was conducted using a study-by-study exclusion method. Meta-analysis of risk factors was performed using the Mantel-Haenszel or inverse variance method and only on the risk factors that have been reported in a minimum of two studies.

RESULTS

A total of 42 studies from 5 countries met the inclusion criteria, involving 11954 older patients. The pooled prevalence in older adults with coronary heart disease was 36% (95%CI: 31%-40%) for frailty. We found a higher prevalence of frailty among older patients with coronary heart disease in females, ≥80 years, case-control studies, EFS evaluation tool and acute coronary syndrome. Age, female, cardiac classification, malnutrition, fall within 1 year, sleep disorder, hypoproteinemia (albumin<35g/L), low level of literacy, depression, anxiety, low BMI, polypharmacy, comorbidities, CCI, diabetes, hypertension, high level of BNP, ADL disability, gait speed, living alone, low level of 25(OH)D3 were risk factors of frailty among older patients with coronary heart disease.

CONCLUSIONS

Coronary heart disease patients have a significantly higher prevalence of frailty. Early screening and timely prevention of frailty by medical practitioners are needed to provide more targeted measures for CHD patients.

Factors related to the treatment burden of patients with coronary heart disease: A cross-sectional study

BACKGROUND

Treatment burden is a significant barrier to patient adherence that may lead to deterioration of health.

OBJECTIVES

The purpose of this study was to understand the treatment burden of Chinese patients with coronary heart disease (CHD) and its associations with demographic, capacity, and workload-related factors.

METHODS

We conducted an observational cross-sectional study. We recruited 396 patients with CHD in a tertiary hospital in Shandong Province, China. Self-report questionnaires were used to measure patients' sociodemographic information, clinical information, treatment burden, health literacy, illness perception, and chronic illness resources. Descriptive statistics and t-tests, one-way analysis of variance, Pearson's correlation analysis, and multiple linear regression analysis were used for data analysis.

RESULTS

A total of 396 participants were included, of whom 273 were male (68.9 %) and 123 were female (31.1 %). The mean age of the participants was 63.10 ± 9.75. The predictors for treatment burden included smoking, taking ≥ 6 kinds of medications/day, health literacy, illness perception, and chronic illness resources, which explained 50.9 % of the variance (p < 0.05).

CONCLUSION

Our findings indicate an association between treatment burden and factors such as smoking, taking ≥ 6 kinds of medications/day, health literacy, illness perception, and chronic illness resource survey. Healthcare staff should develop targeted interventions based on relevant factors and optimize treatment strategies to improve patient adherence.

Beyond secondary prevention drugs: Added benefit in survival and events of a healthy lifestyle in patients after an acute coronary syndrome

Objective

To quantify the added clinical benefit of a healthy lifestyle following an acute coronary syndrome (ACS). Our study seeks to answer the question: Is adherence to medical therapy sufficient or a healthy lifestyle provides additional improvement?.

Methods

This is a prospective observational multi-center study of 685 ACS patients. At 6 months patients were asked about their post-ACS lifestyle and were given a score (range: 0-7) with the following items: Intake of ≥3 fruits and vegetables/day, ≥2 fish servings/week, ≤7 alcohol beverages/week, feeling stress

Results

After adjusting for demographic variables, cardiovascular risk factors, characteristics of the index event, high-sensitivity C-reactive protein (hs-CRP), and drug therapy, multivariate Cox regression showed that the lifestyle SCORE was independently and inversely associated with both the incidence of the primary outcome (ischemic events [any ACS, stroke, or Transient Ischemic Attack] or death) (HR 0.65 (CI95 % 0.44-0.96); p = 0.029) and death (HR 0.41 [95 %CI 0.18-0.91]; p = 0.029). Statin therapy was also independently and inversely associated with the incidence of the primary outcome and death. Kaplan-Meier curves showed a higher event-free survival for both outcomes in patients with SCORE≥4 (healthy lifestyle) than in those with SCORE<4 (unhealthy lifestyle). Additionally, patients with a SCORE≥4 had a significantly greater decrease of total cholesterol and hs-CRP. For each 1-point increase in the score, there was a 35 % reduction in the incidence of the primary outcome (ischemic events or death) and a 59 % reduction in the incidence of death.

Conclusion

Among patients with ACS and similar medical therapy, a healthy lifestyle is an independent and added marker of a lower incidence of new ischemic events and death. It is also associated with a better lipid profile and lower inflammation after the ACS. As the prognosis of ACS has improved over the years due to better therapies; this study shows that lifestyle modifications continue to offer significant benefit at this point in time.

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Key Words

• Acute coronary syndrome
• Coronary artery disease
• Lifestyle
• Secondary prevention

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Affiliation(s)

