Nonobstructive coronary artery disease and risk of myocardial infarction

Fractional Flow Reserve Relates Stronger to Coronary Plaque Burden Than Nonhyperemic Pressure Indexes

BACKGROUND

The relationship between fractional flow reserve (FFR), resting full-cycle ratio (RFR), instantaneous wave-free ratio (iFR), resting distal pressure/aortic pressure (Pd/Pa), and plaque burden as well as phenotype requires further elucidation.

METHODS AND RESULTS

In this single-center cohort study, patients with suspected coronary artery disease who underwent invasive coronary angiography, including routine hyperemic (FFR) and nonhyperemic invasive pressure (Pd/Pa and iFR or RFR) interrogation and computed coronary tomography angiography were prospectively enrolled. Computed coronary tomography angiography was used to assess percentage atheroma volume (PAV), positive remodeling, and low-attenuation plaque.

Among 241 patients with 556 vessels, FFR correlated stronger to PAV compared with Pd/Pa (r=-0.56; versus r=-0.43; P<0.01) and iFR/RFR (r=-0.47; P=0.04). Vessels with FFR and Pd/Pa discordancy showed higher PAV in case of abnormal FFR (34% versus 14%; P<0.01), whereas vessels with FFR and iFR/RFR discordancy showed similar PAV levels. FFR and iFR/RFR, but not Pd/Pa, were independently associated with the presence of low-attenuation plaque (β, -0.03, P<0.01; β, -0.03, P=0.01; and β, -0.02, P=0.10, respectively). None of the invasive pressure measurements was independently associated with positive remodeling. Pressure index discordancy was not associated with positive remodeling or low-attenuation plaque.

CONCLUSIONS

FFR correlated stronger to plaque burden, as defined by PAV, than nonhyperemic pressure indexes. For plaque phenotype, both FFR and iFR/RFR were independently associated with low-attenuation plaque, whereas none of the invasive pressure indexes was associated with positive remodeling.

Understanding Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): a comprehensive meta-analysis of clinical characteristics, management, and prognosis compared to MI with the Obstructive Coronary Artery (MIOCA)

BACKGROUND

MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) represents a unique subset of acute coronary syndrome, distinct from MIOCA (Myocardial Infarction with Obstructive Coronary Arteries) and a control group. This study systematically compares their prevalence, clinical characteristics, management strategies, and outcomes to improve understanding and treatment approaches.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines across multiple databases up to 2024. STATA 17 was used for statistical analyses, and the Newcastle-Ottawa Scale was employed to assess study quality.

RESULTS

One-hundred and twelve studies, including 5,908,768 patients, were analyzed. The pooled prevalence of MINOCA among patients undergoing coronary angiography was 8.92% (95% CI: 8.90-8.94). MINOCA patients were generally younger, predominantly female, and more likely to present with atypical chest pain and dyspnea compared to MIOCA patients. Laboratory findings showed higher levels of CRP, BNP, and fibrinogen in MINOCA patients, suggesting inflammation and microvascular dysfunction as key mechanisms. In contrast, MIOCA patients had higher rates of diabetes and dyslipidemia, highlighting differences in pathophysiological processes. Medication use differed between the groups, with MINOCA patients more likely to be prescribed anticoagulants and β-blockers. Prognostically, MINOCA patients experienced significantly lower rates of adverse short- and long-term outcomes, including major adverse cardiac events (MACE) and cardiovascular death, compared to MIOCA patients.

CONCLUSIONS

This study demonstrated that patients with MINOCA have a better prognosis compared to those with MIOCA and are at a lower risk of serious cardiac events. Based on the findings of this study, we emphasize that microcirculation and vascular spasm are the main mechanisms involved in MINOCA. Considering these findings, it is suggested that a better management strategy for MINOCA patients can be established by precisely defining diagnostic criteria and focusing on anti-inflammatory treatments and risk factor control.

Angiogenesis after acute myocardial infarction: a bibliometric -based literature review

Objective

The prevalence of acute myocardial infarction, a severe ischemic cardiac disease, is on the rise annually. The establishment of coronary collateral circulation in the border zone of the infarct can effectively relieve myocardial ischemia and impede cell death, while angiogenesis can promote the formation of collateral circulation in the ischemic tissues. Over the past two decades, studies related to angiogenesis in acute myocardial infarction have increased rapidly. However, there is a lack of bibliometric studies in this particular field.

Methods

For this study, we employed bibliometric analysis to outline focal points and patterns in scientific and clinical research. The collection of literature was gathered using the Web of Science Core Collection database. Bibliometric and visual analysis were conducted. Knowledge maps were generated using CiteSpace and VOSviewer software.

Results and conclusions

With the deepening of the research, therapeutic angiogenesis will become a treatment direction for acute myocardial infarction in the future.

Underpinnings of Heart Failure With Preserved Ejection Fraction in Women - From Prevention to Improving Function. A Co-publication With the American Journal of Preventive Cardiology and the Journal of Cardiac Failure

Heart failure with preserved ejection fraction (HFpEF) represents a major clinical challenge with rising global prevalence. Women have a nearly double lifetime risk of developing HFpEF compared to heart failure with reduced ejection fraction (HFrEF). In HFpEF, sex differences emerge both in how traditional cardiovascular risk factors (such as hypertension, obesity, and diabetes) affect cardiac function and through distinct pathophysiological mechanisms triggered by sex-specific events like menopause and adverse pregnancy outcomes. These patterns influence not only disease development, but also therapeutic responses, necessitating sex-specific approaches to treatment. This review aims to synthesize existing knowledge regarding HFpEF in women including traditional and sex-specific risk factors, pathophysiology, presentation, and therapies, while outlining important knowledge gaps that warrant further investigation. The impact of HFpEF spans a woman's entire lifespan, requiring prevention and management strategies tailored to different life stages. While understanding of sex-based differences in HFpEF has improved, significant knowledge gaps persist. Through examination of current evidence and challenges, this review highlights promising opportunities for innovative research, therapeutic development, and clinical care approaches that could transform the management of HFpEF in women.

Presence of coronary artery disease in adults with newly detected diabetes mellitus

PURPOSE

We aimed to analyze the presence and extent of coronary artery disease in patients with newly detected diabetes mellitus.

METHODS

Clinical health examinations of asymptomatic community-dwelling adults between 2008 and 2018 at a medical center in Taiwan were reviewed. Coronary computed tomography angiography was performed in 444 participants, of which 338, 54, and 52 were categorized as 'without diabetes mellitus', 'newly detected diabetes mellitus', and 'known diabetes mellitus', respectively.

RESULTS

Prevalence of significant coronary artery disease (≥ 50% stenosis) was higher in participants with newly detected diabetes mellitus than in participants without diabetes mellitus (40.7% vs. 20.1%, p < 0.0001). Among those with coronary artery stenosis, the number of coronary vessels with significant obstruction (0.72 vs. 0.42, p = 0.0147) was also higher in participants with newly detected diabetes mellitus. Using multiple logistic regression analysis, new detection of diabetes mellitus was identified as an independent risk factor for significant coronary artery disease (odds ratio: 2.153, 95% confidence interval: 1.112-4.166).

CONCLUSION

Asymptomatic patients with newly detected diabetes mellitus had higher prevalence and greater extent of coronary artery disease than those without diabetes mellitus. More attention should thus be paid to the assessment of coronary artery disease in patients with newly detected diabetes mellitus.

Evaluation of a machine learning-based metabolic marker for coronary artery disease in the UK Biobank

BACKGROUND AND AIMS

An in silico quantitative score of coronary artery disease (ISCAD), built using machine learning and clinical data from electronic health records, has been shown to result in gradations of risk of subclinical atherosclerosis, coronary artery disease (CAD) sequelae, and mortality. Large-scale metabolite biomarker profiling provides increased portability and objectivity in machine learning for disease prediction and gradation. However, these models have not been fully leveraged. We evaluated a quantitative score of CAD derived from probabilities of a machine learning model trained on metabolomic data.

METHODS

We developed a CAD-predictive learning model using metabolic data from 93,642 individuals from the UK Biobank (median [IQR] age, 57 [14] years; 39,796 [42 %] male; 5640 [6 %] with diagnosed CAD), and assessed its probabilities as a quantitative metabolic risk score for CAD (M-CAD; range 0 [lowest probability] to 1 [highest probability]) in participants of the UK Biobank. The relationship of M-CAD with arterial stiffness index, ejection fraction, CAD sequelae, and mortality was assessed.

