34th Bethesda Conference: Task force #2--What is the pathologic basis for new atherosclerosis imaging techniques?

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.

Gender-Related Discrepancies in Short-Term Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

The sex differences in patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery are still unclear. Our aim was to investigate the impact of gender on short-term outcomes in males and females after off-pump bypass procedures. Our research was designed as a double-center retrospective analysis. Generally, 343 patients (men (n = 255) and women (n = 88)) who underwent an OPCAB procedure were included in our study. To provide a statistical analysis of unequal cohorts, we created a propensity score-based matching (PSM) analysis (men, n = 61; women, n = 61). The primary endpoint was all-cause in-hospital mortality. Dialysis, transient ischemic attack (TIA), low cardiac output syndrome (LCOS), reoperation due to postoperative bleeding, wound infection and duration of hospital stay were secondary outcomes in our analysis. No significant differences were detected within the male and female groups regarding age (p = 0.116), BMI (p = 0.221), diabetes (p = 0.853), cardiogenic shock (0.256), STEMI (p = 0.283), NSTEMI (p = 0.555) and dialysis (p = 0.496). Males underwent significantly more frequently (p = 0.005) total-arterial revascularization with T-graft technique (p = 0.005) than females. In contrast, temporary pacer use was significantly higher (p = 0.022) in females compared to males. The in-hospital mortality rate was not significantly higher (p = 0.496) in the female group compared to the male group. Likewise, secondary outcomes did not differ significantly between the non-adjusted and the adjusted groups. Based on our findings, gender has no impact on short-term outcomes after OPCAB surgery.

Sex Differences in Coronary Atherosclerosis

PURPOSE OF REVIEW

The importance of cardiovascular disease (CVD) in women has long been underestimated. Therefore, we need to understand the impact of sex differences on CVD.

RECENT FINDINGS

Traditional risk factors contribute to coronary artery disease (CAD) differently in women and men. There are female-specific risk factors and comorbid conditions that affect the risk of CAD. Plaque erosion is frequently seen in younger women who smoke, while plaque rupture is common in older women and men who have elevated blood cholesterol. Coronary artery calcification is also different in both sexes. Thus, coronary artery calcification score-based risk stratification in women is challenging. A deeper understanding of the sex differences in the risk factors and plaque morphology of coronary atherosclerosis may lead to improved outcomes of CVD in women.

Identification of the haemodynamic environment permissive for plaque erosion

Endothelial erosion of atherosclerotic plaques is the underlying cause of approximately 30% of acute coronary syndromes (ACS). As the vascular endothelium is profoundly affected by the haemodynamic environment to which it is exposed, we employed computational fluid dynamic (CFD) analysis of the luminal geometry from 17 patients with optical coherence tomography (OCT)-defined plaque erosion, to determine the flow environment permissive for plaque erosion. Our results demonstrate that 15 of the 17 cases analysed occurred on stenotic plaques with median 31% diameter stenosis (interquartile range 28–52%), where all but one of the adherent thrombi located proximal to, or within the region of maximum stenosis. Consequently, all flow metrics related to elevated flow were significantly increased (time averaged wall shear stress, maximum wall shear stress, time averaged wall shear stress gradient) with a reduction in relative residence time, compared to a non-diseased reference segment. We also identified two cases that did not exhibit an elevation of flow, but occurred in a region exposed to elevated oscillatory flow. Our study demonstrates that the majority of OCT-defined erosions occur where the endothelium is exposed to elevated flow, a haemodynamic environment known to evoke a distinctive phenotypic response in endothelial cells.

Scavenger Receptors as Biomarkers and Therapeutic Targets in Cardiovascular Disease

The process of atherosclerosis leads to the formation of plaques in the arterial wall, resulting in a decreased blood supply to tissues and organs and its sequelae: morbidity and mortality. A class of membrane-bound proteins termed scavenger receptors (SRs) are closely linked to the initiation and progression of atherosclerosis. Increasing interest in understanding SR structure and function has led to the idea that these proteins could provide new routes for cardiovascular disease diagnosis, management, and treatment. In this review, we consider the main classes of SRs that are implicated in arterial disease. We consider how our understanding of SR-mediated recognition of diverse ligands, including modified lipid particles, lipids, and carbohydrates, has enabled us to better target SR-linked functionality in disease. We also link clinical studies on vascular disease to our current understanding of SR biology and highlight potential areas that are relevant to cardiovascular disease management and therapy.

Association between serum phosphorus and subclinical coronary atherosclerosis in asymptomatic Korean individuals without kidney dysfunction

BACKGROUND

There are limited data regarding the relation between serum phosphorus concentration (SPC) and subclinical coronary atherosclerosis in the asymptomatic healthy population without kidney dysfunction.

OBJECTIVES

We aimed to investigate the relation between SPC and characteristics of atherosclerotic plaques and cardiac events according to SPCs using a large cohort of asymptomatic Korean individuals.

