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

Association between the difference in estimated GFR based on cystatin C versus creatinine in coronary artery diseases

BACKGROUND

The difference in estimated glomerular filtration rate (eGFR) derived from creatinine and cystatin C (eGFRdiff) has been noticed recently and the relationship with poor cardiovascular prognosis has been proven. However, primary prevention of the risk of coronary artery disease (CAD) is equally important but there is a lack of studies specifically investigating this implication.

METHODS

This prospective cohort study utilized data from the UK Biobank, including 437,536 participants without CAD at baseline. The primary outcome was defined as CAD. The eGFRdiff was calculated by subtracting creatinine-based eGFR from cystatin C-based eGFR. Participants were then categorized into a negative, intermediate range, and positive group based on thresholds of -15 mL/min/1.73 m2 and 15 mL/min/1.73 m2. Cox proportional risk models were used to evaluate the associations of eGFRdiff with CAD and the relationship among different genetic risks of CAD.

RESULTS

During a median follow-up of 13.8 years, CAD occurred in 36,797 participants. In the fully adjusted model, compared to midrange eGFRdiff, participants with a positive eGFRdiff had a lower risk of CAD (HR 0.717, 95%CI 0.675-0.762), while with a negative eGFRdiff had a higher risk (HR 1.433, 95%CI 1.399-1.468). When eGFRdiff was treated as a continuous variable, a statistically significant trend toward a lower risk of CAD as eGFRdiff increased (HR 0.982, 95% CI 0.981-0.982). Moreover, this relationship is independent of genetic susceptibility.

CONCLUSIONS

eGFRdiff was associated with CAD risk, where a high eGFRdiff corresponded to a decreased likelihood of CAD onset no matter genetic susceptibility.

Prognostic value of remnant-like particle cholesterol in ischemic heart failure patients following percutaneous coronary intervention

BACKGROUND

The relationship between remnant-like particle cholesterol (RLP-C) and cardiovascular disease risk and prognosis has been established, but its effect on the prognosis of ischemic heart failure (IHF) patients undergoing percutaneous coronary intervention (PCI) remains uncertain.

METHOD

In this study, 2036 patients with IHF who underwent PCI were included. Patients were categorized into tertiles based on their RLP-C levels. The primary outcome was major adverse cardiovascular events (MACE). Kaplan-Meier survival analysis was used to assess the incidence of MACE and other outcomes. Multivariate Cox regression models were employed to investigate the correlation between RLP-C and the studied outcomes. The nonlinear relationship between RLP-C and MACE was examined through the restricted cubic spline (RCS). Subgroup analyses were performed and interactions were assessed.

RESULT

The study results showed a clear association between higher RLP-C levels and an increased incidence of MACE in the participants. This association was validated by Kaplan-Meier analyses. The multivariate Cox regression demonstrated RLP-C was an independent risk factor for MACE, whether assessed as a continuous variable[hazard ratio (HR), 95% confidence interval (CI): 1.50, 1.15-1.98, p = 0.003] or categorized into tertiles[HR, 95% CI: 2.57, 2.03-3.26, p < 0.001, tertile 3 vs tertile 1]. A nonlinear relationship between RLP-C and MACE was observed, indicating that the risk of MACE increased with higher RLP-C levels(Nonlinear p < 0.001). This association remained consistent across various subgroups, as no significant interactions were found.

CONCLUSION

There was an independent and positive correlation between RLP-C and MACE in patients with IHF who underwent PCI.

The use of antiarrhythmic drugs for atrial fibrillation in Finland 2007-2018

BACKGROUND

Patients with atrial fibrillation (AF) are often treated with antiarrhythmic drugs (AADs) to maintain sinus rhythm and with heart rate-lowering drugs to achieve the optimal rate control. In this study, we investigated trends in the use of AADs and rate control drugs in Finnish patients with AF.

METHODS AND RESULTS

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study including all patients with AF in Finland from 2007 to 2018. The number of AAD purchases and the proportions of all prevalent AF patients in a certain year of interest were calculated. In total, 391030 AF patients were identified between 2007 and 2018, and 39,816 (10.2%) of them had purchased either class I or III AADs. The proportion of patients using classes I and III AADs decreased from 8.6% to 6.3%. Flecainide and amiodarone were the most often used AADs. The use of flecainide and amiodarone decreased from 4.9% to 3.9% and 1.9% to 1.5%, respectively. The proportion of patients on beta-blockers remained stable at 75%. Dronedarone became available in 2011 when it also was the most used (0.8% of patients), but the use decreased thereafter. The use of sotalol and digoxin decreased from 1.5% to 0.6% and 24.6% to 11.0% over the study period.

CONCLUSION

The number of AAD purchases increased alongside with the increasing prevalence of AF, whereas the proportion of AF patients on classes I and III AADs and digoxin decreased between 2007 and 2018. Flecainide remained the most used AAD followed by amiodarone.

"If you ask me … ": experienced cardiac rehabilitation patients' perspectives on maintaining regular heart-healthy physical activity

PURPOSE

Despite the proven benefits of regular exercise and physical activity (PA), engagement of cardiac patients and adherence to recommended PA remain challenging. This study aimed to interview cardiac patients who are experienced in maintaining a physically active lifestyle to gain insight into how regular PA can become part of one's life after a cardiac event.

METHODS

Twenty-five cardiac patients (18 men and 7 women; age range 39-83 years) participated in audio-recorded, semi-structured qualitative interviews. Patients were recruited from a clinical site in Salzburg, Austria, which offers ongoing weekly exercise classes under medical supervision for cardiac patients. Interview transcripts were analysed against the background of the Reasoned Action Approach and coded inductively.

RESULTS

Eight themes were generated that elucidated patients' long-term engagement with PA: well-being and physical benefits; health literacy; community, groups, and partners; attitude, expectation and mindset; professional supervision; digital technology; nice distractions; and possibility of personalized tailoring. These themes are linked to several elements of the Reasoned Action Approach, including attitude, norm, behavioural control, skills, and environment.

CONCLUSION

This study highlights important aspects with respect to shaping a positive attitude towards PA and the significance of the social environment in establishing regular PA in cardiac patients.

Performance evaluation of four scoring systems for mortality prediction in a contemporary cardiac intensive care unit

BACKGROUND

There are limited data addressing the scoring systems for clinical outcome prediction in patients admitted to a contemporary cardiac intensive care unit (CICU). We aimed to compare the Acute Physiology and Chronic Health Evaluation (APACHE), Sequential Organ Failure Assessment (SOFA), Mayo CICU Admission Risk Score (MCARS), and Clinical Frailty Scale (CFS) scores, in predicting 90-day mortality in an unselected CICU population.

METHODS

This is a single-center prospective, cohort study that included all patients admitted to the CICU of a tertiary care center during two consecutive years. The performances of the risk scores in predicting mortality were compared with respect to discriminative ability, calibration, accuracy and net reclassification improvement (NRI). Multivariate Cox regression analysis was also performed.

RESULTS

A total of 1449 consecutive patients were included. The median (IQR) age was 73 (62-82) years, 970 (67 %) were males. The CICU, hospital and 90-day mortality rates were 11 %, 14 % and 17 %, respectively. Compared to APACHE II and SOFA scores, MCARS demonstrated superior calibration (Hosmer-Lemeshow test P = 0.661), accuracy (Brier score = 0.069) and overall performance (area under curve [AUC] = 0.905), as well as the NRI (0.76). It was also independently associated with 90-day mortality after adjustment for several factors (HR = 1.578, 95 % CI: 1.478-1.683, P < 0.001). CFS was also independently associated with 90-day mortality (HR = 1.153, 95 % CI: 1.123-1.185, P < 0.001). However, its goodness-of-fit, overall performance and reclassification improvement were inferior to MCARS. Additionally, MCARS was a reliable predictor for CICU mortality (AUC = 0.935).

CONCLUSION

MCARS outperforms standard risk scores for prediction of 90-day mortality in patients admitted to a contemporary CICU.

Potassium-competitive acid blocker vs proton-pump inhibitor in patients receiving antithrombotic therapy who are at high risk for gastrointestinal bleeding: Rationale and design of the randomized PROTECT- HBR trial

BACKGROUND

Concomitant use of proton pump inhibitor (PPI) is recommended in patients receiving chronic antithrombotic therapy who are at high risk of gastrointestinal (GI) bleeding. However, long-term safety and efficacy of chronic PPI use have been concerned. Potassium-competitive acid blocker (P-CAB) is a novel class of acid suppressants, providing more acid stability, rapid onset of action, less variability with CYP2C19 polymorphisms, and longer duration of action than PPI.

DESIGN

The PROTECT-HBR trial is a multicenter, randomized, double-blind, double-dummy, parallel-group clinical trial. Approximately 3320 patients with known cardiac or vascular disease receiving antithrombotic drugs (either antiplatelet or anticoagulant agents) and who are at high risk of GI bleeding will be randomized to P-CAB (tegoprazan 50mg once daily) or PPI (rabeprazole 20mg once daily) for up to 12 months. The primary endpoint is a composite outcome of upper GI clinical events, including overt or occult GI bleeding, symptomatic gastroduodenal ulcers or erosions, obstruction, or perforation, at 12 months. Secondary endpoints also included cardiovascular events and safety outcomes.

