Association between Achilles tendon xanthoma and severity of coronary artery disease in patients undergoing percutaneous coronary intervention

Widespread xanthomas regression by personalized lipid lowering therapy in heterozygous familial hypercholesterolemia

"The lower, the better" is the recommended approach in the management of high LDL cholesterol. Unfortunately, this does not always achieve as in the case of a 69-year-old woman referred to our Institute for her lipid profile (LDL cholesterol 412mg/dl), bilateral xanthelasma and cutaneous xanthomas. With a maximized and personalized lipid-lowering therapies (rosuvastatin, ezetimibe, PCSK9i and lipoprotein apheresis), after only six months, the patient showed an impressive regression in her cutaneous xanthomas.

Prognostic impact of Achilles tendon thickness in elderly patients after percutaneous coronary intervention: A 5-year follow-up

BACKGROUND

Evaluating the Achilles tendon thickness (ATT) may be beneficial for risk stratification of long-term secondary cardiovascular events among patients who underwent percutaneous coronary intervention (PCI).

METHODS

This observational study evaluated major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death/death from unknown causes, at 5 years after PCI according to the baseline ATT (≥9 mm vs. <9 mm).

RESULTS

Overall, 355 patients aged ≥75 years were enrolled; 47 (13.2 %) and 308 patients (86.8 %) had an ATT ≥9 mm and <9 mm, respectively. The incidence of MACCEs at 5 years was numerically higher but not significantly different for the ATT ≥9 mm group compared with the ATT <9 mm group (Gray's p-value = 0.10). However, the incidence of cardiovascular death/death from unknown causes at 5 years was significantly higher in the ATT ≥9 mm group than in the ATT <9 mm group (Gray's p-value = 0.034). Multivariable Fine and Gray competing risk analysis showed that an ATT ≥9 mm was associated with both MACCEs [hazard ratio (HR), 1.95; 95 % confidence interval (CI), 1.12-3.41; p-value = 0.019] and cardiovascular death/death from unknown causes (HR, 2.81; 95 % CI, 1.31-6.03; p-value = 0.008) at 5 years in patients with an estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2.

CONCLUSIONS

A significantly thick Achilles tendon could be a marker for MACCEs, including cardiovascular death/death from unknown causes, at 5 years among elderly patients with an eGFR ≥30 mL/min/1.73 m2 after PCI.

Patients with Achilles Tendon Rupture Are Prone to Develop Ventricular Arrhythmia

BACKGROUND AND OBJECTIVES

This study aimed to examine the ventricular repolarization (VR) disturbances of patients operated on for acute spontaneous Achilles tendon ruptures (ATRs), by comparing them with a healthy individual control group.

MATERIALS AND METHODS

Between June 2014 and July 2020, a total of 29 patients (28 males, 1 female; mean age: 40 ± 9.78 years; range, 21-66 years) who presented to the emergency department within the first three weeks of injury, and were diagnosed with acute spontaneous ATRs and treated with an open Krackow suture technique, were retrospectively analyzed. Fifty-two healthy individuals (47 males, 5 females; mean age: 39 ± 11.45 years; range, 21-66 years) were recruited as a control group from the cardiology outpatient clinic. Clinical data (demographic features and laboratory parameters (serum glucose, creatinine, hemoglobin, white blood cell count, and lipid profile)) and electrocardiograms (ECGs) were collected from medical records. ECGs were evaluated for heart rate and VR parameters of QRS width, QTc interval, cQTd interval, Tp-e interval, and Tp-e/QT ratio. The clinical data and these ECG parameters were compared between groups.

RESULTS

There was no statistically significant difference between groups, regarding clinical data (all p < 0.05). Among ECG parameters, heart rate, QRS width, QTc interval, and cQTd interval were similar between groups (all p < 0.05). There were two important statistically significant findings of this research: The mean Tp-e interval was longer (ATR group: 72.4 ± 24.7, control group: 58.8 ± 14.5, p: 0.01), and the Tp-e/QT ratio was higher (ATR group: 0.2 ± 0.1, control group: 0.16 ± 0.4, p: 0.027) in the ATR group.