Ester Cánovas Rodríguez Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain
Andrea Kallmeyer Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
Nieves Tarín Department of Cardiology, Hospital Universitario de Móstoles, C. Dr. Luis Montes, s/n, 28935 Móstoles, Madrid, Spain Rey Juan Carlos University, C. Gladiolo, s/n, 28933 Móstoles Madrid, Spain
Carmen Cristóbal Rey Juan Carlos University, C. Gladiolo, s/n, 28933 Móstoles Madrid, Spain Department of Cardiology, Hospital Universitario de Fuenlabrada, Cam. del Molino, 2, 28942, Fuenlabrada, Madrid, Spain
Ana Huelmos Department of Cardiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
Ana María Pello Lázaro Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
Álvaro Aceña Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
Carlos Gutiérrez-Landaluce Department of Cardiology, Hospital Universitario de Fuenlabrada, Cam. del Molino, 2, 28942, Fuenlabrada, Madrid, Spain
Óscar González-Lorenzo Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
Jairo Lumpuy-Castillo Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain CIBERDEM, Madrid, Spain
Joaquín Alonso Rey Juan Carlos University, C. Gladiolo, s/n, 28933 Móstoles Madrid, Spain Department of Cardiology, Hospital de Getafe, Carr. Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
Lorenzo López-Bescós Rey Juan Carlos University, C. Gladiolo, s/n, 28933 Móstoles Madrid, Spain
Jesús Egido Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain CIBERDEM, Madrid, Spain Department of Nephrology, IIS-Fundación Jiménez Díaz, Madrid, Spain
Óscar Lorenzo Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain CIBERDEM, Madrid, Spain
Luis M. Blanco-Colio Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain CIBERCV, ISCIII, Monforte de Lemos, 3-5, 28029 Madrid, Spain
José Tuñón Department of Cardiology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, Moncloa - Aravaca, 28040 Madrid, Spain Autónoma University, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain CIBERCV, ISCIII, Monforte de Lemos, 3-5, 28029 Madrid, Spain

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Utility of MRI and CT in Sports Cardiology

Sports cardiologists specialize in the care of competitive athletes and highly active people by detecting and managing cardiovascular diseases that can impact sports participation and counseling on return to sports after cardiovascular events. Preparticipation evaluation of athletes includes history, physical examination, and electrocardiography (ECG), with exercise ECG added when screening master athletes. If the findings are abnormal or inconclusive, echocardiography is used for further evaluation. Further imaging with MRI, CT, or stress test is performed for establishing a diagnosis when echocardiography is indeterminate or discordant with clinical features and for risk stratification if echocardiography provides a definitive diagnosis. MRI can help distinguish athlete's heart from similar-appearing pathologic entities when echocardiography is inconclusive. Athlete's heart can manifest as left ventricular hypertrophy (LVH), left ventricle (LV) dilatation, prominent LV trabeculations, and right ventricular (RV) dilatation. Adaptive LVH in athletes is concentric and typically measures less than 16 mm, which distinguishes it from pathologic LV thickening of hypertrophic cardiomyopathy, hypertension, valvular disease, and infiltrative cardiomyopathies. Adaptive LV dilatation with normal or mildly reduced ejection fraction can be seen in endurance athletes. LV ejection fraction greater than 40%, augmentation of LV ejection fraction with exercise, and normal or supranormal diastolic function distinguishes it from dilated cardiomyopathy. Physiologic RV dilatation in athletes is distinguished from arrhythmogenic cardiomyopathy (RV type) by global involvement and absence of major regional wall motion abnormalities or late gadolinium enhancement. MRI is also useful in diagnosis and risk stratification of athletes with cardiovascular symptoms and after major cardiovascular events such as arrhythmias, myocardial infarction, and resuscitated sudden cardiac death or arrest. CT angiography provides accurate evaluation of coronary artery anomalies and coronary artery disease. ©RSNA, 2025 Supplemental material is available for this article.

Coronary Plaque Radiomic Phenotypes Predict Fatal or Nonfatal Myocardial Infarction: Analysis of the SCOT-HEART Trial

BACKGROUND

Coronary computed tomography (CT) angiography-derived attenuation-based plaque burden assessments can identify patients at risk of myocardial infarction.

OBJECTIVES

This study sought to assess whether more detailed plaque morphology assessment using patient-based radiomic characterization could further enhance the identification of patients at risk of myocardial infarction during long-term follow-up.

METHODS

Post hoc analysis of coronary CT angiography was performed within the SCOT-HEART (Scottish Computed Tomography of the HEART) clinical trial. Coronary plaque segmentations were used to calculate plaque burdens and eigen radiomic features that described plaque morphology. Univariable and multivariable Cox proportional hazard models were used to evaluate the association between clinical and image-based features and fatal or nonfatal myocardial infarction, whereas Harrell's C-statistic and cumulative/dynamic area under the curve (AUC) values with cross-validation were used to evaluate prognostic performance.

RESULTS

Scans from 1,750 patients (aged 58 ± 9 years; 56% male) were analyzed. Over a median of 8.6 years of follow-up, 82 patients had a fatal or nonfatal myocardial infarction. Among the eigen radiomic features, 15 were associated with myocardial infarction in univariable analysis, and 8 features retained their association following adjustment for cardiovascular risk score and plaque burden metrics. Adding plaque burden metrics to a clinical model incorporating cardiovascular risk score, Agatston score and presence of obstructive coronary artery disease had similar prediction performance (C-statistic 0.70 vs 0.70), whereas further addition of eigen radiomic features improved model performance (C-statistic 0.74). In temporal analysis, the model including eigen radiomic features had higher cumulative/dynamic AUC values following the fifth year of follow-up.

CONCLUSIONS

Radiomics-based precision phenotyping of coronary plaque morphology provided improvements to long-term prediction of myocardial infarction by CT angiography over and above clinical factors and plaque burden. (Scottish Computed Tomography of the HEART [SCOT-HEART]; NCT01149590).