RESULTS

As of December 2024, approximately 1460 patients were enrolled from 32 participating sites in South Korea. The complete enrollment is anticipated at the mid- or late-term of 2025, and the primary results will be available by 2027.

CONCLUSION

PROTECT-HBR is a large-scale, multicenter, clinical trial, which will provide a pivotal comparison of the efficacy and safety of novel P-CAB, tegoprazan with those of PPI, rabeprazole in patients with documented cardiac or vascular disease receiving chronic antithrombotic drugs and at high risk of GI bleeding.

CLINICAL TRIAL REGISTRATION

Potassium-Competitive Acid Blocker versus pROton-Pump Inhibitor for GastroproTECTion Strategies In Patients at High GastroIntestinal Bleeding Risk Receiving Antithrombotic Therapy (PROTECT-HBR): NCT04416581.

Increased dietary acid load May elevate the risk of coronary artery disease severity: Findings from a cross-sectional study

Background

Chronic low-grade metabolic acidosis appears to play a role in the development of chronic disorders. This study aims to examine the relationship between Potential Renal Acid Load (PRAL) and Net Endogenous Acid Production (NEAP) and the risk of severe coronary artery disease (CAD) in participants undergoing elective angiography.

Methods

In this cross-sectional study, the data of 895 participants from the Nutrition Heshmat Registry (NUTHER) was collected. Dietary data were obtained using a validated food frequency questionnaire to calculate PRAL and NEAP. Participants were categorized into severe CAD (Gensini score≥60; n = 526) and non-severe CAD (Gensini score<60; n = 369). Logistic regression was conducted to evaluate the odds ratio (OR) and 95 % confidence interval (95 %CI). Restricted cubic spline (RCS) regression was employed to explore potential nonlinear associations between PRAL, and NEAP and severe-CAD risk.

Results

After adjusting for potential confounding factors, participants in the third to fourth quartiles of energy-adjusted PRAL and NEAP exhibited higher odds of severe CAD that were approximately 1.62-1.80 times and 1.67-2.76 times greater, respectively, compared to those in the 1stquartiles (4thquartile ORs(95 %CI) for: PRAL: 1.62 (1.05, 2.51); and NEAP: 1.67 (1.07, 2.61) (P-for-trend<0.021). RCS analysis showed a linear dose-response relationship between elevated PRAL and severe CAD risk (P-for-overall-trend = 0.0176; P-for-nonlinearity = 0.1552), and a nonlinear association between higher NEAP and increased severe CAD risk (P-for-overall-trend = 0.0001; P-for-nonlinearity = 0.006).

Conclusion

The findings indicate a significant association between higher dietary acid load and increased risk of severe CAD, suggesting that a more acidic diet may contribute to the progression of atherosclerosis. However, further prospective studies are necessary to validate these observations.

Rationale and design of VICAD-RISK study: Visualization of coronary artery disease for modification of risk factors

BACKGROUND

With the increasing use of coronary computed tomography angiography (CTA), the prevalence of patients with nonobstructive atherosclerotic coronary artery disease (NOCAD) is growing. Presence of NOCAD is associated with an increased risk of an unfavorable clinical outcome. Therefore, guideline-directed preventive strategies such as lipid-lowering therapy with statins are important. This study aims to assess whether visualization of personal CTA images to patients with a new diagnosis of NOCAD facilitates reduction of low-density lipoprotein (LDL) cholesterol (primary endpoint), improves statin adherence, influences the perception of statin-associated side effects, and modifies the coronary atherosclerotic phenotype.

METHODS

The VICAD-RISK study is a Danish multicenter randomized trial including statin naïve patients suspected of chronic coronary syndrome with a new diagnosis of NOCAD determined by first-line coronary CTA. A total of 273 patients will be randomized 1:1:1 into; (1) usual care; representing current clinical practice of general practitioner follow-up; (2) low-intensity intervention; specialized nurse consultation, or (3) high-intensity intervention; similar to group 2 and presentation of the personal CTA-images. All participants, including the intervention groups, will be followed at the discretion of their general practitioner. Research follow-up including biochemistry measurements, and coronary CTA investigation will be repeated for all participants after 12 months.

CONCLUSION

The VICAD-RISK study evaluates whether personal CTA image visualization in patients with a new diagnosis of NOCAD improves reduction of LDL cholesterol.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06413641, www.

CLINICALTRIALS

gov.

Independent effect of influenza vaccination on all-cause mortality in critically ill patients with atrial fibrillation: A retrospective study from the MIMIC-IV database

OBJECTIVE

Atrial fibrillation (AF) is common in critically ill patients and associated with higher mortality. The impact of influenza vaccination on all-cause mortality in this population is unclear. This study evaluates the effect of influenza vaccination on mortality in critically ill AF patients.

METHODS

A retrospective cohort analysis was conducted using the MIMIC-IV database. The effect of influenza vaccination on mortality was assessed using Kaplan-Meier survival curves and Cox proportional hazards models, adjusted for confounders. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were used to minimize selection bias. Subgroup analyses examined clinical characteristics among AF patients in the intensive care unit (ICU).

RESULTS

Among 12,137 ICU AF patients, 6554 (54.0 %) received the influenza vaccine. Vaccination was associated with reduced all-cause mortality (28-day hazard ratio [HR] = 0.79, 90-day HR = 0.83, 365-day HR = 0.84; all p-values <0.001). After PSM and covariate adjustment, influenza vaccination remained an independent predictor of better outcomes (28-day HR = 0.83, 90-day HR = 0.82, 365-day HR = 0.84; all p-values <0.001). These findings were consistent in IPTW analyses. Subgroup analyses showed greater benefits in elderly, hypertensive, and non-paroxysmal AF patients.

CONCLUSION

Influenza vaccination is associated with improved survival in critically ill AF patients. These findings support vaccination as a crucial protective measure for high-risk AF patients in the ICU.

Low chronotropic response in post-myocardial infarction exercise test predicts worse prognosis in patients with preserved or mildly reduced left ventricular ejection fraction

BACKGROUND

Chronotropic incompetence is prevalent in post-myocardial infarction (MI) patients and linked to reduced exercise capacity. However, its prognostic significance and the determination of threshold values for prognosis remain unclear.

METHODS

Ninety-six post-MI patients with left ventricular ejection fraction (LVEF) ≥ 40 % at four weeks post-event were assessed. All underwent combined exercise stress echocardiography and cardiopulmonary exercise testing (CPET-SE). The chronotropic response was expressed as a percentage of the maximal predicted heart rate (%MPHR) at peak exercise. The primary endpoint was a composite of all-cause mortality or unplanned hospitalization for coronary syndromes or heart failure.

RESULTS

Eighty-six patients completed follow-up (median: 4.0 years [IQR 2.0, 5.6]). The median age was 60 years (IQR 53, 65); 67 % were male, 86 % on beta-blockers. The median LVEF was 57 % (IQR 51, 62), and the median peak VO2 was 19 mL/kg/min (IQR 15, 22). Fifteen composite endpoint events, including three deaths, occurred. Multivariate Cox regression showed that %MPHR (HR 0.95, 95 % CI 0.92-0.98) and smoking history (HR 2.8, 95 % CI 1.1-7.4) were associated with the primary endpoint. A %MPHR threshold of 67 % best predicted the primary endpoint (AUC 73 %, PPV 29 %, NPV 95 %, sensitivity 87 %, specificity 55 %). Patients with %MPHR <67 % had significantly more composite endpoint events than those with %MPHR ≥67 % (p = 0.002).

CONCLUSIONS

A chronotropic response below 67 % of the maximal predicted heart rate is a negative prognostic marker in post-MI patients with preserved or mildly reduced LVEF. This threshold may help risk-stratify and guide management in this population.

LDL-cholesterol levels and lipid lowering therapy in secondary prevention. Baseline data from the BRING-UP prospective registry

AIMS

To narrow the gap between guidelines recommendation for secondary cardiovascular prevention and clinical practice, we designed a national project based on educational programs and patient data collection.

METHODS

BRING-UP Prevention is an observational, prospective, multicentre study on patients with an atherothrombotic event enrolled in 2 phases: an educational intervention followed by two 3-months data collection, followed by 6 and 12-month follow-up, when the primary, secondary and exploratory endpoints will be evaluated. Clinical characteristics, treatments and target achievement for LDL cholesterol and other modifiable risk factors at baseline are reported in this manuscript.

RESULTS

From September 2023 to February 2024, 189 cardiology centers included 4790 patients, 2500 hospitalized, and 2290 managed as outpatients. Of the 4790 patients, 98 % had CAD, 6.1 % CVD, and 6.9 % PAD. Mean age was 67 ± 11 years, 20 % were females. Patients with LDL-C levels <55 mg/dL were 32.6 %. Patients at target for blood pressure were 39.2 %. Diabetic patients were 27.5 %, HbA1c <7 % was reported in 43.5 % of them. Statins prescription increased from 69 % at entry to 96 % at discharge/end of visit. In 74.5 % of patients, statins were prescribed in combination with ezetimibe. PCSK9-i or inclisiran were prescribed in a low rate of patients.