METHODS

We evaluated 6329 asymptomatic Korean individuals [mean age: 53.6 ± 7.6 y, 4611 men (72.9%)] without kidney dysfunction and coronary artery disease who voluntarily underwent coronary computed tomography angiography (CCTA) as part of a general health examination. Study participants were stratified into quartiles according to their SPCs (≤3.0, 3.1-3.3, 3.4-3.7, ≥3.8 mg/dL). The degree and extent of subclinical coronary atherosclerosis were evaluated with CCTA. Stenosis of diameter ≥50% was defined as significant. A cardiac event was defined as a composite of all-cause death, myocardial infarction, unstable angina, and coronary revascularization.

RESULTS

After adjustment for cardiovascular disease risk factors, the risk of any atherosclerotic plaque was significantly higher with increasing SPC quartiles (P = 0.001). In particular, the risk of calcified plaque increased in the second (OR: 1.27; 95% CI: 1.07, 1.51; P = 0.006), third (OR: 1.39; 95% CI: 1.17, 1.64; P < 0.001), and fourth SPC quartiles (OR: 1.50; 95% CI: 1.24, 1.82; P < 0.001) compared with that in the first quartile. However, there were no significant differences in the adjusted ORs for noncalcified plaque, mixed plaque, or significant stenosis. During a follow-up of median 5.4 y, there was no significant difference in cardiac events between the SPC quartiles.

CONCLUSIONS

In asymptomatic Korean individuals without kidney dysfunction, a high SPC was an independent predictor of calcified plaques without any difference in cardiac events. Further long-term prospective studies are required to validate these results.

Moderate thickness of lipid core in shoulder region of atherosclerotic plaque determines vulnerable plaque A parametric study

Peak stress in the fibrous cap of atherosclerotic plaque is largely determined by the cap thickness which cannot be accurately estimated in vivo. This parametric study investigates idealized atherosclerotic plaque geometries. Finite element modeling is applied to search for larger morphological features associated with high cap stresses. By varying seven geometrical and two loading parameters, 100 3D model geometries of atherosclerotic plaques in common iliac artery were generated. In each model peak cap stress was calculated, and statistical comparison of the geometries generating the highest and lowest peak cap stresses was performed. The analysis showed that, compared to geometries generating the lowest stresses, those with high peak cap stress had a significantly lower cap thickness, higher stenosis ratio, lower relative lipid core volume, and cap shoulder radius larger than lipid core radius. High cap stress was observed for cap thicknesses up to 0.13 mm. It can be concluded that vulnerable plaques contain thin fibrous cap, large stenosis ratio and only moderate small-radius lipid core which reaches the shoulder region of the fibrous cap.

Relationship Between Carbohydrate Antigen 125 and Coronary Artery Calcification in Patients without Known Coronary Artery Disease

BACKGROUND This study was designed to investigate the association between serum carbohydrate antigen 125 (CA125) and coronary artery calcification (CAC) score in patients without known coronary artery disease. MATERIAL AND METHODS The study groups included 348 consecutive subjects with chest pain but without known coronary artery disease, and who underwent an estimation of CAC score in our hospital. RESULTS The clinical and laboratory characteristics of all subjects are presented according to serum CA125 concentrations tertiles. The CAC score was found to be increased in the tertiles (31.6 ±82.10, 73.3±125.6, 122.9±135.9 U/mL, p<0.001). Serum CA125 concentrations are increased in calcium-positive patients compared with calcium-negative ones (9.3±4.79 vs. 11.2±7.36, p=0.003). A positive correlation between serum CA125 and CAC score was observed (r=0.319, p<0.001) in all participants. Similarly, the serum concentrations of CA125 were found to be positively correlated with CAC score in both women and men (r=0.328, p<0.001; r=0.265, p=0.001, respectively). Multiple linear regression analysis results indicated that serum CA125 concentrations are independently related to CAC score in the study population (beta=0.173, p=0.001), and age, sex, diabetes mellitus, and high-sensitivity C-reactive protein (hs-CRP) were also associated with CAC score in multiple linear regression analysis. CONCLUSIONS Serum CA125 concentrations are correlated with CAC score in the population without known coronary artery disease, and serum CA125 may be considered as a marker to estimate CAC in the study population.

Intravascular Ultrasound and Near-Infrared Spectroscopic Characterization of Thin-Cap Fibroatheroma

Thin-cap fibroatheromas (TCFAs) are considered precursors for plaque rupture and subsequent acute coronary events. We investigated intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) characteristics of lesions that were histopathologic TCFAs. IVUS, NIRS, and histopathology were performed in 271 atherosclerotic lesions from 107 fresh coronary arteries from 54 patients at necropsy. The plaque burden and remodeling index calculated by IVUS and maximum lipid core burden index within any 4-mm segment (maxLCBI_4mm) calculated by NIRS were compared among each plaque type based on histopathologic classifications but focusing on TCFA. Lesions classified as TCFAs had the largest plaque burden, the highest remodeling index, and the greatest maxLCBI_4mm. Plaque burden ≥69% (90% sensitivity, 75% specificity, and area under the curve 0.87); remodeling index ≥1.07 (80% sensitivity, 79% specificity, and area under the curve 0.84); and maxLCBI_4mm ≥323 (80% sensitivity, 85% specificity, and area under the curve 0.84) predicted a histopathologic TCFA. In conclusion, a large plaque burden and a high remodeling index assessed by IVUS and lipid-rich plaque determined by the NIRS maxLCBI_4mm are useful predictive markers of TCFA.