Coronary Plaque Quantification with Ultrahigh-Spatial-Resolution Photon-counting Detector CT: Intraindividual Comparison with Energy-integrating Detector CT

Background Other than enhancing the accuracy of stenosis measurements, the improved spatial resolution of photon-counting detector (PCD) CT may have an impact on quantitative plaque assessment at coronary CT angiography (CCTA). Purpose To evaluate the effect of PCD CT on coronary plaque quantification and characterization compared with that of energy-integrating detector (EID) CT. Materials and Methods Consecutive participants undergoing clinically indicated CCTA at EID CT (192 × 0.6-mm collimation) were enrolled to undergo ultrahigh-spatial-resolution (UHR) PCD CT (120 × 0.2-mm collimation) within 30 days. PCD CT was performed using equivalent or lower CT dose index and equivalent contrast media volume as the clinical scan. Total, calcified, fibrotic, and low-attenuation coronary plaque volumes were quantified and compared between scanners. Intra- and interreader reproducibility was assessed for both systems. Results A total of 164 plaques from 48 participants were segmented on both scans. Total plaque volume was lower at PCD CT compared with EID CT (723.5 mm3 [IQR, 500.6-1184.7 mm3] vs 1084.7 mm3 [IQR, 710.7-1609.8 mm3]; P < .001). UHR-based segmentations produced lower fibrotic (325.4 mm3 [IQR, 151.7-519.2 mm3] vs 627.7 mm3 [IQR, 385.8-795.1 mm3], respectively; P < .001) and higher low-attenuation plaque volumes (72.1 mm3 [IQR, 38.6-161.9 mm3] vs 58.1 mm3 [IQR, 23.4-102.3 mm3], respectively; P = .004) than EID CT-based measurements. Calcified plaque volumes did not differ significantly between PCD CT and EID CT (344.5 mm3 [IQR, 174.3-605.7 mm3] vs 342.1 mm3 [IQR, 180.4-607.5 mm3], respectively; P = .13). Total, calcified, and fibrotic plaque volumes demonstrated excellent agreement between repeated measurements and between readers for both PCD CT and EID CT (all intraclass correlation coefficients [ICCs] > 0.90). Whereas low-attenuation plaque volume had strong intrareader (ICC, 0.84; 95% CI: 0.57, 0.94) and interreader (ICC, 0.92; 95% CI: 0.81, 0.97) agreements for PCD CT, EID CT showed only moderate (ICC, 0.62; 95% CI: 0.11, 0.86) and poor (ICC, 0.47; 95% CI: 0.01, 0.79) intrareader and interreader reproducibility. Conclusion Compared with EID CT, PCD CT UHR imaging reduced segmented coronary plaque volume by nearly one-third and improved reproducibility of low-attenuation plaque measurements. © RSNA, 2025 Supplemental material is available for this article.

Aspirin and Hemocompatibility After LVAD Implantation in Patients With Atherosclerotic Vascular Disease: A Secondary Analysis From the ARIES-HM3 Randomized Clinical Trial

Importance

The Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure (ARIES-HM3) study demonstrated that aspirin may be safely eliminated from the antithrombotic regimen after HeartMate 3 (HM3 [Abbott Cardiovascular]) left ventricular assist device (LVAD) implantation. This prespecified analysis explored whether conditions requiring aspirin (prior percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], stroke, or peripheral vascular disease [PVD]) would influence outcomes differentially with aspirin avoidance.

Objective

To analyze aspirin avoidance on hemocompatibility-related adverse events (HRAEs) at 1 year after implant in patients with a history of CABG, PCI, stroke, or PVD.

Design, Setting, and Participants

This was an international, multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial including patients implanted with a de novo HM3 LVAD across 51 centers. Data analysis was conducted from April to July 2024.

Interventions

Patients were randomized in a 1:1 ratio to receive aspirin (100 mg per day) or placebo, in addition to a vitamin K antagonist (VKA) targeted to an international normalized ratio of 2 to 3 in both groups.

Main Outcomes and Measures

Primary end point (assessed for noninferiority) was a composite of survival free of any nonsurgical (>14 days after implant) HRAEs including stroke, pump thrombosis, bleeding, and arterial peripheral thromboembolism at 12 months. Secondary end points included nonsurgical bleeding, stroke, and pump thrombosis events.

Results

Among 589 of 628 patients (mean [SD] age, 57.1 [13.7] years; 456 male [77.4%]) who contributed to the primary end point analysis, a history of PCI, CABG, stroke, or PVD was present in 41% (240 of 589 patients). There was no interaction between the presence of an atherosclerotic vascular condition and effect of aspirin compared with placebo (P for interaction= .23). The preset 10% noninferiority margin was not crossed for the studied subgroup of patients. Thrombotic events were rare, with no differences between aspirin and placebo in patients with and without vascular disease (P for interaction = .77). Aspirin treatment was associated with a higher rate of nonsurgical major bleeding events in the group with prior vascular condition history compared with those without aspirin (rate ratio for placebo compared with aspirin, 0.52; 95% CI, 0.35-0.79).

Conclusions and Relevance

Results of this prespecified analysis of the ARIES-HM3 randomized clinical trial demonstrate that in patients with advanced heart failure who have classical indications for antiplatelet therapy use at the time of LVAD implantation, aspirin avoidance was safe and not associated with increased thrombosis risk. Importantly, elimination of aspirin was associated with no increased thrombosis but a reduction in nonsurgical bleeding events in patients with a history of PCI, CABG, stroke, or PVD.

Trial registration

ClinicalTrials.gov Identifier: NCT04069156.

Association between symptom characteristics and disease severity in patients suspected of coronary artery disease

BACKGROUND

Discrepancies often exist between patient-reported symptoms and diagnostic test findings in patients with suspected obstructive coronary artery disease (CAD).

OBJECTIVES

To quantify the association between patient-reported symptoms and the diagnosis of severe stenosis in patients with suspected obstructive CAD.