RESULTS

The model predicted CAD with an area under the receiver-operating-characteristic curve of 0.712. Arterial Stiffness Index increased by 0.19 and ejection fraction decreased by 0.2 % per 0.1 increase in M-CAD. Both incident and recurrent myocardial infarction increased stepwise over M-CAD quartiles (odds ratio (OR) 15.3 [4.2 %] and 12.5 [0.2 %]) in top quartiles as compared to the first quartile of incident and recurrent MI respectively). Likewise, the hazard ratio and prevalence of all-cause mortality, CVD-associated mortality, and CAD-associated mortality increased stepwise over M-CAD deciles (2.98 [14 %], 9.34 [4.3 %], 26.7 [2.7 %] in the top deciles as compared to the first decile of all-cause, CVD, and CAD mortality respectively).

CONCLUSIONS

Metabolic-based machine learning can be used to build a quantitative risk score for CAD that is associated with atherosclerotic burden, CAD sequelae and mortality.

Prognostic value of coronary plaque composition in symptomatic patients with obstructive coronary artery disease

OBJECTIVES

To determine whether plaque composition analysis defined by cardiac CT can provide incremental prognostic value above coronary artery disease (CAD) burden markers in symptomatic patients with obstructive CAD.

MATERIALS AND METHODS

Between 2009 and 2019, a multicentric registry included all consecutive symptomatic patients with obstructive CAD (at least one ≥ 50% stenosis on CCTA) and was followed for major adverse cardiovascular (MACE) defined by cardiovascular death or nonfatal myocardial infarction. Each coronary segment was scored visually for both the degree of stenosis and composition of plaque, which were classified as non-calcified, mixed, or calcified. To assess the prognostic value of each CCTA findings, different multivariable Cox regression models were used: model 1: clinical (traditional risk factors); model 2: model 1 + CAD burden (number of proximal segments with stenosis ≥ 50% + number of vessels with obstructive CAD); and model 3: model 2 + plaques feature (number of segments with non-calcified plaque).

RESULTS

Of 2312 patients (mean age 70 ± 12 years, 46% men), 319 experienced a MACE (13.8%) (median follow-up: 6.7 years (5.9-9.1)). The number of proximal segments with ≥ 50% stenosis, the number of vessels with obstructive CAD, and the number of segments with non-calcified plaque were all independently associated with MACEs (all p < 0.001). The addition of plaque composition analysis (model 3) showed the best improvement in model discrimination and reclassification (C-statistic improvement = 0.03; net reclassification improvement = 28.6%; integrative discrimination index = 5.4%, all p < 0.001).

CONCLUSIONS

In this population, the analysis of coronary plaque composition had an incremental prognostic value to predict MACEs above a model combining traditional risk factors and CAD burden.

KEY POINTS

Question Several coronary computed tomography angiography (CCTA) studies have shown the potential interest of plaque composition analysis, which can be further evaluated. Findings In symptomatic patients with obstructive coronary artery disease (CAD), plaque composition analysis had an incremental prognostic value above a model combining traditional risk factors and CAD burden. Clinical relevance In symptomatic patients with obstructive CAD, plaque composition analysis using CCTA has a strong incremental prognostic value above a model combining traditional risk factors and CAD burden, thus translating into a more accurate long-term major adverse cardiovascular event prediction.

Prognostic Implication of Computational Angiography-Derived Fractional Flow Reserve in Patients With Nonobstructive Coronary Artery Disease

BACKGROUND

Risk stratification of patients with symptomatic nonobstructive coronary artery disease remains uncertain. Our study assessed the clinical value of single-vessel, multivessel, and 3-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in patients with nonobstructive coronary artery disease.

METHODS AND RESULTS

We enrolled patients with ≤50% stenosis with a caFFR value ≥0.8 in all 3 coronary arteries on coronary angiography. The sum of caFFR values in the 3 vessels was computed for each patient. Patient stratification was based on the median value of the following criteria: single-vessel analysis, multivessel analysis, and 3-vessel analysis. The primary end point of this study was major adverse cardiac events at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. A total of 490 patients were included. The 5-year major adverse cardiac event rates in single-vessel analysis were statistically insignificant between low- and high-caFFR groups (left anterior descending artery [P=0.163]; left circumflex artery [P=0.797]; right coronary artery [P=0.127]). In multivessel analysis, patients in the multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) showed an increased risk of 5-year major adverse cardiac events compared with patients in the single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR], 2.648 [95% CI, 1.141-6.145]; P=0.023). In 3-vessel analysis, patients in the low 3-vessel caFFR group demonstrated a greater 5-year major adverse cardiac event risk than the high 3-vessel caFFR group (HR, 2.43 [95% CI, 1.087-5.433]; P=0.031).

CONCLUSIONS

We demonstrated that both multiple-vessel and 3-vessel caFFR measurements serve as valuable prognostic indicators for risk assessment in patients with nonobstructive coronary artery disease.

Clinical and Genomic Prediction of Coronary Artery Disease Subtypes

BACKGROUND

Coronary artery disease (CAD) is a complex, heterogeneous disease with distinct etiological mechanisms. These different etiologies may give rise to multiple subtypes of CAD that could benefit from alternative preventions and treatments. However, so far, there have been no systematic efforts to predict CAD subtypes using clinical and genetic factors.

METHODS

Here, we trained and applied statistical models incorporating clinical and genetic factors to predict CAD subtypes in 26 036 patients with CAD in the UK Biobank. We performed external validation of the UK Biobank models in the US-based All of Us cohort (8598 patients with CAD). Subtypes were defined as high versus normal LDL (low-density lipoprotein) levels, high versus normal Lpa (lipoprotein A) levels, ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction, occlusive versus nonocclusive CAD, and stable versus unstable CAD. Clinical predictors included levels of ApoA, ApoB, HDL (high-density lipoprotein), triglycerides, and CRP (C-reactive protein). Genetic predictors were genome-wide and pathway-based polygenic risk scores (PRSs).

RESULTS

Results showed that both clinical-only and genetic-only models can predict CAD subtypes, while combining clinical and genetic factors leads to greater predictive accuracy. Pathway-based PRSs had higher discriminatory power than genome-wide PRSs for the Lpa and LDL subtypes and provided insights into their etiologies. The 10-pathway PRS most predictive of the LDL subtype involved cholesterol metabolism. Pathway PRS models had poor generalizability to the All of Us cohort.

CONCLUSIONS

In summary, we present the first systematic demonstration that CAD subtypes can be distinguished by clinical and genomic risk factors, which could have important implications for stratified cardiovascular medicine.

Exploring patients' views regarding the support and rehabilitation needs of people living with myocardial ischaemia and no obstructive coronary arteries: a qualitative interview study

OBJECTIVES

This study aimed to generate new qualitative insights to understand the rehabilitation needs of people living with a confirmed or presumed diagnosis of ischaemia with no obstructive coronary arteries (INOCA), explore which aspects of current cardiovascular prevention and rehabilitation programmes could meet the needs of people with INOCA and where adjustments (if any) may be appropriate.

DESIGN

Semistructured qualitative interview study.

PARTICIPANTS

Interviews were undertaken (n=17; 88% female, age range 31-69 years) with people with a confirmed or presumed diagnosis of INOCA.

RESULTS

Findings highlighted concerns around a lack of evidence-based guidance for cardiovascular prevention and rehabilitation programmes for patients with INOCA. Participants expressed a desire for modular cardiovascular prevention and rehabilitation programmes that could be accessed flexibly to accommodate episodic fluctuations in symptoms. Participants suggested that existing cardiovascular prevention and rehabilitation programme content needed adjustment including enhanced psychosocial support, supervised low-impact physical activity and specialist dietary advice and medication reviews. Additional elements specific to INOCA should be made available as appropriate including acute care planning and a module to provide information and support for female-specific issues. The importance of involving INOCA patients in the codesign of future programmes and associated training was emphasised.

CONCLUSIONS

People with INOCA are willing to engage with cardiovascular prevention and rehabilitation programmes and express a desire for more support. This patient group shares some barriers to rehabilitation programme attendance with other cardiac patient groups, but they also have specific concerns about the need for improved professional knowledge and evidence-based guidance regarding the management of INOCA. Cardiovascular rehabilitation programmes need to be delivered flexibly and individually tailored to ensure the relapsing and remitting nature of INOCA and associated support needs are addressed.

Unveiling the Longitudinal Journey: 3-Year Follow-up of Women with MINOCA and INOCA in a Specialized Heart Centre

Background

Myocardial infarction with no obstructive coronary arteries (MINOCA), and ischemia with no obstructive coronary arteries (INOCA), are female-predominant conditions; clinical trials are lacking to guide medical management for the common underlying vasomotor etiologies. Data on long-term outcomes of (M)INOCA patients following attendance at a women's heart centre (WHC) are lacking.

Methods

Women diagnosed with MINOCA (n = 51) or INOCA (n = 112) were prospectively followed for 3 years at the Leslie Diamond WHC (LDWHC) in Vancouver. Baseline characteristics, diagnoses, chest-pain type, major adverse cardiac events, hospital encounters, medications, and Seattle Angina Questionnaire (SAQ) responses were compared between the baseline and 3-year timepoints. The χ2 test was used to compare categorical variables; the Student t test was used for continuous variables.