Sex Differences in Fractional Flow Reserve-Guided Revascularization: A Nationwide Analysis

BACKGROUND

Women with coronary artery disease are less likely to be revascularized than men based on angiography alone. Recent studies have shown that female patients have higher fractional flow reserve (FFR) values for a given severity of coronary stenosis. However, gender differences in coronary revascularization rates following FFR assessment are unknown.

METHODS

The nationwide inpatient sample database was used to identify all patients who underwent FFR in the United States between January 2009 and December 2010. We used propensity score matching to compare revascularization rates and in-hospital outcomes among men and women undergoing FFR measurements.

RESULTS

Among 3712 patients who underwent FFR during the study period, 1235 matched pairs of men and women were identified. The overall revascularization rates were lower in women than men (40.1% vs. 52.8%, p < 0.01). Women were less likely to undergo either percutaneous (35.2% vs. 45.6%, p < 0.01) or surgical revascularization following FFR than men (5.2% vs. 7.4%, p = 0.03). Women had a nonsignificant trend toward higher in-hospital mortality (0.8% vs. 0.5%, p = 0.32) and significantly higher rates of access site hematoma formation (2.7% vs. 0.8%, p < 0.01) compared to men.

CONCLUSION

In conclusion, this large nationwide study reveals that coronary revascularization rates are significantly lower in women than in men even after functional assessment with FFR.

Pathology of coronary atherosclerosis and thrombosis

The process of early atherosclerotic plaque progression is characterized by the development of pathologic intimal thickening (PIT) with lipid pool that may transform into the necrotic core to form fibroatheroma, where infiltration of foamy macrophages plays a crucial role. The expansion of the necrotic core is also attributable to intraplaque hemorrhage. Thin-cap fibroatheroma (TCFA) is characterized by a relatively large necrotic core with an overlying thin fibrous cap measuring <65 µm typically containing numerous macrophages, and is considered to be the precursor lesion of plaque rupture which is the most common cause of coronary thrombosis. The second common cause of acute thrombosis is plaque erosion, while calcified nodules is known to be the least frequent cause of coronary thrombosis. Coronary thrombosis can occur without symptoms to form healed lesions, which contributes to an increase in plaque burden and luminal narrowing. The process of plaque progression is generally accompanied by the progression of calcification. An understanding of the histomorphological characteristics of coronary plaques should provide important insights into the pathogenesis, diagnosis, and treatment of atherosclerotic coronary disease for both basic and clinical researchers as well as for clinicians.

Acute coronary syndromes in women and men

Evidence of sex-related disparities in the care and outcomes of patients with acute coronary syndrome (ACS) emerged >30 years ago, and yet the mechanisms behind these sex-specific differences remain unclear. In this Review, we discuss the current literature on differences between women and men in the clinical presentation, pathophysiology, evaluation, management, and outcomes of ACS. Although the symptoms of ACS and the benefits of therapy generally overlap between women and men, women continue to receive less-aggressive invasive and pharmacological therapy than men. In addition, young women in particular have worse short-term and long-term outcomes than men. To understand better the mechanisms behind these continued disparities, we have identified areas of future research that need to be urgently addressed in fields that range from clinical evaluation and management, to increasing representation of women in research.

Women and Ischemic Heart Disease: Recognition, Diagnosis and Management

Cardiovascular disease is one of the most frequent causes of death in both males and females throughout the world. However, women exhibit a greater symptom burden, more functional disability, and a higher prevalence of nonobstructive coronary artery disease (CAD) compared to men when evaluated for signs and symptoms of myocardial ischemia. This paradoxical sex difference appears to be linked to a sex-specific pathophysiology of myocardial ischemia including coronary microvascular dysfunction, a component of the 'Yentl Syndrome'. Accordingly, the term ischemic heart disease (IHD) is more appropriate for a discussion specific to women rather than CAD or coronary heart disease. Following the National Heart, Lung, and Blood Institute Heart Truth/American Heart Association, Women's Ischemia Syndrome Evaluation and guideline campaigns, the cardiovascular mortality in women has been decreased, although significant gender gaps in clinical outcomes still exist. Women less likely undergo testing, yet guidelines indicate that symptomatic women at intermediate to high IHD risk should have further test (e.g. exercise treadmill test or stress imaging) for myocardial ischemia and prognosis. Further, women have suboptimal use of evidence-based guideline therapies compared with men with and without obstructive CAD. Anti-anginal and anti-atherosclerotic strategies are effective for symptom and ischemia management in women with evidence of ischemia and nonobstructive CAD, although more female-specific study is needed. IHD guidelines are not "cardiac catheterization" based but related to evidence of "myocardial ischemia and angina". A simplified approach to IHD management with ABCs (aspirin, angiotensin-converting enzyme inhibitors/angiotensin-renin blockers, beta blockers, cholesterol management and statin) should be used and can help to increases adherence to guidelines.