METHODS

Two large-scale cohorts of patients with new-onset symptoms suggestive of obstructive CAD were evaluated. Chest discomfort was assessed by typicality, location, type, exertional/stress factors, and relief with rest/nitroglycerine. Patients underwent non-invasive diagnostic testing (coronary computed tomographic angiography (CCTA) or functional testing), followed by test-result-driven invasive coronary angiography (ICA). Severe stenosis was defined as ≥70 ​% diameter stenosis on ICA. Sensitivity analyses included CCTA stenosis, functional abnormalities, and revascularization.

RESULTS

Of 14,410 patients, 2093 (14.5 ​%) were referred for ICA, and 765 (5.3 ​%) were diagnosed with severe stenosis. Patients with typical angina (n ​= ​224) had higher odds of being diagnosed with severe stenosis on ICA (OR and 95 ​% CIs: 2.84 [2.40-3.34]) than those with atypical or non-anginal symptoms. In patients diagnosed with severe stenosis on ICA, those with exertional/stress factors (n ​= ​418; OR [95 ​% CI]: 2.50 [2.16-2.90]) and relief with rest/nitroglycerine (n ​= ​318, 2.28; [1.96-2.65]) had higher odds compared to those without. Patients reporting pressure or burning pain had higher odds of severe stenosis. Associations were consistent across sex and age groups, and sensitivity references.

CONCLUSIONS

Exertional/stress-related chest discomfort and relief with rest/nitroglycerine increased the odds of severe stenosis in patients with suspected CAD undergoing test-result-driven ICA, while location and type of chest pain were less associated, with no differences across sex or age groups.

Non-atherosclerotic coronary causes of myocardial infarction in women

Ischemic heart disease is the most common cardiovascular cause of death in women worldwide. Obstructive coronary atherosclerosis is the primary cause of myocardial infarction (MI), however, non-atherosclerotic mechanisms of MI, such as spontaneous coronary artery dissection, vasospasm, microvascular dysfunction, embolization, inflammation, coronary anomalies, infectious and infiltrative causes are increasingly being recognized. Emerging data suggest that women are two to five times more likely to have an MI in the absence of coronary atherosclerosis compared to men, but they continue to remain underdiagnosed and undertreated, partly due to underdiagnosis and limited understanding of these mechanisms. Recent advancements in invasive and noninvasive imaging techniques and physiological testing allow for distinguishing these mechanisms from each other, providing a definitive diagnosis and tailored treatment. This review summarizes the existing literature on the non-atherosclerotic coronary causes of MI with a focus on evidence pertaining to women, offering a basis for future studies.

Health behavior and disease self-management indicators in patients with cardiovascular diseases using a health app: Findings from an RCT

Background

Prevention of acute cardiovascular events in patients with cardiovascular disease (CVD) requires promoting health-protective behaviors (e.g., physical activity) and reducing health-compromising behaviors (e.g., sitting). Digital interventions addressing health behavior offer great potential. Based on a multiple behavior change theory, an intervention in the form of a digital health application (app) was evaluated in a pilot trial, testing the following hypotheses (H): H1: Health behaviors (physical activity, sitting) and disease self-management (self-care maintenance, self-care confidence) are closely related; H2: changes in health behaviors and disease self-management indicators over time (T0 to T1) are more pronounced in the intervention group (IG, app users) than in the control group (CG); H3: within the IG, changes in systolic and diastolic blood pressure indicate a positive trajectory.

Methods

A 12-week randomized controlled trial (RCT) was conducted with two measurement points. The IG received an app addressing self-management and health behavior change. A total of N = 40 CVD patients were randomized equally to the CG (45% women; mean age = 60.6 years) and the IG (35% women; mean age = 61.5 years).

Results

Findings support H1 with correlations between behaviors (r = -0.66-0.79) and disease self-management (r = -0.06-0.70). H2 was also partially supported, with significant improvements over time in self-management indicators, especially self-care maintenance, in the IG (Eta² = 0.35; p < 0.001). H3 could not be confirmed as no significant changes were found.

Conclusions

This study provides evidence that an app addressing different behavior change techniques (BCTs) can help to manage CVD by promoting health-protective behaviors and preventing health-compromising behaviors. Taking different behaviors into account may increase the effectiveness of behavioral intervention, thereby improving individual and public health. Replications with larger samples and more objective measures are needed.

The Dual Role of Oxidative Stress in Atherosclerosis and Coronary Artery Disease: Pathological Mechanisms and Diagnostic Potential

Oxidative stress plays a pivotal role in the pathogenesis of atherosclerosis and coronary artery disease (CAD), with both beneficial and detrimental effects on cardiovascular health. On one hand, the excessive production of reactive oxygen species (ROS) contributes to endothelial dysfunction, inflammation, and vascular remodeling, which are central to the development and progression of CAD. These pathological effects drive key processes such as atherosclerosis, plaque formation, and thrombosis. On the other hand, moderate levels of oxidative stress can have beneficial effects on cardiovascular health. These include regulating vascular tone by promoting blood vessel dilation, supporting endothelial function through nitric oxide production, and enhancing the immune response to prevent infections. Additionally, oxidative stress can stimulate cellular adaptation to stress, promote cell survival, and encourage angiogenesis, which helps form new blood vessels to improve blood flow. Oxidative stress also holds promise as a source of biomarkers that could aid in the diagnosis, prognosis, and monitoring of CAD. Specific oxidative markers, such as malondialdehyde (MDA), isoprostanes (isoP), ischemia-modified albumin, and antioxidant enzyme activity, have been identified as potential indicators of disease severity and therapeutic response. This review explores the dual nature of oxidative stress in atherosclerosis and CAD, examining its mechanisms in disease pathogenesis as well as its emerging role in clinical diagnostics and targeted therapies. The future directions for research aimed at harnessing the diagnostic and therapeutic potential of oxidative stress biomarkers are also discussed. Understanding the balance between the detrimental and beneficial effects of oxidative stress could lead to innovative approaches in the prevention and management of CAD.

