Impact of Diabetes Mellitus on the Evaluation of Stable Chest Pain Patients: Insights From the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) Trial

Saudi Heart Association Guidelines on Best Practices in the Management of Chronic Coronary Syndromes

Background

The prevalence of both chronic coronary syndrome (CCS) and its risk factors is alarming in Saudi Arabia and only a minority of patients achieve optimal medical management. Context-specific CCS guidelines outlining best clinical practices are therefore needed to address local gaps and challenges.

Consensus panel

A panel of experts representing the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to local clinical practice considering the characteristics of the Saudi population, the Saudi healthcare system, its resources and medical expertise. They were reviewed by external experts to ensure scientific and medical accuracy.

Consensus findings

Recommendations are provided on the clinical assessment and management of CCS, along with supporting evidence. Risk reduction through non-pharmacological therapy (lifestyle modifications) remains at the core of CCS management. Great emphasis should be placed on the use of available pharmacological options (anti-anginal therapy and event prevention) only as appropriate and necessary. Lifestyle counseling and pharmacological strategy must be optimized before considering revascularization, unless otherwise indicated. Revascularization strategies should be carefully considered by the Heart Team to ensure the appropriate choice is made in accordance to current guidelines and patient preference.

Conclusion

Conscientious, multidisciplinary, and personalized clinical management is necessary to navigate the complex landscape of CCS in Saudi Arabia considering its population and resource differences. The reconciliation of international evidence and local characteristics is critical for the improvement of healthcare outcomes among CCS patients in Saudi Arabia.

Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results

AIMS

The influence of chest wall shape on exercise stress echocardiography (ESE) results has been poorly investigated. We aimed at evaluating the main predictors of true positive (TP)-ESE in a population of subjects with suspected coronary artery disease (CAD), categorized according to chest wall conformation, assessed by modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine).

METHODS

All consecutive patients with suspected CAD referred to our EchoLab for performing ESE between September 2011 and October 2021 were retrospectively enrolled. Preliminary assessment of both pretest probability (PTP) and MHI was performed. All patients with positive ESE underwent coronary angiography. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. Outcome was TP ESE result.

RESULTS

One thousand two hundred and seventy-five consecutive patients (64.9 ± 13.0 years) entered the study. Subjects with concave-shaped chest wall (MHI > 2.5) (10.7%) and those with normal chest shape (MHI ≤ 2.5) (89.3%) were separately analyzed. PTP was similar in both groups (21.8 ± 13.2 vs. 23.5 ± 13.3%, P  = 0.15). One hundred and seventy patients were diagnosed with positive ESE: 129 (75.9%) had obstructive CAD (TP), whereas the remaining 41 (24.1%) had no CAD. Only 2.3% of TP ESE was detected in subjects with MHI >2.5. PTP [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04], dyslipidemia (OR 4.37, 95% CI 2.81-6.80), dyssynergy in the left anterior descending territory (OR 8.21, 95% CI 5.07-13.3) were linearly correlated with TP ESE, whereas MHI >2.5 (OR 0.25, 95% CI 0.14-0.67) was inversely associated with outcome.

CONCLUSIONS

Subjects with MHI >2.5 have low prevalence of TP ESE, regardless of PTP. Preliminary MHI assessment may reduce overestimation of PTP of CAD.

MiR-1290: a potential therapeutic target for regenerative medicine or diagnosis and treatment of non-malignant diseases

MicroRNAs are a set of small non-coding RNAs that could change gene expression with post-transcriptional regulation. MiRNAs have a significant role in regulating molecular signaling pathways and innate and adaptive immune system activity. Moreover, miRNAs can be utilized as a powerful instrument for tissue engineers and regenerative medicine by altering the expression of genes and growth factors. MiR-1290, which was first discovered in human embryonic stem cells, is one of those miRNAs that play an essential role in developing the fetal nervous system. This review aims to discuss current findings on miR-1290 in different human pathologies and determine whether manipulation of miR-1290 could be considered a possible therapeutic strategy to treat different non-malignant diseases. The results of these studies suggest that the regulation of miR-1290 may be helpful in the treatment of some bacterial (leprosy) and viral infections (HIV, influenza A, and Borna disease virus). Also, adjusting the expression of miR-1290 in non-infectious diseases such as celiac disease, necrotizing enterocolitis, polycystic ovary syndrome, pulmonary fibrosis, ankylosing spondylitis, muscle atrophy, sarcopenia, and ischemic heart disease can help to treat these diseases better. In addition to acting as a biomarker for the diagnosis of non-malignant diseases (such as NAFLD, fetal growth, preeclampsia, down syndrome, chronic rhinosinusitis, and oral lichen planus), the miR-1290 can also be used as a valuable instrument in tissue engineering and reconstructive medicine. Consequently, it is suggested that the regulation of miR-1290 could be considered a possible therapeutic target in the treatment of non-malignant diseases in the future.

Comparison of Risk Assessment Strategies for Patients with Diabetes Mellitus and Stable Chest Pain: A Coronary Computed Tomography Angiography Study

BACKGROUND

To compare two risk assessment strategies to identify individuals likely to benefit from further imaging testing in patients with diabetes mellitus (DM) and stable chest pain (SCP) suspected of obstructive coronary artery disease (CAD).