Results

MINOCA patients had significantly more nonexertional chest pain and more diagnoses of vasospasm than did INOCA patients, who had more exertional chest pain and more diagnoses of coronary microvascular dysfunction. Following the baseline timepoint, both groups had significant reductions in cardiovascular emergency room visits, with INOCA patients also experiencing fewer cardiovascular hospitalizations. At 3 years, the most commonly prescribed medications were calcium-channel blockers, long-acting nitrates, and beta-blockers, with MINOCA patients having more acetylsalicylic acid use, and INOCA patients having more short-acting nitrate and ranolazine prescriptions. Both groups observed significant improvements in SAQ scores, with greater improvements observed in INOCA patients. Patients with depression or who were prescribed ranolazine at 3 years had worse SAQ scores at baseline.

Conclusions

The 3-year outcomes of (M)INOCA patients indicate that the LDWHC's comprehensive care model effectively improves diagnostic clarity, reduces the number of hospital encounters, optimizes medication management, and improves self-reported patient well-being.

Reassessing the Role of Ischemia Imaging: Insights from the ISCHEMIA Trial

Ischemia imaging plays an important role in prognostication as well as guiding decision for revascularization with known CAD, as shown in multiple observational registries. However, results from the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) presented conflicting results, hinting at no survival benefit after revascularization in patients with moderate to severe ischemia on nuclear imaging. More recent analysis from the trial did, however, show decrease in cardiac mortality and increase in non-cardiac mortality following early revascularization. However, the ISCHEMIA trial has several limitations; most importantly, the trial design does not support a comparison between imaging modalities. Additionally, results of the trial do not apply to patients with previous CABG or ACS as they are exclusion criteria, which affects the diagnostic accuracy of nuclear stress imaging. Observational imaging registries offer better evidence about the accuracy of single-photon emission computed tomography (SPECT) and positron emission tomography (PET) in guiding revascularization for patients with ischemia. Results from ISCHEMIA trial can be used to guide management of patients with severe to moderate ischemia, provided they meet inclusion criteria. For those who do, shared decision-making is important to decide between invasive management or optimal medical therapy only.

Cross-Sectional Analyses to Assess the Clinical Safety and Effectiveness of Bisoprolol in Patients With Non-obstructive Coronary Artery Disease Who Underwent Percutaneous Coronary Intervention: A Post-hoc Analysis

INTRODUCTION

Elevated central aortic pressure, cardiac output and peripheral vascular resistance contribute to high morbidity in relation to end organ dysfunction in obstructive and non-obstructive coronary artery disease (NOCAD) cases despite revascularization. Bisoprolol preempts further progression of left ventricular dysfunction in such cases due to anti-ischemic and anti-hypertensive effects, further extending its evaluation in local Indian settings.

METHODS

Post-hoc analyses of NOCAD patients with epicardial stenosis (N=378, 30 to 70% stenosis) from cross-sectional analyses conducted across eighty centers in India. Local ethics approval for study documents and endpoints for analyses was conducted in adherence to ICH-Good Clinical Practice (GCP) and Declaration of Helsinki guidelines. Descriptive and analytical statistics were performed using SPSS Version 29.0.1.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Per-protocol analyses of NOCAD (N=378) showed (mean) age: 58.63 years (286 males and 92 females); mean weight: 75.49kg; mean BMI: 27.78kg/m2 and baseline left ventricular ejection fraction (LVEF): (46.85%). Prevalent risk factors include hypertension (100%), dyslipidemia (51.85%), smoking (24.07%), type 2 diabetes (59.52%), stroke (20.37%) and peripheral artery disease (4.76%). In overall population (n=800), bisoprolol (2.5 to 5mg/day) showed significant reduction in resting heart rate (RHR) (14bpm), and LVEF (5.08%). Similarly, in NOCAD cases significant changes in RHR (12.14bpm), and LVEF (4.68%) were noted at 24 weeks. Adverse events included chest congestion (6.61%), asthenia (5.03%), hypotension (4.76%), muscular weakness (3.70%), and bradycardia (1.85%) that were mild to moderate with none requiring treatment withdrawal.

CONCLUSION

Bisoprolol remains a clinically feasible option in Indian patients with NOCAD cases following percutaneous coronary intervention (PCI) as it reduces RHR and improves LVEF. Despite high rates of cardiovascular risk factors like age, type 2 diabetes and diffuse polyvascular disease, the drug was well-tolerated, with fewer adverse events. These results support the use of bisoprolol in managing NOCAD in Indian patients, highlighting its potential therapeutic uses to prevent further cardiac dysfunction.

Safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis and deferred revascularization

INTRODUCTION AND OBJECTIVES

This study investigated the safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their fractional flow reserve (FFR).

METHODS

A nationwide cohort study was conducted using the Korean National Health Insurance Service database. A total of 4657 patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR were identified from 2013 to 2020. FFR was indicated in patients with no prior evidence of myocardial ischemia and intermediate coronary artery stenosis (50%-70%) as determined by quantitative coronary angiography. Patients were classified according to whether antiplatelet therapy was initiated after the index procedure. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during a 5-year follow-up period. The primary safety outcome was any gastrointestinal bleeding.

RESULTS

After propensity score matching, there were 1634 patients in the antiplatelet therapy group and 1634 in the nonantiplatelet therapy group. The risk of MACCE was similar between the 2 groups (24.8% vs 24.7%; adjusted HR, 0.97; 95%CI, 0.84-1.13; P=0.745). The risk of gastrointestinal bleeding was higher in the antiplatelet therapy group than in the nonantiplatelet therapy group (2.2% vs 1.2%; aHR, 2.07; 95%CI, 1.08-4.00). These results were similar in subgroup analyses.

CONCLUSIONS

In patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR, antiplatelet therapy may increase the risk of gastrointestinal bleeding without reducing the risk of future ischemic events.

Diagnostic Yield of Comprehensive Coronary Function Testing in Patients with Angina and Unobstructed Coronary Arteries: Endotype Characterisation and Clinical Implications

Background

Coronary functional disorders (CFD) are significant contributors to angina with non-obstructed coronary arteries (ANOCA). Various endotypes, such as epicardial or microvascular spasm and/or coronary microvascular dysfunction (CMD), have been identified. Previous studies have shown a high prevalence of CFD in ANOCA cases, but often lacked comprehensive coronary functional testing (CFT), which ideally includes coronary spasm provocation testing and CMD assessment. This study aims to investigate the prevalence of CFD and to characterise endotypes in ANOCA patients using comprehensive CFT.

Methods

A total of 89 consecutive ANOCA patients (mean age 64, 69% women) who underwent comprehensive CFT were enrolled. CFT comprised acetylcholine (ACh) spasm provocation testing and assessment of coronary flow reserve (CFR) and hyperaemic microvascular resistance using Doppler technique.

Results

CFT identified at least one coronary vasomotion disorder in 91% of patients with ANOCA. Among them, microvascular spasm was the most common endotype (61%), followed by CMD (43%). Only 9% of patients had isolated CMD with the remaining CMD patients also showing coronary spasm. Low CFR was mainly associated with high resting coronary flow rather than impaired hyperaemic flow (R -0.60, p<0.0001). Additionally, 48% of patients with microvascular spasm exhibited moderate to severe coronary tortuosity.

Conclusion

CFT provides a high diagnostic yield of CFD in ANOCA patients. Coronary spasm, particularly microvascular spasm, is the most frequent endotype. Patients with isolated CMD are rare, highlighting the importance of spasm testing in the ANOCA population.

Effects of statins in patients with coronary artery spasm: A nationwide population-based study

Controversies regarding the benefits of statin treatment on clinical outcomes in coronary artery spasm (CAS) without obstructive coronary artery disease (CAD) persist due to limited data. In this retrospective nationwide population-based cohort study from the Taiwan National Health Insurance Research Database during the period 2000-2012, the matched cohorts consisted of 12,000 patients with CAS. After propensity score matching with 1:1 ratio, 2216 patients were eligible for outcome analysis in either statin or nonstatin group, with the mean follow-up duration of 4.8 and 4.6 years, respectively. Statin users versus nonusers had a significantly reduced risk of major adverse cardiovascular events (MACEs) (6.7% vs. 9.5%, hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.55-0.84) and all-cause mortality (6.0% vs. 7.6%; HR 0.77; 95% CI 0.61-0.96). While the results of MACEs were mainly contributed by cardiovascular death (1.9% vs. 3.2%; HR 0.56; 95% CI 0.38-0.83) and ischemic stroke (3.8% vs. 5.4%; subdistribution HR 0.69; 95% CI 0.52-0.91), they were primarily driven by reductions in ischemic but not hemorrhagic stroke. The benefit of statins was significantly pronounced in patients with hypertension and diabetes. Nevertheless, the effect on MACEs was consistent irrespective of age, sex, dyslipidemia, and mental disorder. Statins significantly reduced the risk of MACEs and all-cause mortality in CAS patients. The benefit of statin therapy in reducing MACEs appeared to be linear, with greater risk reduction with higher doses and longer duration without upper threshold, reflecting the dose-dependent relationship of statins with MACEs in CAS patients.

