Adverse Cardiovascular Events Arising From Atherosclerotic Lesions With and Without Angiographic Disease Progression

Radial Wall Strain Assessment From AI-Assisted Angiography: Feasibility and Agreement With OCT as Reference Standard

Background

High-strain spots in coronary arteries are associated with plaque vulnerability and predict future events. Artificial intelligence currently enables the calculation of radial wall strain (RWS) from coronary angiography (RWSAngio). This study aimed to determine the agreement between novel RWSAngio and RWS derived from optical coherence tomography (OCT) followed by finite element analysis, as the established reference standard (RWSOCT).

Methods

All lesions from a previous OCT study were enrolled. OCT was automatically coregistered with angiography. RWSAngio was computed as the relative luminal deformation throughout the cardiac cycle, whereas RWSOCT was analyzed using finite element analysis on OCT cross-sections at 1-mm intervals. The luminal deformation in the direction of minimal lumen diameter was used to derive RWSOCT, using the same definition as RWSAngio. The maximal RWSOCT and RWSAngio at healthy segments adjacent to the interrogated lesion were also analyzed.

Results

Finite element analysis was performed in 578 OCT cross-sections from 45 lesions stemming from 36 patients. RWSAngio showed good correlation and agreement with RWSOCT (r = 0.91; P < .001; Lin coefficient = 0.85). RWSAngio in atherosclerotic segments was significantly higher than that in healthy segments (12.6% [11.0, 16.0] vs 4.5% [2.9, 5.5], P < .001). The intraclass correlation coefficients for intra- and interobserver variability in repeated RWSAngio analysis were 0.92 (95% CI, 0.87-0.95) and 0.88 (95% CI, 0.81-0.92), respectively. The mean analysis time of RWSOCT and RWSAngio for each lesion was 95.0 ± 41.1 and 0.9 ± 0.1 minutes, respectively.

Conclusions

Radial wall strain from coronary angiography can be rapidly and easily computed solely from angiography, showing excellent agreement with strain derived from coregistered OCT. This novel and simple method might provide a cost-effective biomechanical assessment in large populations.

Short-Term Risk Stratification of Non-Flow-Limiting Coronary Stenosis by Angiographically Derived Radial Wall Strain

BACKGROUND

Deferred revascularization of mildly stenotic coronary vessels based exclusively on physiological evaluation is associated with up to 5% residual incidence of future adverse events at 1 year.

OBJECTIVES

We aimed to evaluate the incremental value of angiography-derived radial wall strain (RWS) in risk stratification of non-flow-limiting mild coronary narrowings.

METHODS

This is a post hoc analysis of 824 non-flow-limiting vessels in 751 patients from the FAVOR III China (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) trial. Each individual vessel had ≥1 mildly stenotic lesion. The primary outcome was vessel-oriented composite endpoint (VOCE), defined as the composite of vessel-related cardiac death, vessel-related myocardial infarction (nonprocedural), and ischemia-driven target vessel revascularization at 1-year follow-up.

RESULTS

During 1-year follow-up, VOCE occurred in 46 of 824 vessels, with a cumulative incidence of 5.6%. Maximum RWS (RWSmax) was predictive of 1-year VOCE with an area under the curve of 0.68 (95% CI: 0.58-0.77; P < 0.001). The incidence of VOCE was 14.3% in vessels with RWSmax >12% vs 2.9% in those with RWSmax ≤12%. In the multivariable Cox regression model, RWSmax >12% was a strong independent predictor of 1-year VOCE in deferred non-flow-limiting vessels (adjusted HR: 4.44; 95% CI: 2.43-8.14; P < 0.001). The risk of deferred revascularization based on combined normal RWSmax and Murray-law-based quantitative flow ratio (μQFR) was significantly reduced compared with μQFR alone (adjusted HR: 0.52; 95% CI: 0.30-0.90; P = 0.019).

CONCLUSIONS

Among vessels with preserved coronary flow, angiography-derived RWS analysis has the potential to further discriminate vessels at risk of 1-year VOCE. (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease [FAVOR III China Study]; NCT03656848).