CONCLUSION

These data show that a low percentage of patients was at goal for LDL-C level and blood pressure. The 6-month follow-up visit will allow us to evaluate the changes in modifiable risk factors.

Favorable impact of FFRCT on myocardial revascularization outcomes: Results from an observational real-world registry

BACKGROUND

Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) strategy significantly decreases unnecessary invasive coronary angiography and refines the appropriateness of revascularization decision. The present study aimed to evaluate how FFRCT guided - strategy impacts outcomes postrevascularization.

METHODS

We included patients with suspected obstructive coronary artery disease (OCAD in a registry from 2013 to 2021. FFRCT entered Heart-Team decision from 2017. Propensity score adjusted Cox - and logistic - regression analyzed FFRCT's impact on post- revascularization major adverse cardiovascular events (MACE) and myocardial injury (PMI).

RESULTS

Among 7541 patients, 1601 had suspected OCAD. 559 patients underwent revascularization: 69.0 % PCI, 29.7 % CABG and 1.2 % both. 252(45.1 %) patients underwent FFRCT. Over 4.4 ± 2.2 years, 137(24.5 %) patients experienced MACE. FFRCT was associated with a trend toward reduced MACE (HR 0.736, 95 % CI 0.513-1.055, p = 0.095) and significantly reduced all-cause mortality (HR 0.476, 95 % CI 0.230-0.985, p = 0.046). In the post-2017 cohort (413 patients, follow-up 3.7 ± 1.5 years), FFRCT significantly reduced MACE (HR 0.610, 95 % CI 0.390-0.954, P = 0.030) and all-cause mortality (HR 0.285, 95 % CI 0.104-0.779, P = 0.014). In CABG patients, FFRCT was associated with lower PMI incidence (5.3 % vs. 15.6 %, p = 0.044). Multivariable analysis revealed no significant association between FFRCT use and PMI.

CONCLUSIONS

Revascularization decision-making with FFRCT translates into better post-revascularization outcomes, primarily by reducing MACE through lower mortality. There was no clear impact on PMI. These findings suggests that FFRCT's value lies indeed in improving patient selection for revascularization, but warrants further confirmation in randomized clinical trials.

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.

Invasive coronary function testing in clinical practice: Implementing the 2024 ESC guidelines on chronic coronary syndromes

Angina with non-obstructive coronary arteries (ANOCA) is increasingly recognized as a significant aspect of chronic coronary syndromes. These patients frequently experience recurrent angina, resulting in high healthcare costs and impaired quality of life. Invasive coronary function testing (ICFT) is able to identify ANOCA endotypes, which can guide treatment and improve quality of life. Despite Class II recommendations for invasive microvascular assessments in the previous 2019 European Society of Cardiology (ESC) Guidelines, ICFT has yet to translate into widespread clinical practice. Patients with ANOCA experience poor quality of life and reduced functional capacity, highlighting the need for earlier ICFT implementation. The 2024 ESC Guidelines now strongly recommend ICFT (Class I, level of evidence B) for patients with non-obstructive coronary arteries and persistent angina despite optimal medical therapy, and for confirming or excluding ANOCA in patients with uncertain diagnoses on non-invasive testing (Class I, level of evidence B). Consequently, a standardized approach to optimize the management of ANOCA patients is warranted. Therefore, this review aims to provide interventional cardiologists with a contemporary review of the literature and a practical guideline on implementation of ICFT. It will discuss the following subjects: the definitions of the different endotypes, an example of an ICFT protocol, discontinuation of medication prior to ICFT, use of radial cocktail, target vessel for testing, acetylcholine injection techniques and rechallenge, adenosine injection techniques, the order of testing, the interpretation of ICFT, safety and feasibility, and the pharmacological treatment.

Coronary Artery Disease Reporting and Data System Update

Coronary Artery Reporting and Data System 2.0 not only establishes a common lexicon for interpreting coronary coronary computed tomography angiography but also offers additional insights into overall plaque burden, the presence of high-risk plaques, lesion-specific ischemia, coronary stents and grafts, and nonatherosclerotic causes of coronary artery narrowing. Furthermore, it provides recommendations for further testing and management based on the degree of stenosis, total plaque burden, and the presence of ischemia.

Myocardial perfusion imaging in advanced coronary artery disease

Myocardial perfusion imaging (MPI) is widely adapted as a noninvasive technique to assess the presence and extent of ischemia in patients with symptoms suggestive of obstructive coronary artery disease (CAD). However, as CAD advances, several factors can complicate the interpretation of MPI, subsequently impacting clinical decision-making. This review focuses on the utility of MPI by means of cardiac magnetic resonance (CMR) imaging, single-photon emission computed tomography (SPECT) and positron emission tomography (PET) in patients with advanced CAD-the latter characterized by documented CAD (i.e. prior myocardial infarction [MI] and/or percutaneous coronary intervention [PCI]), prior coronary artery bypass grafting (CABG) or the presence of a chronic total occlusion (CTO). It will discuss factors impacting the interpretation of MPI, the diagnostic performance for detecting obstructive CAD and coronary microvascular dysfunction (CMD), as well as the role of MPI in guiding revascularization.

Long-term Antithrombotic Therapy in Patients With Chronic Coronary Syndrome: An Updated Review of Current Evidence

PURPOSE

Despite improvements in the secondary prevention of atherothrombosis in patients with coronary artery disease during the past decade, it is estimated that approximately 19 million people annually die from cardiovascular diseases worldwide. Atherothrombosis remains the core pathobiology of acute complications including myocardial infarction (MI), and therefore, antithrombotic therapy plays a pivotal role in the strategies for major adverse cardiovascular event (MACE) prevention. Unlike early antithrombotic management after acute coronary syndrome, less evidence is available on long-term antithrombotic therapy in patients with chronic coronary syndrome (CCS). In addition, greater recognition of the impact of bleeding complications of such therapies has led to a more complex and personalized approach to their application. The purpose of this article is to review the available evidence on long-term antithrombotic therapy in patients with CCS including those with high-risk characteristics such as prior MI or polyvascular disease.

METHODS

A comprehensive literature review was performed in major databases including PubMed, Embase, and the Cochrane Library. The main focus of this narrative review was on available data from guidelines, meta-analysis, randomized controlled trials, and observational studies that assessed the efficacy and safety profile of long-term antithrombotic therapy in patients with CCS.

FINDINGS

Several studies suggest that long-term antithrombotic therapy is effective in reducing the risk of recurrent MACEs in patients with CCS. Current clinical guidelines recommend single antiplatelet therapy with aspirin as a first-line long-term strategy for patients without indication for oral anticoagulation. However, novel approaches focused on P2Y12 inhibitor monotherapy are emerging. More intensive antithrombotic strategies including long-term dual antiplatelet therapy and dual pathway inhibition further reduce ischemic risk but at the cost of increased bleeding.

IMPLICATIONS

This review highlights the importance of close monitoring and regular reassessment of the risk-benefit balance of antithrombotic therapy in patients with CCS. Overall, long-term antithrombotic therapy with either single antiplatelet therapy or dual antiplatelet therapy/dual pathway inhibition is effective in reducing the risk of MACEs in patients with CCS. The choice of antithrombotic therapy should be individualized based on the patient's clinical profile, particularly for thrombohemorrhagic risk. Future research should focus on identifying the optimal antithrombotic regimen for specific subgroups of patients with prior MI particularly for those with high bleeding risk.

A multimodal dataset for coronary microvascular disease biomarker discovery

Coronary microvascular disease (CMD), particularly prevalent among women, is associated with increased morbidity and mortality, making clinical screening vital for effective management. However, limited publicly available screening-level data hinders disease-specific biomarker discovery. To address this gap, 80 female angina patients without obstructive coronary artery disease and 40 age-matched female controls were prospectively enrolled to curate a new dataset. All participants underwent adenosine stress with electrocardiogram (ECG) monitoring across Rest, Stress, and Recovery stages. CMD diagnosis was confirmed with the standard clinical criterion, i.e., coronary flow reserve (CFR) < 2.0 via PET/CT. Using ECG variables from different stages, we developed machine learning models to classify CMD, thus validating dataset's effectiveness in CMD identification. We also validated the potential of ECG for differential diagnosis through joint analysis with the published mental stress-induced myocardial ischemia (MSIMI) dataset, which is based on the same cohort under different stress conditions. Disease-specific ECG variable sets were identified. Our findings highlight the value of multi-stage ECG in CMD screening. We expect this dataset to significantly advance CMD research.