Coronary heart disease with pulmonary embolism: A case report

BACKGROUND

Coronary heart disease (CHD) and pulmonary embolism (PE) are thrombotic diseases. Patients with CHD and PE are common in clinical practice. However, the clinical diagnosis of PE is challenging due to overlapping primary symptoms, such as chest tightness and dyspnea. This confluence frequently leads to the misdiagnosis of PE, thus precipitating treatment delays and compromising patient outcomes. Herein, we report the case of a patient with both diseases who underwent surgery and medication therapy.

CASE SUMMARY

A 51-year-old man with a history of hypertension for 2 years visited a local hospital because of paroxysmal chest tightness for 1 d and was diagnosed with CHD. However, he refused hospitalization. He visited our hospital for the treatment of recurring symptoms. A comprehensive examination after admission revealed elevated D-dimer levels, and computed tomography pulmonary angiography was performed to confirm the diagnosis of PE. The patient successfully underwent coronary artery bypass grafting with anticoagulant and antiplatelet drugs and had a prognosis.

CONCLUSION

D-dimer is useful in screening for PE, whereas computed tomography pulmonary angiography is important for diagnosis. For patients with CHD and PE, coronary artery bypass grafting combined with anticoagulant and antiplatelet therapy is feasible.

Effect of Reconstruction Kernel and Virtual Monoenergetic Imaging on Segmentation-Based Measurement of Coronary Plaque Volume With Photon-Counting CT

OBJECTIVES

Coronary computed tomography angiography is the primary modality for noninvasive assessment of coronary artery disease. Photon-counting computed tomography (PCCT) offers superior spatial resolution and spectral imaging for detailed characterization of atherosclerotic plaques. This study aimed to evaluate the impact of virtual monoenergetic imaging (VMI) energy levels and reconstruction kernels on segmentation-based measurement of plaque volume in individuals with coronary atherosclerosis using PCCT.

MATERIALS AND METHODS

Fifty study participants underwent coronary computed tomography angiography with ultra-high-resolution PCCT. Both polyenergetic, 120 kVp (T3D) images and spectral images at varying VMI energy levels were reconstructed using different kernels. Plaque volumes were measured using semiautomated attenuation-based segmentation, adjusting segmentation thresholds for each VMI energy level. In addition, absolute plaque volume measurements were conducted using a coronary phantom simulating different plaque types.

RESULTS

Using a sharper kernel (Bv64 vs Bv48) significantly increased noncalcified plaque volume measurements ( P < 0.005) in study participants, whereas a 0.2-mm slice thickness reduced calcified plaque volumes compared with 0.4 mm ( P < 0.005). VMI energy level had no impact on measured volumes. Phantom measurements confirmed significant variability in measured volumes of calcified and noncalcified plaques depending on reconstruction method, as well as a minor effect of VMI level.

CONCLUSIONS

In PCCT, the reconstruction kernel predominantly affects noncalcified coronary plaque quantification, whereas slice thickness mainly impacts calcified plaque volumes. In study participants, measured plaque volumes were not affected by VMI energy level when energy-specific segmentation thresholds were used, although a minor effect of VMI was observed in the phantom model.

Association of pericoronary inflammation with atherosclerotic plaque progression in diabetic patients with improved modifiable cardiovascular risk factors: a longitudinal CCTA cohort study

BACKGROUND

Pericoronary adipose tissue (PCAT) attenuation, as assessed by coronary computed tomography angiography (CCTA), has been identified as a marker of pericoronary inflammation and a predictor of future adverse atherosclerotic events. However, the impact of changes in PCAT attenuation, as evaluated by consecutive CCTAs, on plaque progression in high-risk atherosclerotic patients with improved modifiable cardiovascular risk factors (mCRFs) remains unclear.

METHODS

Consecutive patients with type 2 diabetes mellitus (T2DM) who had improved mCRFs and underwent serial, clinically indicated CCTA examinations (time interval ≥ 12 months) at our center between July 2019 and July 2022 were screened. Eligible participants had at least one study plaque, defined as a plaque without significant anatomic stenosis, located in one of the major coronary arteries, which had not been intervened upon or caused adverse events between serial CCTA scans. Percent atheroma volume (PAV) and PCAT attenuation were measured for each study plaque at baseline and follow-up using CCTA plaque analysis software. Changes in PAV (δPAV = follow-up PAV - baseline PAV) were compared based on changes in PCAT attenuation [δPCAT attenuation] (> 0 or ≤ 0). Multivariate linear regression models were used to evaluate the relationship between δPCAT attenuation and δPAV.

RESULTS

A total of 98 T2DM patients (mean age: 59.9 years; 75.3% men; 152 plaques) had mCRFs that reached therapeutic targets at follow-up CCTA. However, overall PAV progressed from baseline in all patients [(41.68 ± 12.47)% vs. (43.71 ± 12.24)%, p = 0.035], accompanied by an increase in coronary inflammation (i.e., PCAT attenuation) during a median follow-up of 13.5 months (interquartile range [IQR]: 12.2, 17.5 months).Compared to patients with δPCAT attenuation ≤ 0, those with δPCAT attenuation > 0 had a significantly greater increase in overall PAV from baseline [(4.09 ± 12.09)% vs. (-0.82 ± 10.74)%, p = 0.011], calcified PAV [1.57% (IQR: 0.13%, 3.84%) vs. 0.38% (IQR: -0.26%, 2.58%), p = 0.008], and a numerical but non-significant increase in non-calcified PAV [(1.29 ± 11.75)% vs. (-1.87 ± 10.47)%, p = 0.089]. Multivariate linear regression models demonstrated that increased PCAT attenuation was significantly associated with the progression of overall PAV (β = 0.339, 95% CI: 0.129-0.549), non-calcified PAV (β = 0.237, 95% CI: 0.019-0.455), and calcified PAV (β = 0.109, 95% CI: 0.019-0.200), independent of age, sex, cardiovascular risk factors, medications, and baseline PCAT attenuation and PAV (all p < 0.05). The effect of elevated PCAT attenuation on overall plaque progression was consistent across subgroups (all p for interaction > 0.05).