Single-Staged Compared With Multi-Staged PCI in Multivessel NSTEMI Patients: The SMILE Trial

BACKGROUND

A lack of clarity exists about the role of complete coronary revascularization in patients presenting with non-ST-segment elevation myocardial infarction.

OBJECTIVES

The aim of our study was to compare long-term outcomes in terms of major adverse cardiovascular and cerebrovascular events of 2 different complete coronary revascularization strategies in patients with non-ST-segment elevation myocardial infarction and multivessel coronary artery disease: 1-stage percutaneous coronary intervention (1S-PCI) during the index procedure versus multistage percutaneous coronary intervention (MS-PCI) complete coronary revascularization during the index hospitalization.

METHODS

In the SMILE (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage Versus Multistaged Percutaneous Coronary Intervention) trial, 584 patients were randomly assigned in a 1:1 manner to 1S-PCI or MS-PCI. The primary study endpoint was the incidence of major adverse cardiovascular and cerebrovascular events, which were defined as cardiac death, death, reinfarction, rehospitalization for unstable angina, repeat coronary revascularization (target vessel revascularization), and stroke at 1 year.

RESULTS

The occurrence of the primary endpoint was significantly lower in the 1-stage group (1S-PCI: n = 36 [13.63%] vs. MS-PCI: n = 61 [23.19%]; hazard ratio [HR]: 0.549 [95% confidence interval (CI): 0.363 to 0.828]; p = 0.004). The 1-year rate of target vessel revascularization was significantly higher in the MS-PCI group (1S-PCI: n = 22 [8.33%] vs. MS-PCI: n = 40 [15.20%]; HR: 0.522 [95% CI: 0.310 to 0.878]; p = 0.01; p log-rank = 0.013). When the analyses were limited to cardiac death (1S-PCI: n = 9 [3.41%] vs. MS-PCI: n = 14 [5.32%]; HR: 0.624 [95% CI: 0.270 to 1.441]; p = 0.27) and myocardial infarction (1S-PCI: n = 7 [2.65%] vs. MS-PCI: n = 10 [3.80%]; HR: 0.678 [95% CI: 0.156 to 2.657]; p = 0.46), no significant differences were observed between groups.

CONCLUSIONS

In multivessel non-ST-segment elevation myocardial infarction patients, complete 1-stage coronary revascularization is superior to multistage PCI in terms of major adverse cardiovascular and cerebrovascular events. (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction [NSTEMI]

PATIENTS

One Stage Versus Multistaged Percutaneous Coronary Intervention [PCI] [SMILE]: NCT01478984).

Endothelial erosion of plaques as a substrate for coronary thrombosis

Myocardial infarction is a prevalent, life-threatening consequence of athero-thrombosis. Post-mortem histology and intravascular imaging in live patients have shown that approximately one third of myocardial infarctions are caused by a thrombus overlying an intact, non-ruptured atherosclerotic plaque. Histology identifies erosion of luminal endothelial cells from smooth muscle and proteoglycan-rich, thick fibrous cap atheromas as the underlying pathology. Unlike plaque ruptures, endothelial erosions tend to occur on thick-capped atherosclerotic plaques and may or may not be associated with inflammation. Smoking and female gender are strong risk factors for erosion. Multiple mechanisms may contribute to endothelial erosion, including endothelial dysfunction, TLR signalling, leukocyte activation and modification of sub-endothelial matrix by endothelial or smooth muscle cells, which may trigger loss of adhesion to the extracellular matrix or endothelial apoptosis. Diagnosis of endothelial erosion by intravascular imaging, especially high resolution optical coherence tomography, may influence treatment strategies, offering prognostic value and utility as an endpoint in trials of agents designed to preserve an intact coronary endothelium.

Predominant location of coronary artery atherosclerosis in the left anterior descending artery. The impact of septal perforators and the myocardial bridging effect

Introduction

Coronary artery atherosclerosis presents characteristic patterns of plaque distribution despite systemic exposure to risk factors. We hypothesized that local hemodynamic forces induced by the systolic compression of intramuscular septal perforators could be involved in atherosclerotic processes in the left anterior descending artery (LAD) adjacent to the septal perforators’ origin. Therefore we studied the spatial distribution of atherosclerosis in coronary arteries, especially in relation to the septal perforators’ origin.

Material and methods

64-slice computed tomography angiography was performed in 309 consecutive patients (92 male and 217 female) with a mean age of 59.9 years. Spatial plaque distribution in the LAD was analyzed in relation to the septal perforators’ origin. Additionally, plaque distribution throughout the coronary artery tree is discussed.