Behavior of Complement System Effectors in Chronic and Acute Coronary Artery Disease

Background/Objectives: The complement system (particularly C5b-9) is an instrumental part of the induction and progression of atherosclerosis. The fluid phase C5b-9, also known as soluble C5b-9 (sC5b-9), is a reliable indicator of terminal complement pathway activation. Response Gene to Complement (RGC)-32 is a C5b-9 effector involved in cell cycle regulation and differentiation, immunity, tumorigenesis, obesity, and vascular lesion formation. RGC-32 regulates the expression of Sirtuin1 (SIRT1), known to delay vascular aging. The aim of this study was to assess the levels of sC5b-9, RGC-32, and SIRT1 in patients with atherosclerotic chronic and acute ischemic coronary syndromes. Methods: We determined the levels of sC5b-9, serum RGC-32, and SIRT1 by enzyme-linked immunosorbent assays (ELISAs) in 41 patients with chronic atherosclerotic coronary syndromes, 36 patients with acute ischemic coronary syndromes, and 21 asymptomatic controls with no history of ischemic heart disease. Results: sC5b-9 was significantly higher in patients with acute coronary syndrome as compared to the control group (p = 0.020, AUC = 0.702). In chronic coronary ischemia patients, serum RGC-32 was correlated with the extension of coronagraphically visualized atherosclerotic lesions (r = 0.352, p = 0.035) as well as with sC5b-9 levels (r = 0.350, p = 0.025). RGC-32 concentration was significantly lower in patients with acute coronary syndrome than in the control group (p = 0.020). We also observed significantly lower serum SIRT1 concentrations in patients with chronic ischemic heart disease than in the control group (p = 0.025). Conclusions: sC5b-9 may function as a possible biomarker for myocardial tissue damage in acute coronary syndrome. In acute coronary syndrome settings, low levels of RGC-32 may indicate a protective, antifibrotic function of RGC-32 in the ischemia-damaged myocardium; however, in stable chronic disease, RGC-32 serum values appear to correlate with the extent of atherosclerotic lesions, suggesting a pro-atherogenic role for RGC-32. Chronic myocardial ischemia decreases SIRT1 protein levels in serum, which underscores the use of SIRT1-modulating drugs in these patients.

Diagnostic accuracy of late iodine enhancement on cardiac CT for myocardial tissue characterization: a systematic review and meta-analysis

PURPOSE

to evaluate the diagnostic accuracy of late iodine enhancement (LIE) in cardiac computed tomography (CCT) compared to late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) for myocardial tissue characterization.

MATERIALS AND METHODS

EMBASE, PubMed/MEDLINE, and CENTRAL were searched for studies reporting the accuracy of LIE with LGE as the gold standard of reference. QUADAS-2 tool was used to assess the risk of bias. A bivariate random-effects model was used to analyze, pool, and plot the diagnostic performance measurements across studies. Pooled sensitivity, specificity, positive (+LR) and negative (-LR) likelihood ratio, diagnostic odds ratio (DOR), and hierarchical summary ROC curve (HSROC) were computed. Prospero registration number: CRD42023484045.

RESULTS

Fourteen studies involving 526 patients and 5758 myocardial segments were included. At the patient level, LIE in CCT showed a pooled sensitivity of 0.96 (95% CI: 0.88-0.99), specificity of 0.95 (95% CI: 0.88-0.98) and the HSROC AUC of 0.98 (95% CI: 0.97-0.99). The +LR was 20.97 (95% CI: 7.54-58.38) and the -LR was 0.04 (95% CI: 0.01-0.13), resulting in a DOR of 535 (95% CI: 94-3024). At the segment level, sensitivity was 0.86 (95% CI: 0.79-0.91), specificity was 0.98 (95% CI: 0.96-0.99), and the HSROC AUC was 0.97 (95% CI:0.95-0.98). The +LR was 55.08 (95% CI: 19.94-152.16) and the -LR was 0.14 (95% CI: 0.09-0.22) with a DOR of 388 (95% CI: 113-1333). Dual-energy CCT improved segment-level sensitivity to 0.93 (95% CI: 0.88-0.96).

CONCLUSION

LIE in CCT shows excellent diagnostic accuracy when compared to LGE in CMR for myocardial tissue characterization, suggesting its potential as a promising alternative to CMR.

KEY POINTS

Question How does myocardial tissue characterization by late iodine enhancement (LIE) on cardiac CT (CCT) compare to late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR)? Findings LIE in CCT demonstrates excellent diagnostic accuracy, with high sensitivity and specificity at both patient and segment levels, using LGE in CMR as the reference. Clinical relevance LIE in CCT provides a reliable alternative to LGE in CMR, especially for patients for whom CMR is not available or feasible or is contraindicated, thus improving access to myocardial tissue characterization.

Plaque burden improves the detection of ischemic CAD over stenosis from coronary computed tomography angiography

In symptomatic patients undergoing coronary CTA for suspected coronary artery disease (CAD), we assessed if quantification of plaque burden, in addition to luminal narrowing and clinical risk factors, offers incremental value for the identification of ischemic CAD on a per patient level. We evaluated 2145 patients who underwent coronary CTA for suspected CAD with sequential selective downstream 15O-water positron emission tomography (PET) myocardial perfusion imaging. Coronary CTA scans were analyzed using Artificial Intelligence-guided Quantitative Computed Tomography (AI-QCT), with measurement of maximum diameter stenosis, percent atheroma volume (PAV), percent calcified plaque volume (CPV) and percent noncalcified plaque volume (NCPV). Ischemic CAD was defined as the presence of abnormal stress perfusion on 15O-water PET. PAV on top of the clinical variables and ≥ 50% stenosis improved the prediction of ischemic CAD on a per patient level as compared to clinical variables and ≥ 50% stenosis (AUC = 0.91 vs. AUC = 0.87, p < 0.001). The best diagnostic performance was achieved when PAV with a cut-off value of 12.2% was applied in patients with intermediate (30-70%) stenosis; using this approach, the sensitivity, specificity, positive and negative predictive values and diagnostic accuracy for ischemic CAD were 76%, 91%, 64%, 95% and 88%. The addition of quantitative plaque volume on top of clinical variables and ≥ 50% diameter stenosis improves the detection of ischemic CAD as defined by PET perfusion imaging. Applying a PAV threshold of 12.2% in patients with intermediate stenosis provided the best diagnostic performance.

CT-derived fractional flow reserve on therapeutic management and outcomes compared with coronary CT angiography in coronary artery disease

OBJECTIVES

To determine the value of on-site deep learning-based CT-derived fractional flow reserve (CT-FFR) for therapeutic management and adverse clinical outcomes in patients suspected of coronary artery disease (CAD) compared with coronary CT angiography (CCTA) alone.

METHODS

This single-centre prospective study included consecutive patients suspected of CAD between June 2021 and September 2021 at our hospital. Four hundred and sixty-one patients were randomized into either CT-FFR+CCTA or CCTA-alone group. The first endpoint was the invasive coronary angiography (ICA) efficiency, defined as the ICA with nonobstructive disease (stenosis <50%) and the ratio of revascularization to ICA (REV-to-ICA ratio) within 90 days. The second endpoint was the incidence of major adverse cardiaovascular events (MACE) at 2 years.

RESULTS

A total of 461 patients (267 [57.9%] men; median age, 64 [55-69]) were included. At 90 days, the rate of ICA with nonobstructive disease in the CT-FFR+CCTA group was lower than in the CCTA group (14.7% vs 34.0%, P=.047). The REV-to-ICA ratio in the CT-FFR+CCTA group was significantly higher than in the CCTA group (73.5% vs. 50.9%, P=.036). No significant difference in ICA efficiency was found in intermediate stenosis (25%-69%) between the 2 groups (all P>.05). After a median follow-up of 23 (22-24) months, MACE were observed in 11 patients in the CT-FFR+CCTA group and 24 in the CCTA group (5.9% vs 10.0%, P=.095).

CONCLUSIONS

The on-site deep learning-based CT-FFR improved the efficiency of ICA utilization with a similarly low rate of MACE compared with CCTA alone.

ADVANCES IN KNOWLEDGE

The on-site deep learning-based CT-FFR was superior to CCTA for therapeutic management.

3D non-contrast whole‑heart coronary MR angiography at 3 T with compressed sensing in elderly patients: Optimization of the acceleration factor

Background

Coronary magnetic resonance angiography (CMRA) is increasingly used in clinical practice, but lengthy scan times can be challenging for elderly patients. This study evaluates the impact of compressed sensing (CS) technology on image quality and diagnostic performance of 3 T CMRA in elderly patients, aiming to identify the optimal acceleration factor.

Methods

We prospectively enrolled elderly individuals who underwent coronary computed tomography angiography (CCTA) from June to November 2023 for non-contrast whole-heart CMRA with CS acceleration factors of 4, 6, or 8. Elderly volunteers rated their experiences with the optimal acceleration factor. Image quality and diagnostic performance were analyzed using a general linear model and the area under the receiver operating characteristic curves (AUC), with CCTA as the reference standard.

Results

Sixty-seven individuals (34 men, mean age 74.3 ± 7.2 years) were enrolled. Scan times significantly decreased from 578.6 ± 131.4 s to 366.1 ± 91.2 s and 261.1 ± 76.5 s for acceleration factors 4, 6, and 8, respectively. Subjective image quality scores, signal-to-noise ratio, and contrast-to-noise ratio were significantly better with CS4 and CS6 than with CS8. Diagnostic performance declined with increasing acceleration, with sensitivities of 92.2 %, 88.0 %, and 72.5 %, and specificities of 94.1 %, 92.6 %, and 85.3 % for CS4, CS6, and CS8, respectively. CS6 was determined to be the optimal acceleration factor. Volunteers reported that CS6 was more acceptable than CS4.