CONCLUSION

In this longitudinal CCTA cohort of T2DM patients with improved mCRFs, increased pericoronary inflammation was associated with the progression of atherosclerotic plaque, particularly non-calcified plaque.

Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome

BACKGROUND

The advantages and disadvantages of direct invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA) + ICA were compared in patients with suspected chronic coronary syndrome (CCS) who presented with angina symptoms or who had nonangina chest pain with abnormal electrocardiogram results.

METHODS

A total of 1200 patients who met the inclusion criteria at TEDA International Cardiovascular Hospital from January 2021 to December 2022 were randomly divided into two groups at a 1:1 ratio: the CCTA + ICA strategy (CCTA group) and the direct ICA strategy (ICA group). The baseline data were collected. All patients in the CCTA group underwent CCTA examination first. If these results showed positive obstructive coronary artery disease (CAD), then typical angina with coronary artery stenosis ranging from 50 to 70% or vascular segments could not be analysed due to severe calcification, so ICA was further performed for definitive diagnosis, and the ICA results were taken as the final diagnosis. All patients in the ICA group underwent ICA examination directly. Demographic data, cardiovascular risk factors, biochemical criteria, chest pain classification, coronary vessel lesion severity and drug use were compared between the two groups. All patients were followed for 1 year after discharge to observe major adverse cardiovascular events (MACE). The differences in unnecessary ICA rates, 1-year MACE rates, allergic reactions to contrast agents and hospitalization costs between the two groups were analysed. On the basis of the baseline clinical data of patients included in this study, a risk prediction model for obstructive CAD was established by logistic regression.

RESULTS

(1) There were 592 patients in the CCTA group and 594 patients in the ICA group. The percentage of unnecessary ICA procedures was 7.5% in the CCTA group and 55.2% in the ICA group (P < 0.001), which was a decrease of 86.4%. (2) Eighteen patients in the CCTA group were readmitted for severe angina, 4 of whom underwent unplanned percutaneous coronary intervention (PCI). Eight patients in the ICA group were readmitted for severe angina, 2 of whom underwent unplanned PCI. There were no cardiac deaths, nonfatal myocardial infarctions or strokes in either group over the 1-year follow-up. There was no statistically significant difference in the rate of MACE-free survival between the two groups (97.0% vs. 98.7%, log-rankχ²=1.996, P = 0.158). (3) Allergic reactions to contrast agent were observed in 28 patients in the CCTA group and 16 in the ICA group (P = 0.190). (4) The median hospitalization cost in the CCTA group was $1259.54, and that in the ICA group was $1399.41, which was a significant difference (P < 0.001) and a decrease of 9.99%. (5) Based on the combination of the logistic regression forward selection method and backward elimination method, variables with P < 0.05, including creatinine, age, physical activity-induced symptoms, hyperlipidaemia, diabetes and smoking history, were selected from the baseline data of patients to predict obstructive CAD. The above variables were used to establish a risk prediction model for obstructive CAD. The area under the ROC curve (AUC) of this model was 0.721, indicating good predictive ability.

CONCLUSION

In patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established on the basis of the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, whereas patients with a high probability can be given priority for ICA.

Renal Function-Stratified Comparison of Short- and Long-Term Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention With Third-Generation Drug-Eluting Stents - Post Hoc Analysis From the HOST-IDEA Randomized Clinical Trial

BACKGROUND

The optimal duration of dual antiplatelet therapy (DAPT) in patients with chronic kidney disease undergoing percutaneous coronary intervention (PCI), especially with third-generation drug-eluting stents (DES), remains unknown.

METHODS AND RESULTS

We conducted a prespecified post hoc analysis of the HOST-IDEA trial, randomizing patients undergoing PCI with third-generation DES to 3- to 6-month or 12-month DAPT. In all, 1,997 patients were grouped by their estimated glomerular filtration rate (eGFR): high (>90 mL/min/1.73 m2), intermediate (60-90 mL/min/1.73 m2), and low (<60 mL/min/1.73 m2). The primary outcome was net adverse clinical events (NACE), a composite of cardiac death, target vessel myocardial infarction, clinically driven target lesion revascularization, stent thrombosis, or major bleeding (Bleeding Academic Research Consortium Type 3 or 5) at 12 months. Secondary outcomes were target lesion failure (TLF) and major bleeding. The low eGFR group had the highest rates of NACE, TLF, and major bleeding compared with the other 2 groups (P<0.001). Rates of NACE were similar in the 3- to 6-month and 12-month DAPT in the high (2.9% vs. 3.2%; P=0.84), intermediate (2.1% vs. 2.8%, P=0.51), and low (8.9% vs. 9.1%; hazard ratio 0.99; P=0.97; Pinteraction=0.88) eGFR groups. TLF and major bleeding events showed similar trends.

CONCLUSIONS

In patients undergoing PCI with third-generation DES, 3- to 6-month DAPT was comparable to 12-month DAPT for clinical outcomes regardless of renal function.