The Role of Cardiac Computed Tomography Angiography in Risk Stratification for Coronary Artery Disease

Coronary computed tomography angiography (CCTA) allows the assessment of the presence and severity of obstructive and nonobstructive atherosclerotic coronary artery disease. With software developments incorporating artificial intelligence-based automated image analysis along with improved spatial resolution of CT scanners, volumetric measurements of atherosclerotic plaque, detection of high-risk plaque features, and delineation of pericoronary adipose tissue density can now be readily and accurately evaluated for a given at-risk patient. Many of these expanded diagnostic measures have been shown to be prognostically useful for prediction of major adverse cardiac events. The incremental value of plaque quantification over diameter stenosis has yet to be thoroughly discovered in current studies. Furthermore, the physiological significance of lesions can also be assessed with CT-derived fractional flow reserve, myocardial CT perfusion, and more recently shear stress, potentially leading to selective invasive coronary angiography and revascularization. Along with these technological advancements, there has been additional high-quality evidence for CCTA including large randomized clinical trials supporting high-level recommendations from many international clinical practice guidelines. Current trials largely compare a CCTA vs functional testing strategy, yet there is minimal evidence on CCTA plaque-guided therapeutic trials to measure regression of atherosclerosis and prevention of major coronary artery disease events. In this review, we summarize current evidence on comprehensive risk assessment with CCTA and future directions.

Association of the triglyceride glucose index with myocardial ischemia in patients with minimal to moderate coronary artery disease

The triglyceride glucose (TyG) index has been suggested as a reliable substitute to indicate insulin resistance. Several studies have identified the association between the TyG index and cardiovascular disease. However, the association between the TyG index and the incidence of myocardial ischemia in patients with minimal to moderate coronary artery disease (CAD) has not been clearly assessed. We aimed to investigate the association between the TyG index and the incidence of myocardial ischemia in patients with minimal to moderate CAD. A total of 1,697 patients who underwent coronary computed tomography angiography (CTA) examinations and had minimal to moderate CAD were retrospectively included in the study. The TyG index and computed tomography-derived fractional flow reserve (CT-FFR) were used to assess insulin resistance (IR) and myocardial ischemia, respectively. Myocardial ischemia was defined as a CT-FFR value ≤ 0.80. Logistic regression models were used to explore the associations between the TyG index and myocardial ischemia. The incidence of myocardial ischemia was higher in the highest TyG index tertile (T3) group than in the lowest TyG index tertile (T1) group. After adjusting for other variables, the T3 group remained associated with a higher risk of myocardial ischemia than the T1 group did (OR, 1.43; 95% CI, 1.01-2.04; p = 0.047). A 1- standard deviation (SD) increase in the TyG index was correlated with a 19-24% elevated risk of myocardial ischemia when regarding the TyG index was considered as a continuous variable. Subgroup analysis revealed similar effects. A TyG index is associated with a higher risk of myocardial ischemia detected by CT-FFR in patients with minimal to moderate CAD.

The LDL cumulative exposure hypothesis: evidence and practical applications

The trapping of LDL and other apolipoprotein B-containing lipoproteins within the artery wall causes atherosclerosis. As more LDL becomes trapped within the artery wall over time, the atherosclerotic plaque burden gradually increases, raising the risk of an acute cardiovascular event. Therefore, the biological effect of LDL on the risk of atherosclerotic cardiovascular disease (ASCVD) depends on both the magnitude and duration of exposure. Maintaining low levels of LDL-cholesterol (LDL-C) over time decreases the number of LDL particles trapped within the artery wall, slows the progression of atherosclerosis and, by delaying the age at which mature atherosclerotic plaques develop, substantially reduces the lifetime risk of ASCVD events. Summing LDL-C measurements over time to calculate cumulative exposure to LDL generates a unique biomarker that captures both the magnitude and duration of exposure, which facilitates the estimation of the absolute risk of having an acute cardiovascular event at any point in time. Titrating LDL-C lowering to keep cumulative exposure to LDL below the threshold at which acute cardiovascular events occur can effectively prevent ASCVD. In this Review, we provide the first comprehensive overview of how the LDL cumulative exposure hypothesis can guide the prevention of ASCVD. We also discuss the benefits of maintaining lower LDL-C levels over time and how this knowledge can be used to inform clinical practice guidelines as well as to design novel primary prevention trials and ASCVD prevention programmes.

Fractional Flow Reserve and Fractional Flow Reserve Gradient From CCTA for Predicting Future Coronary Events

Background

Coronary computed tomography angiography-derived fractional flow reserve (FFRCT) is a per-vessel index reflecting cumulative hemodynamic burden while coronary events occur in focal lesions.

Objectives

The authors sought to evaluate the additive prognostic value of the local gradient of FFRCT (FFRCT gradient) in addition to FFRCT to predict future coronary events.

Methods

The current study included 245 patients (634 vessels) who underwent coronary computed tomography angiography within 6 to 36 months before the index angiography, of which 209 vessels had future coronary events and 425 vessels did not. Future coronary events were defined as a composite of vessel-specific myocardial infarction or urgent revascularization during a mean interval of 1.5 years. Pre-existing disease patterns were classified according to FFRCT of ≤0.80 and FFRCT gradient of ≥0.025/mm.

Results

Both FFRCT (per 0.01 decrease; adjusted HR: 1.040; 95% CI: 1.029-1.051; P < 0.001) and FFRCT gradient (per 0.01 increase; adjusted HR: 1.144; 95% CI: 1.101-1.190; P < 0.001) were significantly associated with the risk of future coronary events. Lesions with FFRCT gradient of ≥0.025/mm showed significantly higher risk of future coronary events than those with FFRCT gradient of <0.025/mm in both the FFRCT >0.80 (49.2% vs 30.1%; HR: 2.069; 95% CI: 1.265-3.385; P = 0.004) and FFRCT ≤0.80 groups (60.9% vs 38.3%; HR: 1.988; 95% CI: 1.317-2.999; P =0 .001). Adding FFRCT gradient into the model with FFRCT alone showed significantly increased predictability of future coronary events (global chi-square: 45.8 vs 39.9; P = 0.015).

Conclusions

Patients with high FFRCT gradient showed increased risk of future coronary events irrespective of FFRCT. Integrating both FFRCT and FFRCT gradient showed incremental predictability of future coronary events compared with FFRCT alone. (Prediction and Validation of Clinical Course of Coronary Artery Disease With CT-Derived Non-Invasive Hemodynamic Phenotyping and Plaque Characterization [DESTINY Study]; NCT04794868).

Comparative effectiveness of positron emission tomography and single-photon emission computed tomography myocardial perfusion imaging for predicting risk in patients with cardiometabolic disease

BACKGROUND

The epidemiology of coronary artery disease (CAD) has shifted, with increasing prevalence of cardiometabolic disease and decreasing findings of obstructive CAD on myocardial perfusion imaging (MPI). Coronary microvascular dysfunction (CMD), defined as impaired myocardial flow reserve (MFR) by positron emission tomography (PET), has emerged as a key mediator of risk. We aimed to assess whether PET MFR provides additive value for risk stratification of cardiometabolic disease patients compared with single-photon emission computed tomography (SPECT) MPI.

METHODS

We retrospectively followed patients referred for PET, exercise SPECT, or pharmacologic SPECT MPI with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. We compared rates and hazards of composite major adverse cardiovascular events (MACEs) (annualized cardiac mortality or acute myocardial infarction) among propensity-matched PET and SPECT patients using Poisson and Cox regression. Normal SPECT was defined as a total perfusion deficit (TPD) of <5%, reflecting the absence of obstructive CAD. Normal PET was defined as a TPD of <5% plus an MFR of ≥2.0.

RESULTS

Among 21,544 patients referred from 2006 to 2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (P < 0.001). Obstructive CAD findings (TPD > 5%) were uncommon (PET: 21% and SPECT: 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In a propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, P < 0.001 compared to normal PET).

CONCLUSIONS

Cardiometabolic disease is common among patients referred for MPI and is associated with a heterogenous level of risk. Compared with pharmacologic SPECT, PET with MFR can detect nonobstructive CAD including CMD and can more accurately discriminate low-risk from higher-risk individuals.