Conclusions

CMRA with CS6 provides rapid scanning while maintaining adequate diagnostic performance, making it a reliable alternative to CCTA for diagnosing coronary artery disease in elderly patients.

Medication adherence and hospitalizations in older patients with coronary heart disease in Vietnam

AIMS

This study aimed to assess medication adherence among older people with coronary heart disease and its relationship with hospitalizations.

METHODS

This is a prospective cohort study conducted at the outpatient clinics of a major hospital in Vietnam from November 2022 to June 2023. Consecutive older patients with coronary heart disease were recruited and followed for 6 months. Medication adherence was defined using the five-item Medication Adherence Report Scale (MARS-5). Multivariable logistic regression models were applied to examine the impact of medication adherence on hospitalization due to cardiovascular disease (CVD) and all-cause hospitalization.

RESULTS

There were 643 participants, mean age 73 ± 8 years, 74.3% were male. Overall, 76.4% (491/643) were classified as 'adherent'. Over 6 months follow-up, 23.3% of the participants were admitted to hospital and of these hospitalizations, 9.2% were due to CVD. The CVD-related hospitalization rate was significantly higher in the non-adherent group compared to the adherent group (13.8% vs. 7.7%, P = 0.023, respectively). In logistic regression models, medication adherence was associated with significantly reduced odds of CVD-related hospitalization (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.27-0.86). Medication adherence was also associated with a trend of reduced all-cause hospitalization (adjusted OR 0.75, 95% CI 0.49-1.15).

CONCLUSIONS

This study showed a positive relationship between medication adherence and reduced risk of CVD-related hospitalization in older people with coronary heart disease. Healthcare providers should consider incorporating adherence assessment into the long-term care for older patients with coronary heart disease.

Chronic kidney disease and increased LAVI as risk factors of new-onset heart failure in atrial fibrillation: A case-control study

Background

Atrial fibrillation (AF) increases heart failure (HF) risk and can eventually increase morbidity and mortality. Therefore, recognizing risk factors in AF patients is crucial to prevent heart failure. To date, there has been no research on this topic in Indonesia.

Objective

To determine risk factors of new-onset HF in AF patients.

Methods

Case-control study was undertaken at Cipto Mangunkusumo Hospital using medical record data from January 2018 to May 2023. AF patients aged ≥18 years with new-onset HF were included in the case group, and AF patients of similar age without HF were included in the control group. Patients with moderate or severe valvular heart disease, congenital heart disease, pacemakers, or implantable cardioverter defibrillators (ICD), or incomplete data were excluded. Logistic regression was used to identify significant risk factors for new-onset HF in AF patients.

Results

A total of 132 subjects consisting of 44 cases and 88 controls were included. Bivariate analysis revealed that the significant risk factors for new-onset HF in AF patients were CAD [p = .037; OR 2.34 (95% CI 1.11-4.93)], CKD [p = .000; OR 7.78 (95% CI 3.45-17.53)], and LAVI [p = .002; OR 3.23 (95% CI 1.52-6.85)]. In multivariate analysis, CKD [p = .000; OR 6.31 (95% CI 2.69-14.77)] and LAVI [p = .000; OR 3.49 (95% CI 1.42-9.97)] retained their statistical significance as risk factors of new-onset HF in AF patients.

Conclusions

CKD and increased LAVI may increase the likelihood of new-onset HF in AF patients, while hypertension, diabetes, CAD, smoking, and obesity were not significant risk factors for new-onset HF in our study.

An updated review on therapeutic strategies in coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is well-known cause of angina, yet treatment options remain limited. This systematic review and meta-analysis examines the current literature and provides a contemporary evaluation of treatments using a stringent definition for CMD with accurate methods of microvascular assessment in accordance with recent consensus guidelines. Methods and Results: A search strategy was conducted independently by two authors (CK and RR). Studies were required to be prospective trials in adult patients with documented CMD by IC doppler wire, thermodilution techniques, or perfusion imaging via PET/MRI. CMD was defined as either coronary flow reserve (CFR)/myocardial perfusion reserve (MPR) < 2.5, and/or index of microvascular resistance (IMR) > 25. Methodological quality of studies was assessed via the Cochrane Risk of Bias tool. The primary and secondary endpoints were change in CFR/MPR/IMR and change in Seattle Angina Questionnaire (SAQ) scores respectively. Two-sided p-values were used and considered significant if p < 0.05. A total of 11,360 records were identified, from which 14 were included in this review covering 9 different treatments. Two treatments (quinapril and ranolazine) showed significant improvement in both CFR and angina. Three ranolazine trials were pooled in meta-analysis. The standardised mean difference showed a weak positive effect (0.24) with wide intervals (-0.21 to 0.26) which was not statistically significant (p = 0.20). We subsequently reviewed all treatments as mentioned in recent European consensus statements. Conclusions: The overall quality of evidence surrounding treatments for CMD is of "low", with lack of robust data highlighting the dire need for higher quality trials in this area.

Long-term outcome of patients presenting with myocardial injury or myocardial infarction

AIMS

Patients with acute or chronic myocardial injury are frequently identified in the context of suspected myocardial infarction (MI). We aimed to investigate their long-term follow-up.

METHODS AND RESULTS

We prospectively enrolled 2714 patients with suspected MI and followed them for all-cause mortality and a composite cardiovascular endpoint (CVE; cardiovascular death, MI, unplanned revascularization) for a median of 5.1 years. Final diagnoses were adjudicated by two cardiologists according to the Fourth Universal Definition of MI, including 143 (5.3%) ST-elevation MI, 236 (8.7%) non-ST-elevation MI (NSTEMI) Type 1 (T1), 128 (4.7%) NSTEMI T2, 86 (3.2%) acute and 677 (24.9%) with chronic myocardial injury, and 1444 (53.2%) with other reasons for chest pain (reference). Crude event rates per 1000 patient-years for all-cause mortality were highest in patients with myocardial injury (81.6 [71.7, 92.3]), and any type of MI (55.9 [46.3, 66.7]), compared to reference (12.2 [9.8, 15.1]). Upon adjustment, all diagnoses were significantly associated with all-cause mortality. Moreover, patients with acute (adj-HR 1.92 [1.08, 3.43]) or chronic (adj-HR 1.59 [1.16, 2.18]) myocardial injury, and patients with NSTEMI T1 (adj-HR 2.62 [1.85, 3.69]) and ST-elevation MI (adj-HR 3.66 [2.41, 5.57]) were at increased risk for cardiovascular events.

CONCLUSION

Patients with myocardial injury are at a similar increased risk for death and cardiovascular events compared to patients with acute MI. Further studies need to determine appropriate management strategies for patients with myocardial injury.

REGISTRATION

Clinicaltrials.gov (NCT02355457).

Efficacy and safety of coronary sinus reducer for refractory angina: a systematic review and meta-analysis of randomized controlled trials

Refractory angina affects patients' quality of life around the world. Coronary sinus reducer (CSR) is a new therapeutic approach that has been investigated in recent years. We aimed to investigate the efficacy and safety of CSR for refractory angina. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Web of Science, Scopus, Embase, and CENTRAL searches until May 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3). With the inclusion of three RCTs, our cohort comprised a total of 180 patients. Compared with the control group, after 6 months, CSR was significantly associated with a decreased mean change of Canadian Cardiovascular Society (CCS) class [MD: -0.54 with 95% CI (-0.80 to -0.27), P  < 0.01], a decreased number of patients in the CCS class III/IV [RR: 0.56 with 95% CI (0.38-0.84), P  < 0.01], and increased exercise time [MD: 50.46 with 95% CI (9.47-91.45), P  = 0.02]. However, there was no significant difference between CSR and the control group in double products, all Seattle Angina Questionnaire domains, and safety outcomes. CSR has been shown to reduce angina severity by lowering CCS class scores and increasing exercise time. Large-scale RCTs are needed to confirm its effectiveness in patients with refractory angina.

Prognostic impact of intravascular imaging in percutaneous coronary intervention according to atherothrombotic risk: a post hoc analysis of a randomized clinical trial

INTRODUCTION AND OBJECTIVES

Recent randomized controlled trials support the use of intravascular imaging-guided percutaneous coronary intervention (PCI) to improve patient prognosis. However, the subsequent risk of clinical events in patients with coronary artery disease is not determined solely by lesion characteristics or how these lesions are treated. The current study investigated whether the effects of intravascular imaging in complex PCI vary according to atherothrombotic risks.

METHODS

This study was a post hoc analysis of the RENOVATE-COMPLEX-PCI trial, which compared intravascular imaging-guided PCI with angiography-guided PCI in patients with complex coronary artery lesions. The study population was stratified by atherothrombotic risk, assessed using the Thrombolysis in Myocardial Infarction risk score for secondary prevention (TRS-2P). TRS-2P is calculated based on the presence of the following factors: age ≥ 75 years, diabetes mellitus, hypertension, smoking, peripheral arterial disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction. Patients were categorized into low-risk (TRS-2P <3) or high-risk (TRS-2P ≥ 3) groups. The primary endpoint was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization.