Remnant cholesterol is associated with unstable carotid plaque in a neurologically healthy population

BACKGROUND

Remnant cholesterol (RC) is considered to be one of the most significant and important risk factors for atherosclerotic cardiovascular disease (ASCVD). Nonetheless, the association between RC and unstable carotid plaque remains unclear. Our primary objective is to ascertain whether RC exhibits an independent and significant association with unstable carotid plaque in a neurologically healthy population.

METHODS

In the cross-sectional study, we enrolled neurologically healthy participants who visited our centre for health checkups between 2021 and 2022. All eligible participants underwent a standardised questionnaire, physical examinations and laboratory testing. The carotid plaque was evaluated with a standard carotid ultrasound and an advanced ultrasound imaging technique called superb microvascular imaging. The correlation between lipids and unstable carotid plaque was primarily assessed utilising univariate and multivariate logistic regression.

RESULTS

The study totally enrolled 1100 participants who had an average age of 57.00 years (IQR: 49.00-63.00), with 67.55% being men. Among the participants, 321 (29.18%) had unstable carotid plaque. In the multivariate logistic regression analysis, higher RC had an independent association with an elevated incidence of unstable carotid plaque compared with the lowest concentrations of RC (OR=1.673, 95% CI 1.113 to 2.515, p=0.0134), but not other lipids. In addition, apolipoprotein A1 was negatively related to unstable carotid plaque (OR=0.549, 95% CI 0.364 to 0.830, p=0.0045).

CONCLUSIONS

Elevated concentrations of RC are independently and excellently correlated with unstable carotid plaque within a neurologically healthy population.

Linking Cardiovascular Disease and Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): The Role of Cardiometabolic Drugs in MASLD Treatment

The link between cardiovascular disease (CVD) and metabolic dysfunction-associated steatotic liver disease (MASLD) is well-established at both the epidemiological and pathophysiological levels. Among the common pathophysiological mechanisms involved in the development and progression of both diseases, oxidative stress and inflammation, insulin resistance, lipid metabolism deterioration, hepatokines, and gut dysbiosis along with genetic factors have been recognized to play a pivotal role. Pharmacologic interventions with drugs targeting common modifiable cardiometabolic risk factors, such as T2DM, dyslipidemia, and hypertension, are a reasonable strategy to prevent CVD development and progression of MASLD. Recently, a novel drug for metabolic dysfunction-associated steatohepatitis (MASH), resmetirom, has shown positive effects regarding CVD risk, opening new opportunities for the therapeutic approach of MASLD and CVD. This review provides current knowledge on the epidemiologic association of MASLD to CVD morbidity and mortality and enlightens the possible underlying pathophysiologic mechanisms linking MASLD with CVD. The role of cardiometabolic drugs such as anti-hypertensive drugs, hypolipidemic agents, glucose-lowering medications, acetylsalicylic acid, and the thyroid hormone receptor-beta agonist in the progression of MASLD is also discussed. Metformin failed to prove beneficial effects in MASLD progression. Studies on the administration of thiazolinediones in MASLD suggest effectiveness in improving steatosis, steatohepatitis, and fibrosis, while newer categories of glucose-lowering agents such as GLP-1Ra and SGLT-2i are currently being tested for their efficacy across the whole spectrum of MASLD. Statins alone or in combination with ezetimibe have yielded promising results. The conduction of long-duration, large, high-quality, randomized-controlled trials aiming to assess by biopsy the efficacy of cardiometabolic drugs to reverse MASLD progression is of great importance.

Sex-Specific Improvements in Myocardial Function and Angiogenesis with SGLT-2 Inhibitor Canagliflozin in a Swine Model of Metabolic Syndrome

There is a significant body of literature to suggest that coronary artery disease (CAD) is a highly sex-specific disease. The study of sex-specific therapeutics and sex-specific responses to treatment for CAD remains underreported in the literature. Sodium-glucose transporter 2 (SGLT2) inhibitors are of growing interest in the treatment of ischemic heart disease and heart failure; however, the sex-specific response to SGLT2 inhibitors is unknown. We studied an SGLT2 inhibitor, canagliflozin, in a swine model of metabolic syndrome (MS) and chronic myocardial ischemia with emphasis on the sex-specific outcomes. Yorkshire swine (n = 21) were obtained at 6 weeks of age and fed a high-fat diet to induce MS. Left thoracotomy was performed on all swine at 11 weeks of age for the placement of an ameroid constrictor to model chronic myocardial ischemia. Swine recovered for two weeks, then were assigned to either the drug group, CAN 300 mg daily group (M = 5, F = 5), or the control group (CON, M = 5, F = 6). Both groups received 5 weeks of therapy. After completion of therapy, swine underwent functional assessment and terminal harvest. The male animals treated with CAN (CAN-M) had significant increases in stroke volume and cardiac output (p = 0.047, p < 0.001) compared to control males (CON-M), which were not seen in females treated with CAN (CAN-F) compared to control females (CON-F). Effective arterial elastance was decreased in CAN-M compared to CON-M. The CAN-F group had a significant increase in ischemic myocardial capillary density compared to CON-F (p = 0.04). There was no difference in capillary density between the CAN-M and CON-M groups. CAN treatment resulted in sex-specific changes in angiogenesis and myocardial function. The CAN-M group had significant improvements in cardiac function based on afterload reduction, stroke volume, and increased cardiac output not seen in the CAN-F group. The CAN-F group had increased ischemic myocardial capillary density. These findings provide a foundation for further investigation of the sex-specific effects of SGLT-2 inhibitors in humans.