A Simple Model to Predict Repeat Revascularization After Drug-Eluting Stent Implantation in Patients With Stable Coronary Artery Disease

Repeat revascularization is still common in the era of drug-eluting stents (DES), especially for non-target lesions. However, few validated models exist to predict the need for revascularization. We aimed to develop and validate an easy-to-use predictive model for repeat revascularization after DES implantation in patients with stable coronary artery disease (CAD). A total of 1,653 stable CAD patients with angiographic follow-up after DES implantation were consecutively enrolled. Split-sample testing was adopted to develop and validate the model. In the training set, male, diabetes, number of target lesions, occlusion lesion, number of non-target lesions, recurrent angina, suboptimal low density lipoprotein-cholesterol level, and high lipoprotein (a) level were independent predictors of repeat revascularization using logistic regression analyses. The established model (Model 1) yielded a bias-corrected concordance index of 0.700 (95% confidence interval: 0.667 to 0.735), with good calibration. It also performed well in the validation set. Compared with the traditional empirical model only including recurrent angina (Model 2), Model 1 had better discriminative ability and clinical usefulness. In conclusion, we established and validated a simple model including 8 easily accessible variables to predict repeat revascularization after DES implantation in stable CAD patients, contributing to better risk stratification, decision making, and patient consultation.

Monomeric C-reactive protein affects cell injury and apoptosis through activation of p38 mitogen-activated protein kinase in human coronary artery endothelial cells

C-reactive protein (CRP) is an important predictor of cardiovascular events and plays a role in vascular inflammation and vessel damage. The aim of this study was to investigate the effect of pentameric CRP (pCRP) and monomeric CRP (mCRP) on the production of atherosclerosis-re-lated factors in cultured human coronary artery endothelial cells (HCAECs). HCAECs were treated with pCRP, mCRP, p38 mitogen-activated protein kinase (MAPK) inhibitor SB203580, or transfected with p38 MAPK siRNA. Western blotting was performed to detect the expression of vascular endothelial growth factor (VEGF), cyclooxygenase-2 (COX-2), intercellular adhesion molecule-2 (ICAM-2) and vascular cell adhe-sion molecule-1 (VCAM-1). Proliferation, damage, and apoptosis of HCAECs were examined using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide, lactate dehydrogenase (LDH), and flow cytometry, respectively. mCRP suppressed VEGF and COX-2 expression and enhanced ICAM-2 and VCAM-1 expression in HCAECs, in both dose-dependent and time-dependent manner. Except at 100 μg/ml concen-tration and 20-hour or 24-hour incubation, pCRP had no apparent effects. mCRP but not pCRP induced HCAEC injury and phosphorylation of p38 MAPK, and the inhibitor SB203580 reversed the effects of mCRP. mCRP promotes injury and apoptosis of HCAECs through a p38 MAPK-dependent mechanism, which provides a new therapy for the injury of HCAECs in atherosclerosis.

[How to detect myocardial ischemia in patients following acute coronary syndrome treated by PCI?]

Unstable coronary artery disease is a more aggressive condition than stable coronary artery disease, accounting for the high incidence of major adverse cardiovascular events following acute coronary syndromes (ACS), which includes the need for iterative repeat revascularization. The aim of myocardial ischemia screening in post-ACS patients is to detect this unfavourable evolution (either on initial culprit or non culprit lesions) and to prevent any clinical complication. Although there is no strict recommendation in this particular situation, screening should be based on the use of stress imaging techniques. The optimal timing and frequency for testing will depend on the clinical characteristics of the patients and the coronary revascularization procedure features.

Change in luminal diameter of the left internal thoracic artery anastomosed to the totally occluded left anterior descending coronary artery

Background

Coronary artery bypass grafting (CABG) with a composite Y-graft made of the left internal thoracic artery (LITA) and another arterial graft has a risk for hypoperfusion. Changes over time in the diameter of the LITA anastomosed to the left anterior descending coronary artery (LAD) are not known.

Methods

Data were collected for 71 patients who had undergone coronary angiography (CAG) immediately and at 1 year following off-pump CABG with a composite Y-graft made of the LITA and either the radial artery or the right gastroepiploic artery. These patients were divided into 2 groups depending on the degree of LAD stenosis. Group 1 (n = 28) consisted of patients with complete occlusion of the LAD. Group 2 (n = 43) consisted of patients with <90% stenosis of the LAD. The clinical state and luminal diameter of the LITA on immediate postoperative and postoperative 1-year CAG were compared and analyzed.

Results

On the immediate postoperative CAG, mean LITA diameter of Group 1 was larger than that of Group 2 (2.09 ± 0.53 vs. 1.61 ± 0.33 mm, P = 0.01). Mean LITA diameter 1 year following CABG was also larger in Group 1 than in Group 2 (2.49 ± 0.31 vs. 2.10 ± 0.45 mm, P = 0.005). Both groups showed significant increases in the LITA diameters at postoperative 1 year.