Results

The coronary calcium score (CCS) was positive in 164 patients (53.1%). In subjects with a CCS > 0, calcifications were more frequent in the LAD (n = 150, 91.5%) compared with the right coronary artery (RCA) (n = 94, 57.3%), circumflex branch (CX) (n = 76, 46.3%) or the left main stem (n = 42, 25.6%) (p < 0.001). Total CCS was higher in the LAD at 46.1 (IQR: 104.2) and RCA at 34.1 (IQR: 90.7) than in the CX at 16.8 (IQR: 61.3) (p = 0.007). In patients with calcifications restricted to a single vessel (n = 54), the most frequently affected artery was the LAD (n = 42, 77.8%). In patients with lesions limited to the LAD, the plaque was located mostly (n = 37, 88.1%) adjacent to the septal perforators’ origin.

Conclusions

We demonstrated that coronary calcifications are most frequently located in the LAD in proximity to the septal branch origin. A possible explanation for this phenomenon could be the dynamic compression of the tunneled septal branches, which may result in disturbed blood flow in the adjacent LAD segment (milking effect).

The presence of calcifications along the course of internal carotid artery in Greek and Brazilian populations: a comparative and retrospective cone beam CT data analysis

OBJECTIVES

We aimed to retrospectively compare the prevalence of soft tissue calcifications (STCs) depicted incidentally along the extra- and intracranial course of the internal carotid artery (ICA) on cone beam computed tomography examinations in 2 different populations (Greeks and Brazilians).

METHODS

The cohort consisted of examinations of 232 Greeks and 174 Brazilians, for a total of 406 patients. The scans were evaluated for the presence of STCs along the course of the ICA, with data analyzed in each ethnic group according to gender and age criteria.

RESULTS

In total, 355 STCs were recorded; 78 (22.0% of all STCs) and 58 (16.3%) were extracranials, and 128 (36.1%) and 91 (25.6%) were intracranials for Greeks and Brazilians, respectively. The χ(2) test indicated no statistical differences between Greeks and Brazilians in the occurrence of STCs; however, their prevalence differed between genders in those populations. The presence of lesions, both extra- and intracranially, was found to increase with age (P < .05). The odds ratios were estimated at 2.23 (95% CI, 1.81-2.74) and 3.26 (95% CI, 2.56-4.16) for extracranial and intracranial lesions, respectively, with increasing age.

CONCLUSIONS

We found an equal distribution for both extra- and intracranial STCs among Greeks and Brazilians. The prevalence of lesions differed between genders within both populations. Aging was found to be a risk factor for STCs, as the odds ratio increased significantly.

Pathophysiology of native coronary, vein graft, and in-stent atherosclerosis

Plaque rupture, usually of a precursor lesion known as a 'vulnerable plaque' or 'thin-cap fibroatheroma', is the leading cause of thrombosis. Less-frequent aetiologies of coronary thrombosis are erosion, observed with greatest incidence in women aged <50 years, and eruptive calcified nodules, which are occasionally identified in older individuals. Various treatments for patients with coronary artery disease, such as CABG surgery and interventional therapies, have led to accelerated atherosclerosis. These processes occur within months to years, compared with the decades that it generally takes for native disease to develop. Morphological identifiers of accelerated atherosclerosis include macrophage-derived foam cells, intraplaque haemorrhage, and thin fibrous cap. Foam-cell infiltration can be observed within 1 year of a saphenous vein graft implantation, with subsequent necrotic core formation and rupture ensuing after 7 years in over one-third of patients. Neoatherosclerosis occurs early and with greater prevalence in drug-eluting stents than in bare-metal stents and, although rare, complications of late stent thrombosis from rupture are associated with high mortality. Comparison of lesion progression in native atherosclerotic disease, atherosclerosis in saphenous vein grafts, and in-stent neoatherosclerosis provides insight into the pathogenesis of atheroma formation in natural and iatrogenic settings.

Emergence of Nonobstructive Coronary Artery Disease: A Woman's Problem and Need for Change in Definition on Angiography

Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.

Coronary plaque characterization using CT

OBJECTIVE. In this article, we review the histopathologic classification of coronary atherosclerotic plaques and describe the possibilities and limitations of CT regarding the evaluation of coronary artery plaques. CONCLUSION. The composition of atherosclerotic plaques in the coronary arteries displays substantial variability and is associated with the likelihood for rupture and downstream ischemic events. Accurate identification and quantification of coronary plaque components on CT is challenging because of the limited temporal, spatial, and contrast resolutions of current scanners. Nonetheless, CT may provide valuable information that has potential for characterization of coronary plaques. For example, the extent of calcification can be determined, lipid-rich lesions can be separated from more fibrous ones, and positive remodeling can be identified.

Sex differences in coronary artery disease: pathological observations

Cardiovascular disease (CVD) remains the most frequent cause of death in both men and women. Many studies on CVD have included mostly men, and the knowledge about coronary artery disease (CAD) in women has largely been extrapolated from studies primarily focused on men. The influence of various risk factors is different between men and women; untoward effects of smoking of CAD are greater in women than men. Furthermore, the effect of the menopause is important in women, with higher incidence of plaque erosion in young women versus greater incidence of plaque rupture in older women. This review focuses on differences in plaque morphology in men and women presenting with sudden coronary death and acute myocardial infarction.