Titanium-nitride-oxide-coated vs. drug-eluting stents in acute coronary syndromes: an individual patient data meta-analysis

BACKGROUND AND AIMS

In acute coronary syndromes (ACS), vascular healing at the site of implantation of drug-eluting stents (DES) can be delayed. Titanium-nitride-oxide-coated stents (TiNOS) demonstrate faster strut coverage without the excessive intimal hyperplasia observed with bare metal stents. The 5-year outcomes of patients presenting with ACS, randomized to receive either TiNOS or DES, were compared.

METHODS

A systematic review and individual participant data meta-analysis of trials comparing TiNOS with DES for the treatment of ACS was conducted (PROSPERO: CRD42024514342). The primary endpoint was major adverse cardiac events (MACE) at 5 years, a composite of cardiac death (CD), myocardial infarction (MI), and ischaemia-driven target lesion revascularization (TLR). Pre-specified secondary endpoints included CD, MI, TLR, and stent thrombosis. Data were pooled using a mixed-effects Cox regression model with random slope and stratified baseline hazards.

RESULTS

Patient-level data (n = 2743) were obtained from three randomized controlled trials (TiNOS: n = 1620 vs. DES: n = 1123). After a median follow-up of 4.93 years, there was no significant difference in the primary endpoint between TiNOS and DES (12.6% vs. 16.2%; hazard ratio [HR] .82, 95% confidence interval [CI] .67-1.00, P = .051), mainly due to a similar rate of TLR (8.0% vs. 8.1%; HR 1.05, 95% CI .80-1.38, P = .733). However, TiNOS was associated with significantly lower rates of CD (1.5% vs. 3.7%; HR .46, 95% CI .26-.81, P = .007), MI (5.2% vs. 9.6%; HR .56, 95% CI .42-.75, P < .001), and stent thrombosis (1.1% vs. 3.8%; HR .30, 95% CI .17-.53, P < .001).

CONCLUSIONS

In ACS patients, TiNOS was associated with similar rates of MACE and TLR as compared with DES but significantly lower rates of CD, MI, and stent thrombosis.

Socio-geographical factors associated with cardiac rehabilitation participation after percutaneous coronary intervention: A registry-based cohort study from France

AIMS

Cardiac rehabilitation (CR) after percutaneous coronary intervention (PCI) for acute (ACS) or chronic (CCS) coronary syndrome is underutilised worldwide. The determinants of underuse are not fully understood. Using real-world data, this study explored the effect of socio-geographical factors on CR participation.

METHODS

Patients from the Aquitaine region (France) who underwent PCI between 2017 and 2019 were selected from a regional PCI register. Their 1-year CR participation was tracked using the French hospital database. Associations between CR participation and socio-geographical factors, (social deprivation, general practitioner accessibility, and distance to the nearest CR centre) were assessed through logistic regression mixed models at 1 and 3 months in ACS, and at 3 and 6 months in CCS.

RESULTS

Among the 19,002 patients, 5,073 (26.7%) participated in CR (ACS: 4,071, 33.0%; CCS: 1,002, 15.0%). A CR centre distance >25 km reduced participation at 3 months in ACS patients (OR = 0.83, 95% CI: 0.70-0.99, p = 0,023), but not at 1 month after PCI. CCS patients from most advantaged areas were more likely to participate in CR at 3 (OR = 0.62, 95% CI: 0.44-0.88, p = 0.002) and 6 months (OR = 0.59, 95% CI: 0.42-0.82, p < 0.001). General practitioner accessibility did not affect participation.

CONCLUSION

Post-PCI CR participation was low. Proximity to CR centres promoted participation for ACS patients, while CR usage correlated with higher socio-economic status for CCS patients. These findings highlight socio-geographical inequalities in CR access, providing a basis for targeted interventions, such as telerehabilitation or expanded coverage.

Anti-inflammatory Therapies for Ischemic Heart Disease

PURPOSE OF REVIEW

The inclusion of immunomodulatory strategies as supportive therapies in ischemic heart disease (IHD) has garnered significant support over recent years. Several such approaches appear to be unified through their ultimate target, the NLRP3 inflammasome. This review presents a brief update on immunomodulatory strategies in the continuum of conditions constituting ischemic heart disease and emphasising on the seemingly unifying mechanism of NLRP3 activation as well as modulation across these conditions.

RECENT FINDINGS

The NLRP3 inflammasome is a multiprotein complex assembled upon inflammatory stimulation, causing the release of pro-inflammatory cytokines and initiating pyroptosis. The NLRP3 pathway is relevant in inflammatory signalling of cardiac immune cells as well as non-immune cells in the myocardium, including cardiomyocytes, fibroblasts and endothelial cells. In addition to a focus on clinical outcome and efficacy trials of targeting NLRP3-related pathways, the potential connection between immunomodulation in cardiology and the NLRP3 pathway is currently being explored in preclinical trials. Colchicine, cytokine-based approaches and SGLT2 inhibitors have emerged as promising agents. However, the conditions comprising IHD including atherosclerosis, coronary artery disease (CAD), myocardial infarction (MI) and ischemic cardiomyopathy/heart failure (iCMP/HF) are not equally amenable to immunomodulation with the respective drugs. Atherosclerosis, coronary artery disease and ischemic cardiomyopathy are affected by chronic inflammation, but the immunomodulatory approach to acute inflammation in the post-MI setting remains a pharmacological challenge, as detrimental and regenerative effects of myocardial inflammation are initiated in unison. The NLRP3 inflammasome lies at the center of cell mediated inflammation in IHD. Recent trial evidence has highlighted anti-inflammatory effects of colchicine, interleukin-based therapy as well as SGLT2i in IHD and that the respective drugs modulate the NLRP3 inflammasome.