Conclusions

The LITA used as a composite Y-graft underwent remodeling, resulting in a larger diameter, to supply adequate myocardial blood. The degree of change in luminal diameter varied according to the severity of the LAD stenosis.

All-cause mortality and cardiovascular events with nicorandil in patients with IHD: systematic review and meta-analysis of the literature

BACKGROUND

Nicorandil is able to protect the cardiomyocytes from ischemic damage, but clear benefits of nicorandil in all-cause mortality and cardiovascular events were not consistently reported in patients with ischemic heart disease (IHD).

MATERIALS AND RESULTS

Cochrane, PubMed, EMBASE, CBM, CNKI and Wangfang databases were searched for randomized controlled trials. Data on all-cause mortality and cardiovascular events were collected. Nicorandil groups were pooled to perform a comparison with control groups and to get the pooled odds ratios (ORs) and associated 95% confidence intervals (CIs) for all-cause mortality, relative risks (RRs), and associated 95% CIs for cardiovascular events. STATA 11.0 software was used for all-cause mortality and cardiovascular events statistics. We retrieved 17 randomized controlled studies enrolling a total of 7305 patients. The addition of nicorandil treatment significantly reduced cardiovascular events (13.83% versus 18.01%; RR, 0.77; 95% CI, 0.69 to 0.86). No differences in all-cause mortality (3.83% versus 4.70%; OR, 0.81; 95% CI, 0.64 to 1.02), and repeat revascularization rate (13.06% versus 13.54%; RR, 0.95; 95% CI, 0.70 to 1.29) were observed. There was a weak linear association between cardiovascular events and nicorandil in IHD with diabetes (P=0.099).

CONCLUSIONS

The results suggest that nicorandil as an adjunct therapy to IHD is associated with reduced cardiovascular events in patients with IHD.

Imaging atherosclerosis and risk of plaque rupture

Atherosclerosis imaging strategies can delineate characteristics of plaques at risk of rupture and thrombosis. Structural plaque imaging identifies high-risk plaque features, including lipid pools, thin fibrous caps, and intraplaque hemorrhage. New molecular imaging techniques complement structural imaging approaches by illuminating important features of plaque biology, with a prominent focus on detecting inflammation as a high-risk phenotype. As we unravel the molecular and structural characteristics underlying thrombosis-prone plaques, there is significant promise for eventual early identification and prediction of atherosclerotic plaque complications before they occur. Here we focus on recent imaging insights into high-risk arterial plaques, the etiologic agent of acute myocardial infarction, stroke, and sudden cardiac death.

Discontinuation of dual antiplatelet therapy over 12 months after acute coronary syndromes increases risk for adverse events in patients treated with percutaneous coronary intervention: systematic review and meta-analysis

INTRODUCTION

Duration of dual antiplatelet therapy (DAPT) following acute coronary syndrome (ACS) hospitalization remains to be defined, both for patients treated medically and for those undergoing percutaneous transluminal coronary angioplasty (PTCA).

METHODS

PubMed, Cochrane, and Google Scholar were systematically searched for studies including patients presenting with ACS, and treated either with DAPT longer than or shorter than 12 months. Multivariable-adjusted risk estimates for death and recurrent ACS with stopping DAPT after 12 months (odds ratios [OR] 95% confidence intervals [CI]) were pooled after logarithmic transformation according to random-effect models with inverse-variance weighting.

RESULTS

Five studies with 49,586 patients were included. Median age was 66 (64-67) years, with 67% (65-75) males. Myocardial infarction (MI) represented the admission diagnosis for 88% (60-100) of the patients, and 66% (50-74) were treated with stenting. After a follow-up of 2.1 years (1.5-2.7), 40% (35-46) still on DAPT after 12 months and the rates of death or recurrent ACS were 16.6 (14.5-17.0). Risk of adverse events for patients stopping DAPT after 1 year was significantly increased (OR = 1.19 [1.07-1.32]) for those receiving stents, but not for patients managed medically (OR = 1.13 [0.95-1.35]). The increased risk did not vary according to age, gender, myocardial infarction as admission diagnosis, and kind of stent.