ACS and STEMI treatment: gender-related issues

Cardiovascular disease is the leading cause of death amongst women, with acute coronary syndromes (ACS) representing a significant proportion. It has been reported that in women presenting with ACS there is underdiagnosis and consequent undertreatment leading to an increase in hospital and long-term mortality. Several factors have to be taken into account, including lack of awareness both at patient and at physician level. Women are generally not aware of the cardiovascular risk and symptoms, often atypical, and therefore wait longer to seek medical attention. In addition, physicians often underestimate the risk of ACS in women leading to a further delay in accurate diagnosis and timely appropriate treatment, including cardiac catheterisation and primary percutaneous coronary intervention, with consequent delayed revascularisation times. It has been acknowledged by the European Society of Cardiology that gender disparities do exist, with a Class I, Level of Evidence B recommendation that both genders should be treated in the same way when presenting with ACS. However, there is still a lack of awareness and the mission of Women in Innovation, in association with Stent for Life, is to change the perception of women with ACS and to achieve prompt diagnosis and treatment.

Diastolic dysfunction in women with signs and symptoms of ischemia in the absence of obstructive coronary artery disease: a hypothesis-generating study

BACKGROUND

Angina, in the absence of obstructive coronary artery disease, is more common in women, is associated with adverse cardiovascular morbidity and mortality, and is a major burden to the healthcare system. Although advancements have been made to understand the mechanistic underpinning of this disease, the functional consequence remains unclear.

METHODS AND RESULTS

Cardiac magnetic resonance imaging was performed to assess left ventricular function in 20 women with signs and symptoms of ischemia, but no obstructive coronary artery disease (cases), and 15 age- and body mass index-matched reference controls. Functional imaging included standard cinematic imaging to assess left ventricular morphology and global function, along with tissue tagging to assess left ventricular tissue deformation. Systolic function was preserved in both cases and controls, with no differences in ejection fraction (mean±SE: 63.1±8% versus 65±2%), circumferential strain (-20.7±0.6% versus -21.9±0.5%), or systolic circumferential strain rate (-105.9±6.1% versus -109.0±3.8% per second). In contrast, we observed significant differences between cases and controls in diastolic function, as demonstrated by reductions in both diastolic circumferential strain rate (153.8±8.9% versus 191.4±8.9% per second; P<0.05) and peak rate of left ventricular untwisting (-99.4±8.0° versus -129.4±12.8° per second; P<0.05).

CONCLUSIONS

Diastolic function is impaired in women with signs and symptoms of ischemia in the absence of coronary artery disease, as assessed by cardiac magnetic resonance tissue tagging. These results are hypothesis-generating. Larger studies are needed to define the exact mechanism(s) responsible and to establish viable treatment strategies.

Is being an elderly woman a risk factor for worse outcomes after percutaneous coronary intervention? A large cohort study from one center

It has remained undefined whether the combination of being elderly (ie, >75 years old) and female is a risk factor for worse outcomes after percutaneous coronary intervention (PCI). A total of 29 211 consecutive patients who underwent PCI were analyzed. Kaplan-Meier estimated 3-year rate of cardiac death was significantly higher in elderly females in comparison with all other groups (P < .05). Using Cox proportional hazard models, being an elderly female was a significant risk factor for cardiac death and cardiac death/MI in comparison with being a young female, OR (95% CI): 2.53 (1.15-5.59), 2.26 (1.27-4.03), or young male, OR (95% CI): 2.22 (1.26-3.91), 2.25 (1.44-3.51); however, it was not a significant risk factor in comparison with being elderly male, OR (95% CI): 1.30 (0.97-1.71), 1.21(0.94-1.55). Elderly females had worse outcomes after PCI therapy than other gender and age groups, but being an elderly female was not an independent risk factor for worse PCI outcomes.

Social factors and coping status in asymptomatic middle-aged Danes: Association to coronary artery calcification

Aims: Understanding the determinants of social and coping inequalities in subclinical cardiovascular disease is an important prerequisite in developing and implementing preventive strategies. The aim of this study was to investigate the association between social factors and coping status, respectively, and subclinical coronary artery disease (CAD) in middle-aged Danes. Methods: This is a DanRisk screening substudy, thus including healthy Danish males and females aged 50 or 60 years. Social measures included grade of education, employment and co-habiting status. The coping status was estimated by the general self-efficacy (GES) scale. Coronary artery calcification (CAC) was assessed by computed tomography using the Agatston score (AS). Conventional clinical risk factors included sex, family history of CAD, BMI > 25, smoking, hypercholesterolaemia and hypertension. Results: In 568 individuals the prevalence of subjects with CAC was 267 (45%). Independent predictors of CAC in males were age (OR = 1.10, 95% CI = 1.04–1.16, p < 0.001), smoking (OR = 1.75, 95% CI = 1.03–2.99, p = 0.038), and low co-habiting status (OR = 3.66, 95% CI = 1.19–11.25, p = 0.023). Independent predictors in females were age (OR = 1.67, 95% CI = 1.02–1.12, p = 0.006), and smoking (OR = 1.71, 95% CI = 1.06–2.78, p = 0.029). Higher AS was associated to lower employment level in females ( p = 0.001) but not in males ( p = 0.833). Conclusions: Social factors are associated to the prevalence and severity of CAC in asymptomatic middle-aged individuals with gender differences. The relative value of gender specific social versus conventional clinical risk factors in the risk assessment of subclinical CAC in middle-aged individuals needs further investigation in future prospective studies.