Patients With Nonobstructive Coronary Artery Disease and Chest Pain: Impact of Obesity and Depressive Symptoms

BACKGROUND

Chest pain (CP) in patients with nonobstructive coronary artery disease is a therapeutic challenge affecting morbidity and mortality. We aimed to identify clinical factors associated with CP in this population, hypothesizing that obesity and depressive symptoms are associated with CP.

METHODS AND RESULTS

In 814 patients with angiographically confirmed nonobstructive coronary artery disease, we measured sociodemographic variables, clinical risk factors, medications, and Patient Health Questionnaire 9 scores for depressive symptoms. We assessed CP frequency and prevalence by using all items from the Seattle Angina Questionnaire angina frequency domain to generate an angina frequency composite score. In the overall sample (58.8±11.7 years old, 52.6% female), 42.8% had obesity, and 71.5% had CP, with an angina frequency composite score (SD) score of 76.4 (22.1). Compared with individuals without obesity, individuals with obesity had a higher prevalence (77.6% versus 67%, P<0.001) and more frequent CP (angina frequency composite score, 74.9 [SD, 22.2] versus 78.3 [SD, 21.9], P=0.02). Obesity was independently associated with CP occurrence (odds ratio [OR], 1.7 [95% CI, 1-2.9], P=0.04). Obesity's connection with CP was only in men: men with obesity had more frequent CP (angina frequency composite score, 75.8 [SD, 20.1] versus 82.1 [SD, 19.9], P=0.002) and more prevalent CP (79.5% versus 58.2%, P<0.001) than their counterparts insofar as men with obesity had similar CP to women. Patient Health Questionnaire 9 score (OR, 1.07 [95% CI, 1.01-1.13], P=0.03) was independently associated with CP and partly mediated the association between obesity and CP.

CONCLUSIONS

Obesity and depressive symptoms were independently associated with CP in individuals with nonobstructive coronary artery disease, particularly in men, and depressive symptoms partly mediated this association.

Pericoronary adipose tissue for predicting long-term outcomes

AIMS

Pericoronary adipose tissue (PCAT) attenuation obtained by coronary computed tomography angiography (CCTA) has been associated with coronary inflammation and outcomes. Whether PCAT attenuation is predictive of major adverse cardiac events (MACE) during long-term follow-up is unknown.

METHODS AND RESULTS

Symptomatic patients with coronary artery disease (CAD) who underwent CCTA were included, and clinical outcomes were evaluated. PCAT was measured at all lesions for all three major coronary arteries using semi-automated software. A comparison between patients with and without MACE was made on both a per-lesion and a per-patient level. The predictive value of PCAT attenuation for MACE was assessed in Cox regression models. In 483 patients (63.3 ± 8.5 years, 54.9% men), 1561 lesions were analysed over a median follow-up duration of 9.5 years. The mean PCAT attenuation was not significantly different between patients with and without MACE. At a per-patient level, the adjusted hazard ratio (HR) and 95% confidence interval (CI) for MACE were 0.970 (95% CI: 0.933-1.008, P = 0.121) when the average of all lesions per patient was analysed, 0.992 (95% CI: 0.961-1.024, P = 0.622) when only the most obstructive lesion was evaluated, and 0.981 (95% CI: 0.946-1.016, P = 0.285) when only the lesion with the highest PCAT attenuation per individual was evaluated. Adjusted HRs for vessel-specific PCAT attenuation in the right coronary artery, left anterior descending artery, and left circumflex artery were 0.957 (95% CI: 0.830-1.104, P = 0.548), 0.989 (95% CI: 0.954-1.025, P = 0.550), and 0.739 (95% CI: 0.293-1.865, P = 0.522), respectively, in predicting long-term MACE.

CONCLUSION

In patients referred to CCTA for clinically suspected CAD, PCAT attenuation did not predict MACE during long-term follow-up.

Prevalence of Coronary Vasomotor Disorders in Patients With Angina and Nonobstructive Coronary Arteries: A Sydney Experience

BACKGROUND

Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes.

METHOD

Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing.

RESULTS

This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007).

CONCLUSIONS

Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.

Increased circulating levels of malondialdehyde-modified low-density lipoprotein in patients with coronary microvascular dysfunction

BACKGROUND

Coronary microvascular dysfunction (CMD) is associated with angina symptoms and adverse clinical outcomes in patients without obstructive coronary artery disease (CAD). Malondialdehyde-modified low-density lipoprotein (MDA-LDL) is reportedly a marker of the initiation and acceleration of epicardial coronary atherosclerosis. However, its impact on CMD remains unclear.

OBJECTIVE

We aimed to investigate the relationship between CMD and MDA-LDL levels.

METHODS

This study included 95 patients who did not receive lipid-lowering medications and had no obstructive CAD. Obstructive CAD was defined as >50% diameter reduction on coronary angiography or fractional flow reserve of ≤0.80. We retrospectively analyzed coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and MDA-LDL levels. CMD was defined as either CFR <2.0 or IMR ≥25.

RESULTS

CMD was observed in 29 (31%) patients. MDA-LDL levels were significantly higher in patients with CMD than in those without CMD (124.8 ± 37.6 vs. 95.3 ± 29.5 U/L; p < 0.01). Univariable logistic regression analysis indicated a significant relationship between CMD and MDA-LDL levels (odds ratio (OR): 1.03; p < 0.01). In the multivariable model, MDA-LDL levels were significantly associated with CMD (OR: 1.02; p < 0.01). Regression analysis showed a significant correlation between MDA-LDL levels and CFR (r = -0.42, p < 0.01) and IMR (r = 0.35, p < 0.01). In the multiple regression analysis, MDA-LDL levels were independently associated with CFR (β = -0.30, p < 0.01) and IMR (β = 0.26, p = 0.02).

CONCLUSION

MDA-LDL levels were associated with CMD in patients without obstructive CAD.

Artificial Intelligence-Enabled Quantitative Coronary Plaque and Hemodynamic Analysis for Predicting Acute Coronary Syndrome

BACKGROUND

A lesion-level risk prediction for acute coronary syndrome (ACS) needs better characterization.

OBJECTIVES

This study sought to investigate the additive value of artificial intelligence-enabled quantitative coronary plaque and hemodynamic analysis (AI-QCPHA).

METHODS

Among ACS patients who underwent coronary computed tomography angiography (CTA) from 1 month to 3 years before the ACS event, culprit and nonculprit lesions on coronary CTA were adjudicated based on invasive coronary angiography. The primary endpoint was the predictability of the risk models for ACS culprit lesions. The reference model included the Coronary Artery Disease Reporting and Data System, a standardized classification for stenosis severity, and high-risk plaque, defined as lesions with ≥2 adverse plaque characteristics. The new prediction model was the reference model plus AI-QCPHA features, selected by hierarchical clustering and information gain in the derivation cohort. The model performance was assessed in the validation cohort.

RESULTS

Among 351 patients (age: 65.9 ± 11.7 years) with 2,088 nonculprit and 363 culprit lesions, the median interval from coronary CTA to ACS event was 375 days (Q1-Q3: 95-645 days), and 223 patients (63.5%) presented with myocardial infarction. In the derivation cohort (n = 243), the best AI-QCPHA features were fractional flow reserve across the lesion, plaque burden, total plaque volume, low-attenuation plaque volume, and averaged percent total myocardial blood flow. The addition of AI-QCPHA features showed higher predictability than the reference model in the validation cohort (n = 108) (AUC: 0.84 vs 0.78; P < 0.001). The additive value of AI-QCPHA features was consistent across different timepoints from coronary CTA.

CONCLUSIONS

AI-enabled plaque and hemodynamic quantification enhanced the predictability for ACS culprit lesions over the conventional coronary CTA analysis. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary Computed Tomography Angiography and Computational Fluid Dynamics II [EMERALD-II]; NCT03591328).

Coronary microvascular dysfunction in autoimmune rheumatic diseases: beyond coronary flow velocity reserve

Autoimmune rheumatic diseases (ARDs) are a heterogeneous group of disorders characterized by an inappropriate immune reactivity against different body tissues. Patients affected by ARDs present increased cardiovascular morbidity and mortality, which significantly impacts long-term prognosis. Endothelial dysfunction, inflammation, oxidative stress, and autoimmunity are strictly involved in atherosclerosis progression and coronary microvascular dysfunction (CMD), both of which contribute to increased cardiovascular risk. CMD represents the inability of the coronary microvasculature to respond with vasodilation to increased cardiac metabolic demands and can be assessed by non-invasive and invasive imaging tests. Coronary flow velocity reserve assessed by echocardiography has been demonstrated to accurately identify ARDs patients with CMD. However, stress cardiac magnetic resonance (CMR) accurately assesses myocardial ischemia, perfusion, and viability in ARDs patients. The myocardial perfusion reserve index (MPRI) is a robust semiquantitative imaging marker that represents the vasodilatory capacity of the coronary microcirculation in response to a vasodilator stress. In the absence of significant coronary stenosis, ARDs patients revealed a reduced MPRI in comparison with the general population, regardless of the presence of myocardial fibrosis. Identification of CMD in asymptomatic patients could be crucial to precociously start targeted medical therapy, avoiding major adverse cardiac events in this clinical setting. This review aims to summarize the current evidence regarding CMD in ARDs patients, focusing on the role of stress CMR and the promising myocardial perfusion analysis.