CONCLUSIONS

According to the ventricular repolarization disturbances found in this study, patients with ATR may be at a higher risk of ventricular arrhythmia than healthy people. As a result, ATR patients should be assessed for ventricular arrhythmia risk by an expert cardiologist.

HDL Cholesterol Efflux and Serum Cholesterol Loading Capacity Alterations Associate to Macrophage Cholesterol Accumulation in FH Patients with Achilles Tendon Xanthoma

Achilles tendon xanthoma (ATX) formation involves macrophage cholesterol accumulation within the tendon, similar to that occurring in atheroma. Macrophage cholesterol homeostasis depends on serum lipoprotein functions, namely the high-density lipoprotein (HDL) capacity to promote cell cholesterol efflux (cholesterol efflux capacity, CEC) and the serum cholesterol loading capacity (CLC). We explored the HDL-CEC and serum CLC, comparing 16 FH patients with ATX to 29 FH patients without ATX. HDL-CEC through the main efflux mechanisms mediated by the transporters ATP binding cassette G1 (ABCG1) and A1 (ABCA1) and the aqueous diffusion (AD) process was determined by a cell-based radioisotopic technique and serum CLC fluorimetrically. Between the two groups, no significant differences were found in terms of plasma lipid profile. A trend toward reduction of cholesterol efflux via AD and a significant increase in ABCA1-mediated HDL-CEC (+18.6%) was observed in ATX compared to no ATX patients. In ATX-presenting patients, ABCG1-mediated HDL-CEC was lower (−11%) and serum CLC was higher (+14%) compared to patients without ATX. Considering all the patients together, ABCG1 HDL-CEC and serum CLC correlated with ATX thickness inversely (p = 0.013) and directly (p < 0.0001), respectively. In conclusion, lipoprotein dysfunctions seem to be involved in ATX physiopathology and progression in FH patients.

Achilles Tendon Thickening as a Risk Factor of Cardiovascular Events after Percutaneous Coronary Intervention

AIM

The Achilles tendon (AT) thickening may be affected by several factors (e.g., lipid disorders or age). This study aims to determine the prevalence rate of AT thickening in patients with coronary artery disease (CAD) and investigate the correlation between AT thickening and the incidence of major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI).

METHODS

The clinical records of 887 patients who had undergone successful PCI and measured Achilles tendon thickness (ATT) using soft X-ray radiographs were retrospectively examined. Subjects were divided into two groups depending on the presence or absence of AT thickening. AT thickening was defined as having ATT of ＞8.0 and ＞7.5 mm in men and women, respectively. Among the two groups, the incidence of MACE was measured for a maximum of 5 years after PCI. MACE was defined as cardiovascular mortality, nonfatal myocardial infarction, or revascularization due to restenosis or the increase of stenosis in other lesions.

RESULTS

This study found that 241 (27.2%) patients have AT thickening. Patients with AT thickening had higher low-density lipoprotein cholesterol (LDL-C) levels. In addition, the Kaplan-Meier curve with a log-rank test demonstrated that patients with AT thickening had a significantly higher incidence of MACE. Furthermore, the multivariate analysis indicated that the presence of AT thickening was independently correlated with the incidence of MACE after PCI.

CONCLUSION

A high percentage of patients with CAD were found to have AT thickening. In addition, the presence of AT thickening was significantly associated with a higher incidence of MACE, independent of LDL-C levels.

Extent of lipid core plaque in patients with Achilles tendon xanthoma undergoing percutaneous coronary intervention for coronary artery disease

BACKGROUND

It has been reported that Achilles tendon xanthoma (ATX), being one of the important diagnostic criteria for familial hypercholesterolemia, is independently associated with the severity of coronary artery disease (CAD). The aim of this study was to investigate plaque vulnerability in CAD patients with ATX.

METHODS

Patients with CAD who underwent percutaneous coronary intervention (PCI) with near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) guidance were enrolled. Soft X-ray radiography of the Achilles tendon was performed, and a maximum thickness of 9 mm or more was regarded as ATX. Using NIRS-IVUS, the degree of lipid core plaque (LCP) was evaluated by calculating the maximum value of lipid core burden index (LCBI) for any of the 4-mm segments (maxLCBI_4mm) in the target lesion and non-target vessel.

