(Epicardial and microvascular) angina or atypical chest pain: differential diagnoses with cardiovascular magnetic resonance

The utility of capnography in determining the risk of major cardiac adverse events in patients with atypical chest pain

INTRODUCTION

Various scoring systems have been developed to safely rule out the diagnosis of acute coronary syndrome. Furthermore, the efficacy of these scoring systems in predicting the risk of major adverse cardiac events (MACE) is debated. Our aim was to compare parameters such as Integrated Pulmonary Index (IPI) and End Tidal Carbon Dioxide (etCO2) measured in the emergency department with the HEART score in terms of its success in predicting the risk of major adverse cardiac events.

METHOD

Patients with atypical chest pain were registered for the study by the emergency room physician. The patients were investigated regarding gender, age, background characteristics, prognostic accuracy of etCO2, IPI, MACE, and HEART scores.

RESULTS

As a result of the analysis, higher HEART Score and lower etCO2 values were determined in the MACE group compared to the group without MACE. ROC analysis was performed to determine the power of IPI, HEART Score, and etCO2 to predict MACE. The findings revealed that IPI significantly predicted MACE with an AUC value of 0.737.

CONCLUSION

In our study, although the highest sensitivity values in determining the risk of 30-day MACE belonged to the HEART score, etCO2 and IPI might be other parameters that could be used to determine the risk of 30-day MACE.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Cardiovascular magnetic resonance image analysis and mechanism study for the changes after treatments for primary microvascular angina pectoris

ABSTRACT

Most cases of primary microvascular angina pectoris (PMVA) are diagnosed clinically, but the etiology and pathological mechanisms are unknown. The effect of routine clinical medications is minimal, and PMVA can progress to serious cardiovascular events. To improve the diagnosis and effective treatment of this disease, this study was designed to diagnose PMVA via cardiovascular magnetic resonance (CMR) and the coronary angiography thrombolysis in myocardial infarction (TIMI) blood flow grade, as well as to analyze vascular endothelial function to elucidate the pathogenesis of PMVA and compare the effects of routine clinical medications.The present randomized controlled trial including a parallel control group will be conducted on 63 PMVA patients in our cardiovascular department. The patients will be selected and randomly divided into the control, diltiazem, and nicorandil groups. The control group will be administered routine drug treatments (aspirin, atorvastatin, betaloc ZOK, perindopril, and isosorbidemononitrate sustained-release tablets). The diltiazem group will be additionally treated with 90 mg qd diltiazem sustained-release capsules. The nicorandil group was additionally given 5 mg tid nicorandil tablets. Coronary angiography will be performed before treatment, the severity and frequency of chest pain will be evaluated before and after 9 months of treatment, and homocysteine and von Willebrand factor levels will be measured. Electrocardiography, echocardiography, dynamic electrocardiography, a treadmill exercise test, and CMR will be performed. Sex, age, body mass index, complications, smoking, and family history will also be recorded. The SPSS19.0 statistical software package will be used to analyze the data. The measurements will be expressed as the mean ± standard deviation. Measurement data will be compared between the groups using Student's t-test. A relative number description will be used for the counting data, and the chi-squaretest will be used to compare the groups. A multivariate logistic regression analysis will be performed A P-value < .05 will be considered significant.The direct indices (CMR and coronary angiographic TIMI blood flow grade) may improve after adding diltiazem or nicorandil during routine drug treatments (such as aspirin, statins, and nitrates) in PMVA patients, and indirect indices (homocysteine and von Willebrand factor levels) may be reduced.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (http://www.chictr.org.cn/showprojen.aspx?proj=41894), No. CHiCTR1900025319, Registered on August 23, 2019; pre initiation.

Stress CMR in Known or Suspected CAD: Diagnostic and Prognostic Role

The recently published 2019 guidelines on chronic coronary syndromes (CCS) focus on the need for noninvasive imaging modalities to accurately establish the diagnosis of coronary artery disease (CAD) and assess the risk of clinical scenario occurrence. Appropriate patient management should rely on controlling symptoms, improving prognosis, and guiding each therapeutic strategy as well as monitoring disease progress. Among the noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) has gained broad acceptance in past years due to its unique features in providing a complete assessment of CAD through data on cardiac anatomy and function and myocardial viability, with high spatial and temporal resolution and without ionizing radiation. In detail, evaluation of the presence and extent of myocardial ischemia through stress CMR (S-CMR) has shown a high rule-in power in detecting functionally significant coronary artery stenosis in patients suspected of CCS. Moreover, S-CMR technique may add significant prognostic value, as demonstrated by different studies which have progressively evidenced the valuable power of this multiparametric imaging modality in predicting adverse cardiac events. The latest scientific progress supports a greater expansion of S-CMR with improvement of quantitative myocardial perfusion analysis, myocardial strain, and native mapping within the same examination. Although further study is warranted, these techniques, which are currently mostly restricted to the research field, are likely to become increasingly prevalent in the clinical setting with the scope of increasing accuracy in the selection of patients to be sent to invasive revascularization. This review investigates the diagnostic and prognostic role of S-CMR in the context of CAD, by analysing a strong, long-standing, scientific evidence together with an appraisal of new advanced techniques which may potentially enrich CAD management in the next future.

Recent updates on novel therapeutic targets of cardiovascular diseases

In recent times cardiovascular diseases (CVDs) are the leading cause of mortality universally, caused more or less 17.7 million casualties with 45% of all illnesses (except communicable ones) in 2015 as per World Health Organization (WHO). According to American National Center for Health Statistics, cardiac disorders are costliest. Moreover, health care expenditures related to cardiac disorders are anticipated to exceed than diabetes and Alzheimer's. Straining of reactive oxygen species with diminished neutralization & inflammation critically adds to atherosclerosis and also proceed to other cardiovascular diseases such as cardiac remodeling and myocardial infarction (MI). In the past few years, researchers revealed multiple drug targets from animal studies and evaluated them in the therapeutics of cardiac disorders, which offered exciting clues for novel therapeutic strategies. Although, only few newer agents approved clinically and actual approaches for treatment are lagging behind. Several novel drugs found effective for the treatment of hypertension, congestive heart failure, cardiac arrhythmia and angina pectoris. Detailed mechanism of action, basic and clinical pharmacology of all novel drugs has been discussed in this review.