Epicardial adipose tissue attenuation on computed tomography in women with coronary microvascular dysfunction: A pilot, hypothesis generating study

BACKGROUND

Patients with myocardial ischemia without obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) and associated increased risk of cardiovascular (CV) events and anginal hospitalizations. Epicardial adipose tissue (EAT) covers much of the myocardium and coronary arteries and when dysfunctional, secretes proinflammatory cytokines and is associated with CV events. While oxidative stress and systemic inflammation are associated with CMD, the relationship between EAT and CMD in women is not well known.

METHODS

Women diagnosed with CMD (n = 21) who underwent coronary computed tomography with coronary artery calcium (CAC) scoring were compared to a reference group (RG) of women referred for CAC screening for preventive risk assessment (n = 181). EAT attenuation (Hounsfield units (HU)) was measured adjacent to the proximal right coronary artery, along with subcutaneous adipose tissue (SCAT). Two-sample t-tests with unequal variances were utilized.

RESULTS

Mean age of the CMD group was 56 ± 8 years and body mass index (BMI) was 31.6 ± 6.8 kg/m2. CV risk factors in the CMD group were prevalent: 67 % hypertension, 44 % hyperlipidemia, and 33 % diabetes. Both CMD and RG had similar CAC score (25.86 ± 59.54 vs. 24.17 ± 104.6; p = 0.21. In the CMD group, 67 % had a CAC of 0. Minimal atherosclerosis (CAD-RADS 1) was present in 76 % of women with CMD. The CMD group had lower EAT attenuation than RG (-103.3 ± 6.33 HU vs. -97.9 ± 8.3 HU, p = 0.009, respectively). There were no differences in SCAT attenuation. Hypertension, smoking history, age, BMI, and CAC score did not correlate with EAT in either of the groups.

CONCLUSIONS

Women with CMD have decreased EAT attenuation compared to RG women. EAT-mediated inflammation and changes in vascular tone may be a mechanistic contributor to abnormal microvascular reactivity. Clinical trials testing therapeutic strategies to decrease EAT may be warranted in the management of CMD.

Evaluating Ischemic Heart Disease in Women: Focus on Angina With Nonobstructive Coronary Arteries (ANOCA)

Ischemic heart disease (IHD) is common in women, and cardiovascular disease is a leading cause of morbidity and mortality. While obstructive coronary artery disease is the most common form of IHD, millions of women suffer from angina with nonobstructive coronary arteries (ANOCA), an umbrella term encompassing multiple nonatherosclerotic disorders of the coronary tree. The underlying pathology leading to ischemia in these syndromes may be challenging to diagnose, leaving many women without a diagnosis despite persistent symptoms that impact quality of life and adversely affect long-term cardiovascular prognosis. In the last decade, there have been significant advances in the recognition and diagnostic evaluation of ANOCA. Despite these advances, the standard approach to evaluating suspected IHD in women continues to focus predominantly on the assessment of atherosclerotic coronary artery disease, leading to missed opportunities to accurately diagnose and treat underlying coronary vasomotor disorders. The goal of this review is to describe advances in diagnostic testing that can be used to evaluate angina in women and present a pragmatic diagnostic algorithm to guide evaluation of ANOCA in symptomatic patients. The proposed approach for the assessment of ANOCA is consistent with prior expert consensus documents and guidelines but is predicated on the medical interview and pretest probability of disease to inform a personalized diagnostic strategy.

Cardiovascular disease among bariatric surgery candidates: coronary artery screening and the impact of metabolic syndrome

BACKGROUND

Obesity is known as a risk factor for cardiovascular disease (CVD). However, there is an absence of preoperative cardiac risk assessment in bariatric surgery candidates and the incidence of CVD among these high-risk patients is still unknown.

METHODS

A consecutive series of bariatric surgery candidates at two Chinese tertiary hospitals received coronary CT angiography or coronary angiography from 2017 to 2023. Patients were categorized as metabolically unhealthy obesity (MUO) and metabolically healthy obesity (MHO) based on the presence or absence of MetS. CVD was diagnosed based on the maximum intraluminal stenosis > 1% in any of the segments of the major epicardial coronary arteries. Obstructive CVD was defined as coronary stenosis ≥ 50%. Binary multivariable logistic regression was performed to analyze the association between CVD and metabolic status. The number of principal MetS components was categorized into zero (without glycemic, lipid, and BP components), one (with one of the components), two (with any two components), and three (with all components) to explore their association with CVD.

RESULTS

A total of 1446 patients were included in the study. The incidence of CVD and obstructive CVD were 31.7% and 9.6%. Compared with MHO patients, MUO patients had a significantly higher incidence of mild (13.7% vs. 6.1%, P < 0.05), moderate (7.4% vs. 0.8%, P < 0.05), and severe CVD (3.1% vs. 0%, P < 0.05). Following complete adjustment, compared with zero or one component, two principal MetS components was found to be associated with a notable increase in the risk of CVD (OR 2.05, 95% CI 1.18-3.58, P < 0.05); three principal MetS components were observed to have a higher risk of CVD and obstructive CVD (OR 2.68, 95% CI 1.56-4.62, P < 0.001; OR 3.93, 95% CI 1.19-12.93, P < 0.05). Each increase in the number of principal MetS components correlated with a 1.47-fold (95% CI 1.20-1.81, P < 0.001) and 1.78-fold (95% CI 1.24-2.55, P < 0.05) higher risk of CVD and obstructive CVD, respectively.

CONCLUSION

This study reported the incidence of CVD based on multicenter bariatric surgery cohorts. CVD is highly prevalent in patients with obesity, especially in MUO patients. Increased number of principal MetS components will significantly elevate the risk of CVD.

Myocardial Ischemia: Differentiating between Epicardial Coronary Artery Atherosclerosis, Microvascular Dysfunction and Vasospasm in the Catheterization Laboratory

Ischemic heart disease is currently the most common cause of mortality and morbidity worldwide. Although myocardial ischemia is classically determined by epicardial coronary atherosclerosis, up to 40% of patients referred for coronary angiography have no obstructive coronary artery disease (CAD). Ischemia with non-obstructive coronary artery disease (INOCA) has typically been underestimated in the past because, until recently, its prognostic significance was not completely clear. This review aims to highlight differences and patterns in myocardial ischemia caused by epicardial obstructive CAD, coronary microvascular dysfunction (CMD) or vasomotor abnormalities and to elucidate the state of the art in correctly diagnosing these different patterns.

Exome sequence analysis identifies rare coding variants associated with a machine learning-based marker for coronary artery disease

Coronary artery disease (CAD) exists on a spectrum of disease represented by a combination of risk factors and pathogenic processes. An in silico score for CAD built using machine learning and clinical data in electronic health records captures disease progression, severity and underdiagnosis on this spectrum and could enhance genetic discovery efforts for CAD. Here we tested associations of rare and ultrarare coding variants with the in silico score for CAD in the UK Biobank, All of Us Research Program and BioMe Biobank. We identified associations in 17 genes; of these, 14 show at least moderate levels of prior genetic, biological and/or clinical support for CAD. We also observed an excess of ultrarare coding variants in 321 aggregated CAD genes, suggesting more ultrarare variant associations await discovery. These results expand our understanding of the genetic etiology of CAD and illustrate how digital markers can enhance genetic association investigations for complex diseases.

Myeloperoxidase as a Promising Therapeutic Target after Myocardial Infarction

Coronary artery disease (CAD) and myocardial infarction (MI) remain leading causes of death and disability worldwide. CAD begins with the formation of atherosclerotic plaques within the intimal layer of the coronary arteries, a process driven by persistent arterial inflammation and oxidation. Myeloperoxidase (MPO), a mammalian haem peroxidase enzyme primarily expressed within neutrophils and monocytes, has been increasingly recognised as a key pro-inflammatory and oxidative enzyme promoting the development of vulnerable coronary atherosclerotic plaques that are prone to rupture, and can precipitate a MI. Mounting evidence also implicates a pathogenic role for MPO in the inflammatory process that follows a MI, which is characterised by the rapid infiltration of activated neutrophils into the damaged myocardium and the release of MPO. Excessive and persistent cardiac inflammation impairs normal cardiac healing post-MI, resulting in adverse cardiac outcomes and poorer long-term cardiac function, and eventually heart failure. This review summarises the evidence for MPO as a significant oxidative enzyme contributing to the inappropriate inflammatory responses driving the progression of CAD and poor cardiac healing after a MI. It also details the proposed mechanisms underlying MPO's pathogenic actions and explores MPO as a novel therapeutic target for the treatment of unstable CAD and cardiac damage post-MI.