RESULTS

In a total of 156 patients, 14 patients (9.0%) had ATX. MaxLCBI_4mm in the ATX group was significantly greater in the target lesion (p<0.001) and in the non-target vessel (p=0.032) compared to the non-ATX group. When patients were divided into tertiles according to Achilles tendon thickness, maxLCBI_4mm was progressively increased in favor of thickness, although there was only a tendency in the target lesion (p=0.062), and no statistical significance in the non-target vessel (p=0.189). Multiple linear regression analysis determined ATX as an independent predictor for maxLCBI_4mm in the target lesion and non-target vessel.

CONCLUSIONS

ATX was associated with the degree of LCP in CAD patients requiring PCI. High-risk patients with lipid-rich vulnerable plaque can possibly be detected by evaluating Achilles tendon thickness.

Relations of physical signs to genotype, lipid and inflammatory markers, coronary stenosis or calcification, and outcomes in patients with heterozygous familial hypercholesterolemia

BACKGROUND

Although the presence of physical signs [tendon xanthomas and/or corneal arcus (TX/CA)], are associated with the risk of coronary artery disease in patients with heterozygous familial hypercholesterolemia (HeFH), their relationship with genotypes and clinical characteristics has not been fully determined. This study aimed to examine the association of TX/CA with genetic mutation, lipid- and inflammation-related markers, the severity of coronary stenosis or calcification, and cardiovascular events (CVEs) in patients with HeFH.

METHODS

LDLR, APOB, and PCSK9 genes were screened in 523 HeFH patients, and patients with TX/CA (n = 50) were 1:4 propensity score-matched to patients without TX/CA (n = 200) to adjust for age and sex. Laboratory markers (proprotein convertase subtilisin/kexin type 9 [PCSK9], lipoprotein(a) and high-sensitivity C-reactive protein [hsCRP]), computed tomography angiography, coronary angiography, and follow-up for CVEs were performed.

RESULTS

Patients with physical signs had significantly higher low-density lipoprotein cholesterol levels; higher PCSK9 or hsCRP concentrations; more LDLR positive mutations; and higher prevalence of high tertiles of Gensini, SYNTAX and Jeopardy scores as well as coronary artery calcium scores than did those without. Over an average follow-up of 3.7 years, the incidence of CVEs was significantly higher in patients with TX/CA (log-rank p < 0.001). Patients with physical signs and mutation positivity had threefold higher risks of CVEs (adjusted hazard ratio 3.34, 95% confidence interval 1.04-10.72, p = 0.024).

CONCLUSIONS

Physical signs were associated with genotypes and phenotypes, and worse outcomes in patients with HeFH, suggesting that these signs may help in risk stratification in these patients.

Achilles tendon thickness is associated with coronary lesion severity in acute coronary syndrome patients without familial hypercholesterolemia

BACKGROUND

Thickening of Achilles tendon (≥9 mm on radiography) is one of the diagnostic criteria for familial hypercholesterolemia (FH). Since FH is associated with premature coronary artery disease (CAD) including acute coronary syndrome (ACS), measurement of Achilles tendon thickness (ATT) is important for early diagnosis of FH. However, clinical significance of mild thickening of Achilles tendon in non-FH patients with CAD is unclear. The present study investigated the association of ATT with coronary lesion severity in early-onset ACS without clinically diagnosed FH.

METHODS

From outpatients who had a history of ACS under 60 years old, 76 clinically non-FH subjects (71 men and 5 women; mean age at the onset of ACS, 50.5 years) with maximum ATT of <9 mm were enrolled in this study. The severity of coronary lesions was assessed by SYNTAX score derived from coronary angiography at the onset of ACS.