Coronary artery calcium and physical performance as determinants of mortality in older age: the AGES-Reykjavik Study

BACKGROUND

Coronary artery calcium (CAC) and physical performance have been shown to be associated with mortality, but it is not clear whether one of them modifies the association. We investigated the association between the extent of CAC and physical performance among older individuals and explored these individual and combined effects on cardiovascular disease (CVD) mortality and non-CVD mortality.

METHODS

We studied 4074 participants of the AGES-Reykjavik Study who were free from coronary heart disease, had a CAC score calculated from computed tomography scans and had data on mobility limitations and gait speed at baseline in 2002-2006 at a mean age of 76 years. Register-based mortality was available until 2009.

RESULTS

Odds for mobility limitation and slow gait increased according to the extent of CAC. Altogether 645 persons died during the follow-up. High CAC, mobility limitation and slow gait were independent predictors of CVD mortality and non-CVD mortality. The joint effect of CAC and gait speed on non-CVD mortality was synergistic, i.e. compared to having low CAC and normal gait, the joint effect of high CAC and slow gait exceeded the additive effect of these individual exposures on non-CVD mortality. For CVD mortality, the effect was additive i.e. the joint effect of high CAC and slow gait did not exceed the sum of the individual exposures.

CONCLUSIONS

The extent of CAC and decreased physical performance were independent predictors of mortality and the joint presence of these risk factors increased the risk of non-CVD mortality above and beyond the individual effects.

Update on acute coronary syndromes: the pathologists' view

Although mortality rates from coronary heart disease in the western countries have declined in the last few decades, morbidity caused by this disease is increasing and a substantial number of patients still suffer acute coronary syndrome (ACS) and sudden cardiac death. Acute coronary syndrome occurs as a result of myocardial ischaemia and its manifestations include acute myocardial infarction and unstable angina. Culprit plaque morphology in these patients varies from thrombosis with or without coronary occlusion to sudden narrowing of the lumen from intraplaque haemorrhage. The coronary artery plaque morphologies primarily responsible for thrombosis are plaque rupture, and plaque erosion, with plaque rupture being the most common cause of acute myocardial infarction, especially in men. Autopsy data demonstrate that women <50 years of age more frequently have erosion, whereas in older women, the frequency of rupture increases with each decade. Ruptured plaques are associated with positive (expansive) remodelling and characterized by a large necrotic core and a thin fibrous cap that is disrupted and infiltrated by foamy macrophages. Plaque erosion lesions are often negatively remodelled with the plaque itself being rich in smooth muscle cells and proteoglycans with minimal to absence of inflammation. Plaque haemorrhage may expand the plaque rapidly, leading to the development of unstable angina. Plaque haemorrhage may occur from plaque rupture (fissure) or from neovascularization (angiogenesis). Atherosclerosis is now recognized as an inflammatory disease with macrophages and T-lymphocytes playing a dominant role. Recently at least two subtypes of macrophages have been identified. M1 is a pro-inflammatory macrophage while M2 seems to play a role in dampening inflammation and promoting tissue repair. A third type of macrophage, termed by us as haemoglobin associated macrophage or M(Hb) which is observed at site of haemorrhage also can be demonstrated in human atherosclerosis. In order to further our understanding of the specific biological events which trigger plaque instability and as well as to monitor the effects of novel anti-atherosclerotic therapies newer imaging modalities in vivo are needed.

Multislice computed tomography angiography in the diagnosis of coronary artery disease

Multislice CT angiography represents one of the most exciting technological revolutions in cardiac imaging and it has been increasingly used in the diagnosis of coronary artery disease. Rapid improvements in multislice CT scanners over the last decade have allowed this technique to become a potentially effective alternative to invasive coronary angiography in patients with suspected coronary artery disease. High diagnostic value has been achieved with multislice CT angiography with use of 64- and more slice CT scanners. In addition, multislice CT angiography shows accurate detection and analysis of coronary calcium, characterization of coronary plaques, as well as prediction of the disease progression and major cardiac events. Thus, patients can benefit from multislice CT angiography that provides a rapid and accurate diagnosis while avoiding unnecessary invasive coronary angiography procedures. The aim of this article is present an overview of the clinical applications of multislice CT angiography in coronary artery disease with a focus on the diagnostic accuracy of coronary artery disease; prognostic value of coronary artery disease with regard to the prediction of major cardiac events; detection and quantification of coronary calcium and characterization of coronary plaques. Limitations of multislice CT angiography in coronary artery disease are also briefly discussed, and future directions are highlighted.