Coronary Atherosclerotic Plaque Activity and Risk of Myocardial Infarction

BACKGROUND

Total coronary atherosclerotic plaque activity across the entire coronary arterial tree is associated with patient-level clinical outcomes.

OBJECTIVES

We aimed to investigate whether vessel-level coronary atherosclerotic plaque activity is associated with vessel-level myocardial infarction.

METHODS

In this secondary analysis of an international multicenter study of patients with recent myocardial infarction and multivessel coronary artery disease, we assessed vessel-level coronary atherosclerotic plaque activity using coronary 18F-sodium fluoride positron emission tomography to identify vessel-level myocardial infarction.

RESULTS

Increased 18F-sodium fluoride uptake was found in 679 of 2,094 coronary arteries and 414 of 691 patients. Myocardial infarction occurred in 24 (4%) vessels with increased coronary atherosclerotic plaque activity and in 25 (2%) vessels without increased coronary atherosclerotic plaque activity (HR: 2.08; 95% CI: 1.16-3.72; P = 0.013). This association was not demonstrable in those treated with coronary revascularization (HR: 1.02; 95% CI: 0.47-2.25) but was notable in untreated vessels (HR: 3.86; 95% CI: 1.63-9.10; Pinteraction = 0.024). Increased coronary atherosclerotic plaque activity in multiple coronary arteries was associated with heightened patient-level risk of cardiac death or myocardial infarction (HR: 2.43; 95% CI: 1.37-4.30; P = 0.002) as well as first (HR: 2.19; 95% CI: 1.18-4.06; P = 0.013) and total (HR: 2.50; 95% CI: 1.42-4.39; P = 0.002) myocardial infarctions.

CONCLUSIONS

In patients with recent myocardial infarction and multivessel coronary artery disease, coronary atherosclerotic plaque activity prognosticates individual coronary arteries and patients at risk for myocardial infarction.

Multivessel Coronary Function Testing Increases Diagnostic Yield in Patients With Angina and Nonobstructive Coronary Arteries

BACKGROUND

Invasive CFT is the gold standard for diagnosing coronary vasomotor dysfunction in patients with ANOCA. Most institutions recommend only testing the left coronary circulation. Therefore, it is unknown whether testing multiple coronary territories would increase diagnostic yield.

OBJECTIVES

The aim of this study was to evaluate the diagnostic yield of multivessel, compared with single-vessel, invasive coronary function testing (CFT) in patients with angina and nonobstructive coronary arteries (ANOCA).

METHODS

Multivessel CFT was systematically performed in patients with suspected ANOCA. Vasoreactivity testing was performed using acetylcholine provocation in the left (20 to 200 μg) and right (20 to 80μg) coronary arteries. A pressure-temperature sensor guidewire was used for coronary physiology assessment in all three epicardial vessels.

RESULTS

This multicenter study included a total of 228 vessels from 80 patients (57.8 ± 11.8 years of age, 60% women). Compared with single-vessel CFT, multivessel testing resulted in more patients diagnosed with coronary vasomotor dysfunction (86.3% vs 68.8%; P = 0.0005), coronary artery spasm (60.0% vs 47.5%; P = 0.004), and CMD (62.5% vs 36.3%; P < 0.001). Coronary artery spasm (n = 48) predominated in the left coronary system (n = 38), though isolated right coronary spasm was noted in 20.8% (n = 10). Coronary microvascular dysfunction (CMD), defined by abnormal index of microcirculatory resistance and/or coronary flow reserve, was present 62.5% of the cohort (n = 50). Among the cohort with CMD, 27 patients (33.8%) had 1-vessel CMD, 15 patients (18.8%) had 2-vessel CMD, and 8 patients (10%) had 3-vessel CMD. CMD was observed at a similar rate in the territories supplied by all 3 major coronary vessels (left anterior descending coronary artery = 36.3%, left circumflex coronary artery = 33.8%, right coronary artery = 31.3%; P = 0.486).

CONCLUSIONS

Multivessel CFT resulted in an increased diagnostic yield in patients with ANOCA compared with single-vessel testing. The results of this study suggest that multivessel CFT has a role in the management of patients with ANOCA.

Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance

For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.

Relation Between Serum Uric Acid to Albumin Ratio and Severity of Chronic Coronary Artery Disease

Uric acid (UA) to albumin ratio (UAR) is an emerging marker to predict coronary artery disease (CAD)-related events. There is limited data on the relationship between UAR and the severity of the disease in chronic CAD patients. We aimed to evaluate UAR as an indicator for CAD severity using the Syntax score (SS). We retrospectively enrolled 558 patients with stable angina pectoris and underwent coronary angiography (CAG). Patients were divided into 2 groups, according to CAD severity: low SS (≤22) and intermediate-high SS (>22) groups. UA levels were higher and albumin levels were lower in the intermediate-high SS score group (P < .001). UAR levels were significantly higher in the intermediate-high SS group (P < .001). Also, there was a significant correlation between UAR levels and SS (r = .55, 95% confidence interval (CI): .49-.60, P < .001). In multivariable analysis, UAR >1.34 (Odds ratio, 3.8 [2.3-6.2]; P < .001) was an independent predictor of intermediate-high SS while albumin and UA levels were not. In conclusion, UAR predicted disease burden in chronic CAD patients. It may prove useful as a simple and readily available marker to select patients for further evaluation.

Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle

Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.

The importance of nonobstructive plaque characteristics in symptomatic and asymptomatic coronary artery disease

BACKGROUND

We examined obstructive and nonobstructive plaque volumes in populations with subclinical and clinically manifested coronary artery disease (CAD) using quantitative computed tomography (QCT).

METHODS

855 participants with CAD (274 asymptomatic individuals, 254 acute chest pain patients without acute coronary syndrome (ACS), and 327 patients with ACS) underwent QCT of proximal coronary segments to assess participant-level plaque volumes of dense calcium, fibrous, fibrofatty, and necrotic core tissue.

RESULTS

Nonobstructive (<50% stenosis) plaque volumes were greater than obstructive plaque volumes, irrespective of population (all p<0.0001): Asymptomatic individuals (mean (95% CI)): 218 [190-250] vs. 16 [12-22] mm3; acute chest pain patients without ACS: 300 [263-341] vs. 51 [41-62] mm3; patients with ACS: 370 [332-412] vs. 159 [139-182] mm3. After multivariable adjustment, nonobstructive fibrous and fibrofatty tissue volumes were greater in acute chest pain patients without ACS compared to asymptomatic individuals (fibrous tissue: 122 [107-139] vs. 175 [155-197] mm3, p<0.01; fibrofatty tissue: 44 [38-50] vs. 71 [63-80] mm3, p<0.01. Necrotic core tissue was greater in ACS patients (29 [26-33] mm3) compared to both asymptomatic individuals (15 [13-18] mm3, p<0.0001) and acute chest pain patients without ACS (21 [18-24] mm3, p<0.05). Nonobstructive dense calcium volumes did not differ between the three populations: 29 [24-36], 29 [23-35], and 41 [34-48] mm3, p>0.3 respectively.

CONCLUSION

Nonobstructive CAD was the predominant contributor to total atherosclerotic plaque volume in both subclinical and clinically manifested CAD. Nonobstructive fibrous, fibrofatty and necrotic core tissue volumes increased with worsening clinical presentation, while nonobstructive dense calcium tissue volumes did not.

Impact of body mass index on long-term outcomes in patients undergoing percutaneous coronary intervention stratified by diabetes mellitus: a retrospective cohort study

BACKGROUND

Patients with diabetes mellitus (DM) caused by obesity have increased in recent years. The impact of obesity on long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) with or without DM remains unclear.

METHODS

We retrospectively analysed data from 1918 patients who underwent PCI. Patients were categorized into four groups based on body mass index (BMI, normal weight: BMI < 25 kg/m2; overweight and obese: BMI ≥ 25 kg/m2) and DM status (presence or absence). The primary endpoint was the occurrence of major adverse cardiac and cerebrovascular events (MACCE; defined as all-cause death, myocardial infarction, stroke, and unplanned repeat revascularization).

RESULTS

During a median follow-up of 7.0 years, no significant differences in MACCE, myocardial infarction, or stroke were observed among the four groups. Overweight and obese individuals exhibited lower all-cause mortality rates compared with normal-weight patients (without DM: hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.37 to 0.78; with DM: HR: 0.57, 95% CI: 0.38 to 0.86). In non-diabetic patients, the overweight and obese group demonstrated a higher risk of unplanned repeat revascularization than the normal-weight group (HR:1.23, 95% CI:1.03 to 1.46). After multivariable adjustment, overweight and obesity were not significantly associated with MACCE, all-cause death, myocardial infarction, stroke, or unplanned repeat revascularization in patients with and without diabetes undergoing PCI.