RESULTS

ATT levels were not significantly different among patients with ST-elevation myocardial infarction (STEMI, n=47), non-STEMI (n=12), and unstable angina (n=17). Whereas, both average and maximum ATT were significantly larger in patients with multivessel lesions (n=25) than in those with single-vessel disease (n=51). Furthermore, SYNTAX score was positively correlated with average ATT (r=0.368, p=0.0011) and maximum ATT (r=0.388, p=0.0005). As for the relation to clinical parameters, maximum ATT had positive correlations with body mass index and C-reactive protein. A multiple regression analysis revealed that average and maximum ATT were significantly associated with SYNTAX score, independently of various confounding factors.

CONCLUSIONS

Our findings demonstrated that ATT, even though its level was <9 mm, was associated with coronary lesion severity in clinically non-FH patients with early-onset ACS. Apart from diagnosing FH, ATT may be a predictor of the progression of CAD.

Coronary lesion complexity in patients with heterozygous familial hypercholesterolemia hospitalized for acute myocardial infarction: data from the RICO survey

BACKGROUND

Although patients with familial heterozygous hypercholesterolemia (FH) have a high risk of early myocardial infarction (MI), the coronary artery disease (CAD) burden in FH patients with acute MI remains to be investigated.

METHODS

The data for all consecutive patients hospitalized in 2012-2019 for an acute MI and who underwent coronary angiography were collected from a multicenter database (RICO database). FH (n = 120) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥ 6). We compared the angiographic features of MI patients with and without FH (score 0-2) (n = 234) after matching for age, sex, and diabetes (1:2).

RESULTS

Although LDL-cholesterol was high (208 [174-239] mg/dl), less than half of FH patients had chronic statin treatment. When compared with non-FH patients, FH increased the extent of CAD (as assessed by SYNTAX score; P = 0.005), and was associated with more frequent multivessel disease (P = 0.004), multiple complex lesions (P = 0.022) and significant stenosis location on left circumflex and right coronary arteries. Moreover, FH patients had more multiple lesions, with an increased rate of bifurcation lesions or calcifications (P = 0.021 and P = 0.036, respectively). In multivariate analysis, LDL-cholesterol levels (OR 1.948; 95% CI 1.090-3.480, P = 0.024) remained an independent estimator of anatomical complexity of coronary lesions, in addition to age (OR 1.035; 95% CI 1.014-1.057, P = 0.001).

CONCLUSIONS

FH patients with acute MI had more severe CAD, characterized by complex anatomical features that are mainly dependent on the LDL-cholesterol burden. Our findings reinforce the need for more aggressive preventive strategies in these high-risk patients, and for intensive lipid-lowering therapy as secondary prevention.

Achilles tendon thickening is associated with higher incidence of adverse cardiovascular event in patients with coronary artery disease

Achilles tendon thickening (ATT) is a marker of high risk for coronary artery disease (CAD). However, the association between the presence of ATT and the incidence of cardiovascular events in patients with CAD is unclear. A total of 406 consecutive patients who underwent percutaneous coronary intervention (PCI) and ATT assessment were analyzed. ATT was defined as the Achilles tendon thickness of 9 mm or more on radiography. The incidence of major adverse cardiovascular events (MACE) at 1-year was compared between patients with ATT and those without ATT. MACE included cardiac death, non-fatal myocardial infarction, stroke, target vessel revascularization (TVR), and non-TVR. ATT was found in 67 patients (16.5%). The incidence of cardiac death (3.2 vs. 0.0%, p = 0.001), TVR (12.7 vs. 4.0%, p = 0.005) and MACE (20.6 vs. 9.6%, p = 0.011) was significantly higher in the ATT group than the no ATT group. Patients with ATT had significantly higher incidence of cardiac death (5.6 vs. 0%, p < 0.001) than those without ATT even if they did not meet the diagnostic criteria of familial hypercholesterolemia. A multivariate model demonstrated that ATT was independently associated with the MACE at 1-year (Hazard ratio, 2.09; 95% Confidence Interval, 1.09-4.00, p = 0.026). The presence of ATT was independently associated with 1-year recurrence of cardiovascular events in patients with CAD undergoing PCI. Assessment of ATT might be useful for risk stratification of secondary cardiovascular events.