RESULTS

Among the total study population, 1247 patients were categorized as low-risk, and 392 as high-risk. The risk of target vessel failure was significantly higher in the high-risk group than in the low-risk group (15.5% vs 7.2%; HR, 2.13; 95%CI, 1.51-3.00; P <.001). The benefits of intravascular imaging-guided PCI over angiography-guided PCI did not differ between the low-risk group (5.6% vs 10.4%; HR, 0.56; 95%CI, 0.36-0.86) and the high-risk group (14.1% vs 18.5%; HR, 0.71; 95%CI, 0.41-1.24), with no significant interaction (interaction P=.496).

CONCLUSIONS

In this hypothesis-generating post hoc analysis of the RENOVATE-COMPLEX-PCI trial, patients with high atherothrombotic risk had significantly worse clinical outcomes than those with low atherothrombotic risk. Nevertheless, the prognostic impact of intravascular imaging-guided PCI compared with angiography-guided PCI was similarly observed in both low- and high-risk groups. RENOVATE-COMPLEX-PCI clinical trial register number: NCT03381872.

Prognostic value of myocardial flow reserve by PET imaging in patients with suspected coronary artery disease: A systematic review and meta-analysis

Purpose

We performed a systematic review and meta-analysis of published studies evaluating the value of myocardial flow reserve (MFR) assessed by positron emission tomography (PET) imaging in predicting adverse cardiovascular events in patients with suspected coronary artery disease (CAD).

Material and methods

Studies published until December 2024 were identified by database search. We included studies evaluating MFR by PET imaging with data on adjusted hazard ratio (HR) for the occurrence of adverse cardiovascular events.

Results

We identified 8 eligible articles including 12.087 patients with a mean follow-up of 2.98 ± 0.69 years. The pooled HR for the occurrence of events was 2.19 (95 % CI 1.80-2.68) and no heterogeneity was observed. The pooled incidence rate ratio (IRR) was 3.26 (95 % CI 2.43-4.37) and the heterogeneity was 37.7 %. At meta-regression analysis no significant association was found between HR for adverse events and demographic and clinical variables considered.

Conclusion

MFR assessed by PET imaging is a valuable noninvasive prognostic indicator in the evaluation of patients with suspected CAD.

Partial versus Complete Sternotomy for Aortic Valve Replacement-Multicenter Study

BACKGROUND

 The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort.

METHODS

 A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS (n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy.

RESULTS

 Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days (p = 0.02) and in 5-year follow-up (p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up (p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter (p = 0.03), Dressler's syndrome occurred less frequently (p = 0.006), and the rate of rehospitalization was reduced significantly (p < 0.001). There were 3.8% conversions to full sternotomy.

CONCLUSION

 In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Clinical and demographic moderators of self-care and hospitalizations in pre-coronary artery bypass grafting patients: A cross-sectional study

AIM

To examine the influence of clinical and demographic factors on self-care behaviour and hospitalization rates among patients with coronary heart disease awaiting coronary artery bypass grafting.

BACKGROUND

Appropriate self-care behaviour can improve the management of patients with coronary heart disease and reduce hospitalization rates among those awaiting coronary artery bypass graft surgery. However, little is known about the influence of clinical and demographic factors on self-care or hospitalizations in this population.

DESIGN

A cross-sectional study.

METHODS

A convenience sample of 99 participants diagnosed with coronary heart disease awaiting coronary artery bypass grafting surgery were recruited from an outpatient clinic of a public tertiary hospital in southern Thailand. Data were collected on clinical (left ventricular ejection fraction, symptom severity and comorbid disease) and demographic (age, education level and marital status) factors, self-care behaviour and hospitalization rates. Path analysis using LISREL was performed to examine the influence of self-care on hospitalizations, with clinical and demographic factors as moderators.

RESULTS

Path analysis showed that clinical and demographic factors accounted for nearly half of the variance (46%) in self-care, and that self-care accounted for nearly half of the variance (48%) in hospitalization rates.

CONCLUSION

Our findings demonstrate that clinical and demographic factors play an important role in self-care behaviour, and in turn hospitalization rates of pre-coronary artery bypass graft surgery patients. It is suggested that the period pre-surgery is an ideal time to introduce programmes designed to bolster self-care and minimize uncertainty among this patient population and that nurses are well-positioned to do so.

REPORTING METHOD

Study methods and results reported in adherence to the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed their consent, time and data to the study.

Calcium deblooming in coronary computed tomography angiography via semantic-oriented generative adversarial network

Calcium blooming artifact produced by calcified plaque in coronary computed tomography angiography (CCTA) is a significant contributor to false-positive results for radiologists. Most previous research focused on general noise reduction of CT images, while performance was limited when facing the blooming artifact. To address this problem, we designed an automated and robust semantics-oriented adversarial network that fully exploits the calcified plaques as semantic regions in the CCTA. The semantic features were extracted using a feature extraction module and implemented through a global-local fusion module, a generator with a semantic similarity module, and a matrix discriminator. The effectiveness of our network was validated both on a virtual and a clinical dataset. The clinical dataset consists of 372 CCTA and corresponding coronary angiogram (CAG) results, with the assistance of two cardiac radiologists (with 10 and 21 years of experience) for clinical evaluation. The proposed method effectively reduces artifacts for three major coronary arteries and significantly improves the specificity and positive predictive value for the diagnosis of coronary stenosis.

Machine learning approaches for cardiovascular disease prediction: A review

Cardiovascular disease is a leading cause of death worldwide and is associated with significant morbidity and mortality. The use of artificial intelligence techniques, particularly machine learning algorithms, has emerged as a transformative approach for enhancing early diagnostic accuracy of disease compared with conventional diagnostic methods. This systematic review examines three core aspects: (1) comparative analysis of current machine learning algorithms in early diagnosis of cardiovascular disease, (2) operational frameworks for clinical implementation, and (3) critical evaluation of regulatory compliance and ethical implications. It summarizes recent advancements in machine learning-based heart disease prediction, outlines a typical workflow for applying machine learning in clinical settings, and discusses the regulatory and ethical challenges associated with its implementation. Finally, this review explores potential directions for future research in this rapidly evolving field.

Progress of nanomaterials in the treatment of ischemic heart disease

Medical or surgical interventions are commonly used to alleviate the clinical symptoms of individuals suffering from ischemic heart disease (IHD), but global morbidity and mortality remain high. This is due to the complexity of disease progression and the pathological basis of IHD, which primarily includes myocardial infarction (MI), myocardial ischemia-reperfusion injury (IRI), and heart failure (HF), as well as underlying mechanisms, such as mitochondrial damage, inflammation, oxidative stress, and cardiomyocyte death. However, many drugs have limitations, such as poor stability and low bioavailability, and surgical strategies are often ineffective in preventing disease recurrence. To overcome these problems, it is necessary to develop effective drug delivery systems and technologies. Due to their advantages in enhancing drug utilization, nanomaterials are being used to control drug biodistribution and achieve targeted accumulation, addressing the therapeutic needs of IHD. In this work, we first described the clinical aspects of MI, IRI, and HF in the context of IHD as well as their shared pathological origins. Next, clinical interventional procedures for IHD are summarized. Finally, recent developments in the use of nanomaterials for the treatment of MI, IRI, and HF are highlighted, along with potential directions for future research.

Left ventricular deformation predicts major adverse cardiac events following acute myocardial infarction independently of afterload and ventricular-arterial coupling

BACKGROUND

Load dependence on left ventricular (LV) strain is under constant debate with its interference with prognostic implications remaining unclear. Consequently, we sought to investigate their interaction and prognostic value following acute myocardial infarction (AMI) using state-of-the-art cardiac magnetic resonance (CMR) imaging.

METHODS

In total, 1235 patients (n = 795 ST-elevation [STEMI] and 440 non-STEMI) underwent CMR in median 3 days following AMI. Infarct characteristics were described by CMR using tissue characterisation (infarct size, microvascular obstruction, area at risk) and deformation imaging including LV global longitudinal and circumferential strain (GLS/GCS). Non-invasive haemodynamic indices included effective arterial elastance Ea (end-systolic pressure (ESP)/stroke volume) and the non-geometric LV end-systolic afterload index NGI [(ESP × LV end-systolic volume (ESV))/LV mass] for estimation of LV afterload. LV contractility was assessed using end-systolic elastance Ees (ESP/LV ESV). Ventriculo-arterial coupling was described as Ea/Ees. Major adverse cardiac events (MACE) were recorded within the first year.

RESULTS

All haemodynamic indices were impaired in patients with MACE during follow-up compared to patients without (p < 0.001-0.005). Ventriculo-arterial coupling showed the highest correlation to infarct properties (infarct size r = 0.51, p < 0.001) and deformation imaging (GLS r = 0.54, GCS r = 0.72, p < 0.001). GLS and GCS were associated with MACE independently of all haemodynamic indices (p < 0.001 for all except of GCS-Ea/Ees p = 0.024).