CONCLUSION

Overweight and obesity did not demonstrate a significant protective effect on long-term outcomes in patients with and without diabetes undergoing PCI.

Elevated plasma pyruvate kinase M2 concentrations are associated with the clinical severity and prognosis of coronary artery disease

Introduction

Pyruvate kinase M2 (PKM2) was involved in the pathophysiology of atherosclerosis and coronary artery disease (CAD). We tested whether plasma PKM2 concentrations were correlated with clinical severity and major adverse cardiovascular events (MACEs) in CAD patients.

Materials and methods

A total of 2443 CAD patients and 238 controls were enrolled. The follow-up time was two years. Plasma PKM2 concentrations were detected by enzyme-linked immunosorbent assay (ELISA) kits (Cloud-Clone, Wuhan, China) using SpectraMax i3x Multi-Mode Microplate Reader (Molecular Devices, San Jose, USA). The predictors of acute coronary syndrome (ACS) were assessed by logistic regression analysis. The association between PKM2 concentration in different quartiles and MACEs was evaluated by Kaplan-Meier (KM) curves with log-rank test and Cox proportional hazard models. The predictive value of PKM2 and a cluster of conventional risk factors was determined by Receiver operating characteristic (ROC) curves. The net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) were utilized to evaluate the enhancement in risk prediction when PKM2 was added to a predictive model containing a cluster of conventional risk factors.

Results

In CAD patients, PKM2 concentration was the independent predictor of ACS (P < 0.001). Kaplan-Meier cumulative survival curves and Cox proportional hazards analyses revealed that patients with a higher PKM2 concentration had higher incidence of MACEs compared to those with a lower PKM2 concentration (P < 0.001). The addition of PKM2 to a cluster of conventional risk factors significantly increased its prognostic value of MACEs.

Conclusion

Baseline plasma PKM2 concentrations predict the clinical severity and prognosis of CAD.

Risk factors and the CCTA application in patients with vulnerable coronary plaque in type 2 diabetes: a retrospective study

BACKGROUND

Diabetes is an independent risk factor for cardiovascular disease. The purpose of this study was to identify the risk factors for vulnerable coronary plaques (VCPs), which are associated with adverse cardiovascular events, and to determine the value of coronary CT angiography (CCTA) in patients with type 2 diabetes mellitus (T2DM) and VCPs.

METHODS

Ninety-eight T2DM patients who underwent CCTA and intravascular ultrasound (IVUS) were retrospectively included and analyzed. The patients were grouped and analyzed according to the presence or absence of VCPs.

RESULTS

Among the patients with T2DM, time in range [TIR {the percentage of time blood glucose levels were in the target range}] (OR = 0.93, 95% CI = 0.89-0.96; P < 0.001) and the high-density lipoprotein-cholesterol (HDL-C) concentration (OR = 0.24, 95% CI = 0.09-0.63; P = 0.04) were correlated with a lower risk of VCP, but the triglycerides (TG) concentration was correlated with a higher risk of VCP (OR = 1.79, 95% CI = 1.01-3.18; P = 0.045). The area under the receiver operator characteristic curve (AUC) of TIR, and HDL-C and TG concentrations were 0.76, 0.73, and 0.65, respectively. The combined predicted AUC of TIR, and HDL-C and TG concentrations was 0.83 (P < 0.05). The CCTA sensitivity, specificity, false-negative, and false-positive values for the diagnosis of VCP were 95.74%, 94.12%, 4.26%, and 5.88%, respectively. The identification of VCP by CCTA was positively correlated with IVUS (intraclass correlation coefficient [ICC] = 0.90).

CONCLUSIONS

The TIR and HDL-C concentration are related with lower risk of VCP and the TG concentration was related with higher risk of VCP in patients with T2DM. In clinical practice, TIR, HDL-C and TG need special attention in patients with T2DM. The ability of CCTA to identify VCP is highly related to IVUS findings.

Repeat Coronary Angiography in Patients Aged over 50 Years with Previously Normal/Non-Obstructive Coronary Angiogram-Insights from a Retrospective Study

(1) Introduction: A significant proportion of patients undergoing coronary angiography (CAG) have normal (NCA) or non-obstructive coronary artery disease (NOCAD). This study retrospectively tested the incidence of re-catheterization, and long-term outcomes of this population in patients aged over 50 years. (2) Methods: We identified all patients above 50 years of age with NOCAD who underwent their first CAG at our center between January 2008 and December 2019. Patients were evaluated for their baseline characteristics, risk factors profile, and indication for CAG. Patients undergoing repeat CAG after the index procedure were assessed for the above, including the primary preventive pharmacotherapy prescribed. (3) Results: A total of 1939 patients were reported to have NOCAD. Of these, 1756 (90%) patients (62% males, median age 66 (56-75) years) had no repeat angiography (group 1). Repeat angiography was performed in 10%: 136 (7%) proved futile (median time for repeat angiography 5 (3-8) years) (group 3), and 47 (3%) ended with angioplasty (median time for repeat angiography 4 (3-6) years) (group 2). Male gender, BMI above 30 (23% vs. 13%), hypertension (68% vs. 57%), diabetes (28% vs. 17%) and smoking (36% vs. 19%) were significantly higher in the interventional group. Regression analysis showed both paroxysmal atrial fibrillation and hyperlipidemia were significantly associated with repeat CAG. The indication for the first CAG was mainly symptoms related. In the interventional repeat angiography (n = 47) the incidence of troponin positive cases increased from 8.2% before intervention to 57.5%, 50% being ST elevation cases. The symptoms-related cases went from 36.7% to 18.4%. Intriguingly, 85% of the interventional group were not prescribed statin and/or aspirin on a regular basis, and/or did not adhere to treatment. (4) Conclusions: NOCAD is a frequent occurrence. The threshold for repeat angiography must be higher, better reserved to troponin positive cases. Moreover, patients must be handled according to their risk profile, not being mistakenly reassured by a snapshot benign coronary angiography.

Ischemia but no obstructive coronary artery disease: more than meets the eye

Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.

Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting

OBJECTIVE

International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED.

METHODS

In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records.

RESULTS

Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred.

CONCLUSIONS

The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.

The invasive investigation of INOCA in the coronary catheterization lab

Over half of all patients with angina have no angiographically demonstratable obstructive coronary disease, with a significant proportion of these patients having undiagnosed microvascular dysfunction and/or vasospastic angina. In chronic coronary syndrome, ischemia with non-obstructive coronary artery disease (INOCA) often remains undiagnosed, or uninvestigated. INOCAmay occur due to vasospastic angina and microvascular dysfunction and require invasive assessment in the coronary catheterization lab. To evaluate INOCA coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) are used to assess microvascular dysfunction before acetylcholine provocation testing for coronary spasm. This review provides an overview of the invasive investigation of INOCA in the coronary catheterization lab for patients with angina to be optimally managed.

Assessing the Impact of Long-Term High-Dose Statin Treatment on Pericoronary Inflammation and Plaque Distribution-A Comprehensive Coronary CTA Follow-Up Study

Computed tomography angiography (CTA) has validated the use of pericoronary adipose tissue (PCAT) attenuation as a credible indicator of coronary inflammation, playing a crucial role in coronary artery disease (CAD). This study aimed to evaluate the long-term effects of high-dose statins on PCAT attenuation at coronary lesion sites and changes in plaque distribution. Our prospective observational study included 52 patients (mean age 60.43) with chest pain, a low-to-intermediate likelihood of CAD, who had documented atheromatous plaque through CTA, performed approximately 1 year and 3 years after inclusion. We utilized the advanced features of the CaRi-Heart® and syngo.via Frontier® systems to assess coronary plaques and changes in PCAT attenuation. The investigation of changes in plaque morphology revealed significant alterations. Notably, in mixed plaques, calcified portions increased (p < 0.0001), while non-calcified plaque volume (NCPV) decreased (p = 0.0209). PCAT attenuation generally decreased after one year and remained low, indicating reduced inflammation in the following arteries: left anterior descending artery (LAD) (p = 0.0142), left circumflex artery (LCX) (p = 0.0513), and right coronary artery (RCA) (p = 0.1249). The CaRi-Heart® risk also decreased significantly (p = 0.0041). Linear regression analysis demonstrated a correlation between increased PCAT attenuation and higher volumes of NCPV (p < 0.0001, r = 0.3032) and lipid-rich plaque volume (p < 0.0001, r = 0.3281). Our study provides evidence that high-dose statin therapy significantly reduces CAD risk factors, inflammation, and plaque vulnerability, as evidenced by the notable decrease in PCAT attenuation, a critical indicator of plaque progression.