Imaging Tests, Provocative Tests, Including Exercise Testing in Women with Suspected Coronary Artery Disease

Evolving knowledge regarding sex differences in coronary heart disease has demonstrated that the prevalence, symptomatology, and pathophysiology of coronary atherosclerosis vary between genders. Women experience higher mortality rates and more adverse outcomes after acute myocardial infarction than men, despite a lower prevalence of obstructive coronary artery disease. Based on recent insights into the complex pathophysiology of coronary heart disease which includes a spectrum of obstructive coronary artery disease and dysfunction of the coronary microvasculature and endothelium, the term ischemic heart disease is a more accurate term for discussion of coronary atherosclerosis specific to women. In women, with clinical features and risk factors for ischemic heart disease, the detection and evaluation of ischemic heart disease is challenging due to the diverse pathogenic mechanisms of ischemic heart diseases in women. In this article, we discuss noninvasive imaging tests, provocative tests, including exercise testing in women with suspected ischemic heart disease.

Myocardial ischemia in women: lessons from the NHLBI WISE study

Cardiovascular disease (CVD) remains the leading cause of death for women. For almost 3 decades, more women than men have died from CVD, with the most recent annual statistics on mortality reporting that CVD accounted for 421 918 deaths among women in the United States. Although there have been significant declines in coronary heart disease (CHD) mortality for females, these reductions lag behind those seen in men. In addition, where there has been a decrease in mortality from CHD across all age groups over time in men, in the youngest women (age <55 years) there has been a notable increase in mortality from CHD. There are differences in the prevalence, symptoms, and pathophysiology of myocardial ischemia that occurs in women compared with men. In this paper, we review the pathophysiology and mechanisms of ischemic heart disease (IHD) in women, particularly focusing on what we have learned from the WISE study. We examine the sex-specific issues related to myocardial ischemia in women in terms of prevalence and prognosis, traditional and novel risk factors, diagnostic testing, as well as therapeutic management strategies for IHD.

Histopathological correlates of the napkin-ring sign plaque in coronary CT angiography

OBJECTIVE

The purpose of this study was to identify histologic characteristics of advanced coronary atherosclerotic plaques that are related with the detection of the napkin-ring sign (NRS) in coronary CT angiography (CCTA).

METHODS

CCTA was performed in 7 human donor hearts. Histological slicing and stainings were performed in 1 mm increments of each major coronary artery. Histology was co-registered with the CT-data and classified according to the modified AHA classification.

RESULTS

Advanced plaques (types IV-VI) were present in 139 (23%) of 611 cross sections. Of these 33 (24%) demonstrated an NRS in CCTA. NRS plaques were associated with greater non-core plaque area (median 10.2 vs. 6.4 mm(2), p < 0.01) and larger vessel area (median 17.1 vs. 13.0 mm(2), p < 0.01). The area of the necrotic/lipid core was larger in plaques with NRS (median 1.1 vs. 0.5 mm(2), p = 0.05). Angiogenesis tended to be more frequent in plaques with NRS (48% vs. 30%) whereas micro-calcifications tended to be more frequent in plaques without NRS (27% vs. 46%) (p = 0.06 and 0.07 respectively). In a multivariate analysis, necrotic/lipid core area (OR = 1.9), non-core plaque area (OR = 1.6), and total vessel area (OR = 0.9) independently predicted the appearance of the NRS in coronary CT angiography.

CONCLUSION

Delineation of NRS in CCTA is independently linked to the size of the necrotic/lipid core, the size of the non-core plaque and to the vessel area as measured in histology of advanced coronary atherosclerotic plaques.

Association between gamma-glutamyltransferase and coronary artery calcification

BACKGROUND

The exact mechanisms behind the association between atherosclerosis and gamma-glutamyltransferase (GGT) are unclear. Coronary artery calcification (CAC) detected by computerized tomography is an important marker of atherosclerosis and its severity correlates with coronary plaque burden. The aim of this study was to investigate if serum GGT levels are associated with CAC in patients without known coronary heart disease (CHD) who had low-intermediate risk for CHD.

METHODS

Two hundred and seventy two patients who had low-intermediate risk for coronary artery disease were included in the study. Serum GGT levels were measured spectrophotometrically. CACS (Agatston method) were performed using a 64-slice computerized tomography scanner. The patients were grouped according to their GGT values in four quartiles.

RESULTS

Patients in higher GGT quartiles had elevated CAC score (P<0.001). Patients in higher GGT quartiles were predominantly males (P<0.001) and were more likely to be smoking (P=0.004), and have elevated uric acid (P<0.001), fasting blood glucose (P<0.001), CRP levels (P=0.003) and 10-year total cardiovascular risk (P=0.007) and low HDL levels (P<0.001). Positive correlations were found between log GGT and CAC (r=0.233, P<0.001). In the multivariate analysis GGT, age, smoking and serum uric acid levels appeared as independent factors predictive of presence of CAC.

CONCLUSIONS

We demonstrated a significant correlation between serum GGT levels and CAC and CHD risk factors. Serum GGT level was an independent marker of CAC.