CONCLUSIONS

Interruption of DAPT over 12 months after ACS increases the risk of adverse events for patients treated with PTCA, but not for those managed conservatively, independently from baseline features and admission diagnosis. This hypothesis-generating finding should be tested in randomized controlled trials.

Plaque composition and clinical outcomes in acute coronary syndrome patients with metabolic syndrome or diabetes

OBJECTIVES

The goal of this study was to characterize the extent and composition of coronary atherosclerosis in patients with diabetes mellitus or the metabolic syndrome (Met Syn) presenting with acute coronary syndromes (ACS).

BACKGROUND

Diabetes and Met Syn patients have increased rates of major adverse cardiac events (MACE), yet a systematic description of nonculprit lesions for these high-risk groups is incomplete.

METHODS

In the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study, ACS patients underwent 3-vessel quantitative coronary angiography, grayscale, and radiofrequency intravascular ultrasound after successful percutaneous coronary intervention (PCI). Subsequent MACE (cardiac death or arrest, myocardial infarction, or rehospitalization for unstable or progressive angina) were adjudicated to the originally treated culprit versus untreated nonculprit lesions in 3 patient groups: 1) diabetes; 2) Met Syn; and 3) neither. Median length of follow-up was 3.4 years.

RESULTS

Of 673 patients, 119 (17.7%) had diabetes and 239 (35.5%) had Met Syn. The cumulative 3-year MACE rate was 29.4% in patients with diabetes, 21.3% with Met Syn, and 17.4% with neither (p = 0.03). MACE adjudicated to untreated nonculprit lesions occurred in 18.7%, 11.7%, and 9.7% of patients, respectively (p = 0.06). Nonculprit lesions in diabetes and Met Syn patients were longer and had greater plaque burden, smaller lumen areas, with greater necrotic core and calcium content. Diabetes and Met Syn patients with future MACE had greater necrotic core and calcification compared with the normal cardiometabolic group.

CONCLUSIONS

In this PCI ACS population, patients with diabetes and Met Syn had higher 3-year MACE rates. Lesion length, plaque burden, necrotic core, and calcium content were significantly greater among nonculprit lesions of patients with diabetes and Met Syn, but only necrotic core and calcium were significantly greater in the nonculprit lesions of patients with a future MACE in this exploratory analysis.

Coronary plaque composition, morphology, and outcomes in patients with and without chronic kidney disease presenting with acute coronary syndromes

OBJECTIVES

This study sought to evaluate the impact of chronic kidney disease (CKD) on coronary atherosclerotic plaque composition, morphology, and outcomes in patients with acute coronary syndromes (ACS).

BACKGROUND

CKD patients presenting with ACS are at increased risk for adverse events. Whether or not this increased risk reflects differences in coronary plaque composition remains unknown.

METHODS

In the PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study, patients presenting with ACS in whom percutaneous coronary intervention was successful underwent 3-vessel grayscale and radiofrequency intravascular ultrasound imaging. Lesions were prospectively characterized, and patients were followed for a median of 3.4 years. We conducted a patient-level and lesion-level analysis of study participants by comparing intravascular ultrasound parameters of untreated nonculprit lesions in patients with and without CKD.

RESULTS

Patients with CKD (n = 73, 11.3%) were older, more often female and diabetic compared to those without CKD (n = 573). Nonculprit lesions in patients with (n = 280) versus without (n = 2,390) CKD were more likely to have plaque burden ≥ 70% (11.8% vs. 8.5%, p = 0.05) and minimal luminal area ≤ 4.0 mm(2) (25.9% vs. 19.2%, p = 0.005). The percentage of plaque comprised of necrotic core (15.0% vs. 13.0%, p = 0.0001) and dense calcium (8.2% vs. 6.4%, p < 0.0001) was higher while fibrous tissue (57.7% vs. 59.8%, p < 0.0001) was lower in CKD versus non-CKD lesions. The 3-year composite rate of cardiac death, cardiac arrest, or myocardial infarction (15.1% vs. 3.3%, p < 0.0001) was significantly higher in patients with than in those without CKD, although there were no differences in the rates of events adjudicated to nonculprit lesions.

CONCLUSIONS

Following percutaneous coronary intervention of all culprit lesions in ACS, patients with versus without CKD have more extensive and severe atherosclerosis remaining in their coronary tree with plaque composed of greater necrotic core and less fibrous tissue. These influences resulted in nonsignificantly different rates of non-culprit lesion-related adverse events, although cardiac death, arrest, or myocardial infarction were more common in patients with CKD.