METHODS

602 DM patients referred to coronary computed tomography angiography (CCTA) for SCP were included. They were divided into high- and low-risk groups according to the 2016 National Institute of Health and Care Excellence guideline-determined strategy (NICE strategy) which focused on symptom evaluation and 2019 European Society of Cardiology guideline-determined strategy (ESC strategy) which was based on pretest probability (PTP) sequentially determined by the ESC-PTP estimator and risk factor-weighted clinical likelihood (RF-CL) model, respectively. The associations of clinical outcomes with risk groups and net reclassification improvement (NRI) were evaluated.

RESULTS

The NICE and ESC strategy classified 44% and 39% patients into the low-risk group, respectively. Compared to the NICE strategy, the ESC strategy indicated stronger associations between risk groups and events (hazard ratios: 4.24 versus 1.91), intensive clinical management, and a positive NRI (27.71%, p < 0.0001). The application of the RF-CL model ameliorated the underestimation of risk in patients with borderline ESC-PTP, which principally account for the improvement of the ESC strategy.

CONCLUSION

Compared to the NICE strategy, the ESC strategy seemed to be associated with greater efficiency in identifying high risk individuals in patients with DM and SCP.

Prevalence of osteoporosis in patients with type 2 diabetes mellitus in the Chinese mainland: A protocol of systematic review and meta-analysis

BACKGROUND

Osteoporosis, as a metabolic disease, has become one of the most rapidly growing complications of diabetes mellitus. Previously, we conducted a systematic review to report the estimated prevalence of osteoporosis among patients with type 2 diabetes mellitus (T2DM) from 2001 to 2016. However, some newer studies have been reported, and more potential risk factors for osteoporosis remain controversial and vague. Therefore, the presented review is tailored to synthesize available evidence regarding the pooled prevalence and related risk factors of osteoporosis among T2DM patients in mainland China.

METHODS

Both cross-sectional study and cohort study reporting on the prevalence of osteoporosis among patients with T2DM in mainland China, published in Chinese or English, will be considered for inclusion. Records from 4 English databases and 2 Chinese databases will be retrieved from their inceptions to March 2020. The process of study selection, data extraction, and methodologic quality assessment will be independently executed by 2 reviewers. The pooled prevalence of osteoporosis and the prevalence in the exposed and unexposed groups for each potential risk factor will be calculated by the software Stata version 12.0.

RESULTS

The current systematic review and meta-analysis will provide more precise prevalence rates and associated risk factors of osteoporosis among people with T2DM in mainland China.

CONCLUSION

The study will offer high-quality and explicit evidence for assisting diabetic patients to prevent osteoporosis in mainland China.

OSF REGISTRATION

DOI 10.17605/OSF.IO/5ZKJ6.

Stress Testing Versus CT Angiography in Patients With Diabetes and Suspected Coronary Artery Disease

BACKGROUND

The optimal noninvasive test (NIT) for patients with diabetes and stable symptoms of coronary artery disease (CAD) is unknown.

OBJECTIVES

The purpose of this study was to assess whether a diagnostic strategy based on coronary computed tomographic angiography (CTA) is superior to functional stress testing in reducing adverse cardiovascular (CV) outcomes (CV death or myocardial infarction [MI]) among symptomatic patients with diabetes.

METHODS

PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) was a randomized trial evaluating an initial strategy of CTA versus functional testing in stable outpatients with symptoms suggestive of CAD. The study compared CV outcomes in patients with diabetes (n = 1,908 [21%]) and without diabetes (n = 7,058 [79%]) based on their randomization to CTA or functional testing.

RESULTS

Patients with diabetes (vs. without) were similar in age (median 61 years vs. 60 years) and sex (female 54% vs. 52%) but had a greater burden of CV comorbidities. Patients with diabetes who underwent CTA had a lower risk of CV death/MI compared with functional stress testing (CTA: 1.1% [10 of 936] vs. stress testing: 2.6% [25 of 972]; adjusted hazard ratio: 0.38; 95% confidence interval: 0.18 to 0.79; p = 0.01). There was no significant difference in nondiabetic patients (CTA: 1.4% [50 of 3,564] vs. stress testing: 1.3% [45 of 3,494]; adjusted hazard ratio: 1.03; 95% confidence interval: 0.69 to 1.54; p = 0.887; interaction term for diabetes p value = 0.02).

CONCLUSIONS

In diabetic patients presenting with stable chest pain, a CTA strategy resulted in fewer adverse CV outcomes than a functional testing strategy. CTA may be considered as the initial diagnostic strategy in this subgroup. (PROspective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550).

Imaging in ESC clinical guidelines: chronic coronary syndromes

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). The 2019 guideline identified six common clinical scenarios of CCS defined by the different evolutionary phases of coronary artery disease (CAD), excluding the situations in which an acute coronary event, often with coronary thrombus formation, dominates the clinical presentation. This review aims at providing a summary of novel or revised concepts in the guidelines together with the recent data underlying the major changes on the use of cardiac imaging in patients with suspected or known CCS.

Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of CAD based on age, sex and symptoms have been adjusted substantially downward as compared with 2013 ESC guidelines. Further, the impact of various risk factors and modifiers on the pre-test probability was highlighted and a new concept of ‘Clinical likelihood of CAD’ was introduced. Recommendations regarding diagnostic tests to establish or rule-out obstructive CAD have been updated with recent data on their diagnostic performance in different patient groups and impact on patient outcome. As the initial strategy to diagnose CAD in symptomatic patients, non-invasive functional imaging for myocardial ischaemia, coronary computed tomography angiography or invasive coronary angiography combined with functional evaluation may be used, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests instead of the exercise electrocardiogram are recommended when following the non-invasive diagnostic strategy.

Clinical significance of chronic myocardial ischemia in coronary artery disease patients

Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.