CONCLUSIONS

Non-invasive haemodynamic indices are associated with outcome following AMI with ventriculo-arterial coupling showing the most prominent association to infarct properties and outcome. GCS showed higher correlation to haemodynamic indices compared to GLS whilst both are independent predictors for MACE.

Coronary Computed Tomographic Angiography to Optimize the Diagnostic Yield of Invasive Angiography for Low-Risk Patients Screened With Artificial Intelligence: Protocol for the CarDIA-AI Randomized Controlled Trial

BACKGROUND

Invasive coronary angiography (ICA) is the gold standard in the diagnosis of coronary artery disease (CAD). Being invasive, it carries rare but serious risks including myocardial infarction, stroke, major bleeding, and death. A large proportion of elective outpatients undergoing ICA have nonobstructive CAD, highlighting the suboptimal use of this test. Coronary computed tomographic angiography (CCTA) is a noninvasive option that provides similar information with less risk and is recommended as a first-line test for patients with low-to-intermediate risk of CAD. Leveraging artificial intelligence (AI) to appropriately direct patients to ICA or CCTA based on the predicted probability of disease may improve the efficiency and safety of diagnostic pathways.

OBJECTIVE

he CarDIA-AI (Coronary computed tomographic angiography to optimize the Diagnostic yield of Invasive Angiography for low-risk patients screened with Artificial Intelligence) study aims to evaluate whether AI-based risk assessment for obstructive CAD implemented within a centralized triage process can optimize the use of ICA in outpatients referred for nonurgent ICA.

METHODS

CarDIA-AI is a pragmatic, open-label, superior randomized controlled trial involving 2 Canadian cardiac centers. A total of 252 adults referred for elective outpatient ICA will be randomized 1:1 to usual care (directly proceeding to ICA) or to triage using an AI-based decision support tool. The AI-based decision support tool was developed using referral information from over 37,000 patients and uses a light gradient boosting machine model to predict the probability of obstructive CAD based on 42 clinically relevant predictors, including patient referral information, demographic characteristics, risk factors, and medical history. Participants in the intervention arm will have their ICA referral forms and medical charts reviewed, and select details entered into the decision support tool, which recommends CCTA or ICA based on the patient's predicted probability of obstructive CAD. All patients will receive the selected imaging modality within 6 weeks of referral and will be subsequently followed for 90 days. The primary outcome is the proportion of normal or nonobstructive CAD diagnosed via ICA and will be assessed using a 2-sided z test to compare the patients referred for cardiac investigation with normal or nonobstructive CAD diagnosed through ICA between the intervention and control groups. Secondary outcomes include the number of angiograms avoided and the diagnostic yield of ICA.

RESULTS

Recruitment began on January 9, 2025, and is expected to conclude in mid to late 2025. As of April 14, 2025, we have enrolled 81 participants. Data analysis will begin once data collection is completed. We expect to submit the results for publication in 2026.

CONCLUSIONS

CarDIA-AI will be the first randomized controlled trial using AI to optimize patient selection for CCTA versus ICA, potentially improving diagnostic efficiency, avoiding unnecessary complications of ICA, and improving health care resource usage.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06648239; https://clinicaltrials.gov/study/NCT06648239/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/71726.

A machine learning model using echocardiographic myocardial strain to detect myocardial ischemia

Coronary functional assessment plays a critical role in guiding decisions regarding coronary revascularization. Traditional methods for evaluating functional myocardial ischemia, such as invasive procedures or those involving radiation, have their limitations. Echocardiographic myocardial strain has emerged as a non-invasive and convenient indicator. However, the interpretation of strain values can be subject to inter-operator variability. Artificial intelligence (AI) and machine learning techniques may promise to reduce the variability. By training AI algorithms on a diverse range of echocardiographic data, including strain values, and correlating them with ischemia, it may be possible to develop a robust and automated diagnostic tool. This study aims to provide a non-invasive and effective solution for automated myocardial ischemia detection that can be used in clinical practice. To construct the machine learning model, we used an automatic left ventricular endocardium tracing tool to extract myocardial strain data and integrated it with six clinical features. A coronary angiography-derived fractional flow reserve (caFFR) ≤ 0.80 was defined as the indicator of myocardial ischemia. A total of 636 suspected coronary artery disease subjects were enrolled in this pilot study, where 282 cases (44.3%) had myocardial ischemia. These subjects were randomly divided into training (n = 508) and testing (n = 128) sets at a 4:1. Using ensemble-learning algorithms to train and optimize the model, its diagnostic performance versus caFFR was diagnostic accuracy 85.9%, sensitivity 88.9%, specificity 83.1%, positive predictive value 83.6%, negative predictive value 88.5%. The optimized model achieved an area under the receiver operating characteristic curve (AUC) of 0.915 (95% confidence interval [CI] 0.862-0.968). Our machine learning prototype model based on echocardiographic myocardial strain shows promising results in detecting myocardial ischemia. Further studies are needed to validate its robustness and generalizability on larger patient populations.

Coronary computed tomography angiography in primary care patients with chest pain or dyspnea - a cross-sectional study

AIMS

Coronary Computed Tomography Angiography (CCTA) is recommended as a first-line investigation to exclude significant coronary artery stenosis in case of low to intermediate pre-test probability (PTP). The aim was to investigate CCTA findings in relation to the PTP of patients referred directly from primary health care centres.

METHODS/RESULTS

In this retrospective cohort study consecutive primary care CCTA referrals in a Swedish county 1st of June 2021 until 30th Nov. 2022 were included. CCTA reports were obtained for 483 patients ≥ 30 years old, without known CAD and stratified as no CAD, with atheromatosis or with suspected significant stenosis. For the 381 patients with eligible PTP data, the mean age was 60 years and 70% were women. While the median PTP was 11%, significant stenosis was suspected on CCTA in 18%. Among patients with PTP ≤ 15%, CCTA exposed no significant stenosis in 88%. No significant stenosis was found in patients with PTP < 5% true to patient age and gender in a sensitivity analysis (n = 25).

CONCLUSIONS

CCTA ruled out coronary stenosis as the cause of chest pain and dyspnea in 88% of patients referred from primary care with PTP 5-15%. PTP estimations by primary care physicians in CCTA referrals agreed with the occurrence of suspected significant stenosis among patients with PTP 5-15%, but underestimated it in PTP > 15%. The validity of PTP estimates < 5% was low.

Nutritional risk score predicts the length of stay in patients undergoing coronary angiography

AIM

Nutritional status is a factor that impacts the clinical outcomes of various medical conditions, including cardiovascular disease and surgical procedures; however, little is known about its role in percutaneous procedures. This study aimed to assess the association between nutritional status and risk in patients undergoing coronary angiography and in-hospital mortality and length of stay to improve risk stratification and peri-procedural care.

METHODS

Patients who underwent coronary angiography between January 2022 and August 2023. Nutritional status was assessed with body mass index, and nutritional risk was assessed with the Nutritional Risk Screening 2002 score. Multivariate regression models assessed independent predictors of in-hospital mortality, adjusting for age, sex, coronary event, Canadian Cardiovascular Society class, and cardiac arrest at admission. Subgroup analyses were performed based on coronary event type to evaluate whether the associations differed across clinical presentations.

RESULTS

Patients who underwent angiography (n = 1343) were aged 69.2 ± 11.1 years, 51% male, and 49% had acute coronary syndrome. The mean length of stay at the hospital was 4.5 ± 4.8 days; 38% of patients stayed ≥5 days. The in-hospital mortality rate was 1.3%. Regression analyses revealed that the Nutritional Risk Screening 2002 score independently predicted the length of stay (β = 0.63, p = 0.002), and this relationship was strongest in the non-ST segment elevation myocardial infarction subgroup (β = 1.26, p = 0.02). Body mass index did not predict the length of stay. There was no significant relationship between in-hospital mortality and body mass index or the Nutritional Risk Screening 2002 score.

CONCLUSION

Nutritional risk significantly predicts the length of stay after coronary angiography, independent of age, sex, and coronary event type. Clinicians should consider routine nutritional risk assessment preceding coronary angiography to help individualise post-procedure, in-hospital care.

A Novel Angiography-Derived Computational Coronary Flow Reserve to Evaluate Non-Obstructive Coronary Artery Disease

Coronary flow reserve (CFR) is a key parameter for risk stratification in coronary artery disease but is limited by high cost, prolonged procedure time, and suboptimal reproducibility. We proposed a novel angiography-based method (Angio-CFR) to overcome these challenges and assessed its diagnostic performance. 107 consecutive patients underwent invasive coronary angiography with thermodilution-derived CFR (CFRthermo) were prospectively enrolled. Flow velocity at hyperemia and rest was estimated from angiographic images, and Angio-CFR was calculated as their ratio. Angio-CFR correlated well with CFRthermo (r = 0.72, p < 0.001), and showed good discrimination of CFRthermo < 2.5 (AUC = 0.879, p < 0.001) with an optimal cut-off of 2.5. The accuracy, sensitivity, and specificity of Angio-CFR were 81.71%, 83.33%, and 81.25%, respectively. Angio-CFR provides a pressure-wire-free method for coronary function assessment, demonstrating promising diagnostic accuracy and offering a more accessible approach for CFR measurement in clinical practice.

Impact of BMI, heart rhythm, and heart rate on photon-counting detector virtual coronary calcium scoring

The study evaluates the impact of body mass index (BMI), heart rate and rhythm on coronary artery calcium scoring (CACS) derived from calcium-sensitive virtual non-contrast (VNC) series of photon-counting detector (PCD) computed tomography angiography (CTA) compared to true non-contrast (TNC) series. Patients who underwent cardiac imaging with TNC and CTA on a PCD-CT were included. Agatston scores from TNC and VNC images were used to assign CACS risk category. Analyses considered BMI, heart rhythm and heart rate. Distributions were tested for differences between TNC and VNC derived scores and their correlation was assessed. The final cohort included 88 patients. CACS on VNC showed an underestimation of TNC derived values on median Agatston score TNC = 542 (IQR 200-1294), on median Agatston score VNC = 449 (IQR 130-1183), p < 0.001, percentage difference - 11%. However, linear correlation coefficient was high (r2 = 0.95), and the CAC severity was categorized equivalent in 80%. In approximately 11% of the study cohort, the misclassification of CAC severity could have potentially led to inappropriate treatment following established guidelines. An impact on the significance and extent of the difference in CACS for BMI > 28 kg/m2 and heart rate groups > 69 bpm was found. VNC reconstructions from PCD-CT reliably estimates TNC CACS for BMI ≤ 28 kg/m2 and heart rate ≤ 69 bpm in patients with severe coronary artery disease. Potential underestimation of risk category, especially with increased BMI and heart rate, must be considered for clinical decision making.

Pharmacodynamic effects of cangrelor in patients with acute or chronic coronary syndrome undergoing percutaneous coronary intervention: the POMPEII Registry

BACKGROUND

Cangrelor is approved for oral P2Y12 inhibitor-naïve patients undergoing percutaneous coronary intervention (PCI). Pharmacodynamic (PD) investigations in various clinical settings, with various assays, have shown contrasting data in terms of the extent of platelet inhibition and rates of high residual platelet reactivity (HRPR).

AIMS

We aimed to assess the PD effects of cangrelor in all patients receiving it during PCI.

METHODS

PharmacOdynaMic Effects of Cangrelor in PatiEnts wIth Acute or chronIc Coronary Syndrome Undergoing Percutaneous Coronary Intervention (POMPEII Registry; ClinicalTrials.gov: NCT04790032) is an investigator-initiated, prospective study assessing PD effects at 4 timepoints with 3 assays. Clinical outcomes at 30 days were also assessed.

RESULTS

From March 2021 to June 2024, 150 patients undergoing PCI and receiving cangrelor were enrolled (64 patients underwent elective PCI; 30 had non-ST-elevation acute coronary syndrome; and 56 had ST-segment elevation myocardial infarction [STEMI], of whom 24 were pretreated with ticagrelor). Most patients switched from cangrelor to either clopidogrel or ticagrelor. Inhibition of platelet aggregation was moderate during cangrelor infusion (light transmittance aggregometry with adenosine diphosphate 20 μM: 57.6±16.5%), with rates of 3.2% for HRPR and 1.3% for bailout tirofiban. Rates of HRPR were relevant at 3 h (37.9%) and 4-6 h (15.3%), and HRPR occurred significantly more frequently in patients switching to clopidogrel compared with ticagrelor. Rates of ischaemic and bleeding events were low.

CONCLUSIONS

Cangrelor provided effective platelet inhibition in most patients with ACS or CCS undergoing PCI, including those with STEMI who were pretreated with ticagrelor. Switching from cangrelor to an oral P2Y12 inhibitor, mainly clopidogrel, exposed a large number of patients to a variable period of on-treatment HRPR.

Ticagrelor monotherapy versus ticagrelor plus aspirin in patients with chronic coronary syndrome and high ischaemic risk: a post hoc analysis of the TWILIGHT trial

BACKGROUND

Short dual antiplatelet therapy (DAPT) followed by ticagrelor monotherapy may be a valuable therapeutic option for patients with chronic coronary syndrome (CCS) and high ischaemic risk (HIR) undergoing percutaneous coronary intervention (PCI).

AIMS

We aimed to compare ticagrelor monotherapy with ticagrelor-based DAPT in CCS patients with and without HIR undergoing PCI.

METHODS

The present analysis included the CCS cohort of the TWILIGHT trial, which randomised PCI patients to ticagrelor alone or in combination with aspirin for 12 months after 3 months of ticagrelor-based DAPT. Patients were stratified into HIR and non-HIR based on the 2019 European Society of Cardiology (ESC) CCS guidelines definition. Outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction or stroke, and Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding at 1 year.

RESULTS

Of the 2,503 CCS patients who underwent randomisation, the ESC definition classified 1,264 (50.5%) as HIR and 1,239 (49.5%) as non-HIR. HIR patients displayed a higher risk of MACCE (3.9% vs 2.3%; p=0.015) and similar rates of BARC Type 2-5 bleeding (5.1% vs 5.7%; p=0.455) as compared to non-HIR patients. Ticagrelor monotherapy and ticagrelor-based DAPT were associated with similar risks of MACCE (HIR: 4.0% vs 3.8%, hazard ratio [HR] 1.06, 95% confidence interval [CI]: 0.60-1.85; non-HIR: 2.1% vs 2.6%, HR 0.80, 95% CI: 0.38-1.66, pinteraction=0.553) and bleeding (HIR: 4.7% vs 5.7%, HR 0.82, 95% CI: 0.50-1.33; non-HIR: 4.9% vs 6.7%, HR 0.71, 95% CI: 0.44-1.14; pinteraction=0.684) in both the HIR and non-HIR groups.

CONCLUSIONS

In a post hoc analysis of the TWILIGHT trial that included CCS patients undergoing PCI, ticagrelor monotherapy after 3 months of DAPT appeared to be safe and was not associated with increased risks of ischaemic or bleeding events, regardless of baseline HIR status, compared with standard ticagrelor-based DAPT. These findings suggest the potential to expand guideline recommendations for ticagrelor monotherapy in CCS.

The working mechanism of biomarkers related to sumoylation modification in coronary artery disease

Coronary artery disease (CAD) remains a leading global cause of mortality. The expression of small ubiquitin-like modifier 1 (SUMO-1) is reduced in heart failure. However, the mechanisms underlying its modification in CAD remain underexplored. This study sought to identify SUMOylation-related biomarkers and elucidate the potential mechanisms in CAD pathogenesis. This study analyzed three CAD datasets (GSE42148, GSE23561, and GSE121893) alongside 187 SUMOylation-related genes (SRGs). The overlap between differentially expressed genes (DEGs) and SRGs was used to identify differentially expressed SUMOylation-related genes (DE-SRGs). Biomarkers were validated through expression profiling and receiver operating characteristic (ROC) curve analysis. Enrichment and immune infiltration analyses were performed to explore the molecular mechanisms by which these biomarkers influence CAD. A drug-gene interaction network was constructed using the Drug-Gene Interaction database (DGIdb). Single-cell analysis was conducted to identify key cellular players and validate the differential expression of biomarkers across cell types. A total of 12 DE-SRGs were identified in CAD. Among them, SUMO1 and PPARG were validated as biomarkers, with their expression significantly elevated in the CAD group compared to the control group. Single-sample gene set enrichment analysis (ssGSEA) revealed distinct immune cell distributions in CAD, with central memory CD4+ T cells and memory B cells positively correlated with the biomarkers. Gene set enrichment analysis (GSEA) linked these biomarkers to ribosomal activity, olfactory transduction, and other pathways. Single-cell analysis confirmed the expression of SUMO1 and PPARG in endothelial cells, particularly in the CAD group. Additionally, SUMO1 was differentially expressed in cardiomyocytes, exhibiting higher expression in controls. SUMO1 and PPARG were identified as novel SUMOylation-related biomarkers in CAD, suggesting new therapeutic avenues for CAD management.

Direct evaluation of antiplatelet therapy in coronary artery disease by comprehensive image-based profiling of circulating platelets

Coronary artery disease (CAD) is a leading cause of death globally. Antiplatelet therapy remains crucial in preventing and treating CAD-associated thrombotic complications, but it concurrently amplifies the risk of bleeding. Unfortunately, traditional platelet function measurement methods cannot directly evaluate its efficacy and safety. Here we demonstrate comprehensive image-based profiling of circulating platelets to directly observe thrombotic conditions and assess antiplatelet therapy in CAD patients. Deep learning-based analysis of whole blood samples from 207 CAD patients revealed elevated concentrations of circulating platelet aggregates, especially in acute versus chronic coronary syndrome patients. It also indicated a regimen-dependent reduction in these concentrations upon treatment with antiplatelet drugs, thereby verifying the direct efficacy of the therapy. Notably, consistent concentrations of these aggregates were found in both venous and arterial blood, suggesting venous blood as a reliable therapy efficacy indicator, despite CAD's arterial nature. These findings support personalized and improved antiplatelet therapy in CAD management.