Clinical Characteristics, Sex Differences, and Outcomes in Patients With Normal or Near-Normal Coronary Arteries, Non-Obstructive or Obstructive Coronary Artery Disease

Coronary slow flow and angiography-derived index of microcirculatory resistance as prognostic predictors in patients with angina and normal coronary arteries: a retrospective cohort study

BACKGROUND

This study aims to investigate prognostic implications of coronary slow flow (CSF) and angiography-derived index of microcirculatory resistance (caIMR) in patients with angina and normal coronary arteries.

METHODS

A total of 582 patients were enrolled with angiographically normal coronary arteries. caIMR was calculated using a commercial software. Patients were followed up for a median of 45 months. The primary endpoint was defined as major adverse cardiovascular events (MACEs) comprising death, myocardial infarction and readmission for angina or heart failure.

RESULTS

CSF was diagnosed when TIMI grade 2 flow presented in at least one coronary artery. Multivariate analysis indicated TIMI-flow-based determination of CSF was not significantly associated with MACEs [hazard ratio (HR): 2.14; 95% confidence interval (CI): 0.87-5.31; p = 0.099), while caIMR >42 (HR: 2.53; 95% CI: 1.02-6.32; p = 0.047) were independent predictors of MACEs. Incorporation of caIMR improved the area under the curve from 0.587 to 0.642.

CONCLUSIONS

caIMR was an independent prognostic factor of long-term cardiovascular events in patients with CSF. Evaluation of caIMR improved the risk stratification of patients with angiographically-normal coronary arteries.

Predictive value of the systemic immune inflammatory index in cardiac syndrome x

İNTRODUCTION: Patients with normal coronary arteries in whom increased vasospasm cannot be detected with the stress test should be evaluated in terms of cardiac syndrome x (CSX). İnflammatory systems are effective in endothelial activation and dysfunction in CSX. The systemic immune inflammation index (SII) is thought to be an important factor in determining the course of diseases, especially in infectious diseases or other diseases, as an indicator of the inflammation process. The aim of this study is to determine the role of SII levels in the diagnosis of CSX disease.

METHODS

The study group included 80 patients who applied to the cardiology department of Fırat University with typical anginal complaints between October 2021 and April 2022, and were diagnosed with ischemia after the myocardial perfusion scan, and then coronary angiography was performed and normal coronary arteries were observed.

RESULTS

When the study and control groups were examined according to age, gender and body mass index, hypertension, smoking, diabetes mellitus, dyslipidemia and family history, no statistical significant difference was observed between the groups. It was observed that there was a significant difference between the high sensitive C- reactive protin levels of the individuals in the study and control groups (p = 0.028). SII levels measured in samples taken from patients were significantly higher than control subjects (p = 0.003). SII cutoff at admission was 582 with 82% sensitivity and 84% specificity (area under the curve 0.972; 95% CI:0.95-0.98;p < 0.001).

CONCLUSION

It has been demonstrated that systemic SII parameters, which can be simply calculated with the data obtained from the complete blood count and do not require additional costs, can contribute to the prediction of CSX disease.

Nonobstructive coronary atherosclerosis is associated with adverse prognosis among patients diagnosed with myocardial infarction without obstructive coronary arteries

BACKGROUND AND AIMS

The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA.

METHODS

We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS).

RESULTS

Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25-2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03-1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03-4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56-0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44-0.98; p=0.041) were associated with lower MAE-risk.

CONCLUSIONS

In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization.

The sex-dependent response to psychosocial stress and ischaemic heart disease

Stress is an important risk factor for modern chronic diseases, with distinct influences in males and females. The sex specificity of the mammalian stress response contributes to the sex-dependent development and impacts of coronary artery disease (CAD). Compared to men, women appear to have greater susceptibility to chronic forms of psychosocial stress, extending beyond an increased incidence of mood disorders to include a 2- to 4-fold higher risk of stress-dependent myocardial infarction in women, and up to 10-fold higher risk of Takotsubo syndrome-a stress-dependent coronary-myocardial disorder most prevalent in post-menopausal women. Sex differences arise at all levels of the stress response: from initial perception of stress to behavioural, cognitive, and affective responses and longer-term disease outcomes. These fundamental differences involve interactions between chromosomal and gonadal determinants, (mal)adaptive epigenetic modulation across the lifespan (particularly in early life), and the extrinsic influences of socio-cultural, economic, and environmental factors. Pre-clinical investigations of biological mechanisms support distinct early life programming and a heightened corticolimbic-noradrenaline-neuroinflammatory reactivity in females vs. males, among implicated determinants of the chronic stress response. Unravelling the intrinsic molecular, cellular and systems biological basis of these differences, and their interactions with external lifestyle/socio-cultural determinants, can guide preventative and therapeutic strategies to better target coronary heart disease in a tailored sex-specific manner.

Effect of nonobstructive coronary stenosis on coronary microvascular dysfunction and long-term outcomes in patients with INOCA

BACKGROUND

Ischemic pain with no-obstructive coronary artery (INOCA) is clinically significant and defined by nonobstructive coronary stenosis <50%. Coronary microvascular dysfunction (CMD) is a relevant cause associated with adverse outcomes.

OBJECTIVES

Investigated the effect of no-stenosis (0% stenosis) and non-obstructive (0% < stenosis < 50%) on the prognostic impact of CMD in INOCA.

METHOD

A retrospective study assessed the coronary microvascular function in 151 INOCA patients who underwent invasive angiography by the coronary angiography-derived index of microcirculation-resistance (caIMR). CZT-SPECT was performed to evaluate myocardial perfusion imaging (MPI) abnormalities. Chi-square test/Fisher exact test, Student t-test, Kaplan-Meier curve, and Uni-multivariable Cox proportional models were used for analysis. Clinical outcomes were major adverse cardiovascular events (MACE) during a median follow-up of 35 months.

RESULT

No-stenosis was present in 71 (47%) INOCA patients, and 80 (53%) were with nonobstructive. CMD (caIMR ≥ 25) was more prevalent in patients with no-stenosis than nonobstructive (76.1% vs. 48.8%, p = .001), along with abnormal MPI (39.4% vs. 22.5%, p = .024). The MACE rates were not different between no-stenosis and nonobstructive stenosis. CMD showed an increased risk of MACE for all INOCA. No-stenosis with CMD had the worst prognosis. Cox regression analysis identified CMD and abnormal MPI as predictors of MACE in all INOCA and patients with no-stenosis. However, no-stenosis and nonobstructive stenosis were not predictors of MACE in INOCA.

CONCLUSION

CMD was more frequently present in INOCA with no-stenosis. However, there was no difference in long-term clinical outcomes between no-stenosis and nonobstructive stenosis. CMD could independently predict poor outcomes in INOCA, particularly in patients with no-stenosis.

Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease

BACKGROUND

Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia.

OBJECTIVE

To assess the association between CorT and myocardial ischemia.

METHODS

Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level.

RESULTS

A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021).

CONCLUSION

This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

Oxygen pulse variation in symptomatic patients with suspected coronary artery disease: a diagnostic analysis

Background

Cardiopulmonary exercise testing (CPET) has been found high sensitivity and specificity in cardiac ischemia. However, the role of CPET in coronary artery disease (CAD) is unclear. This study was to explore the diagnostic value of CPET indicators in CAD.

Methods

A total of 138 symptomatic patients with suspected CAD who underwent a CPET were included in this cross-sectional study. CPET indicators of all individuals were collected. ΔVO₂/HR_(Peak-AT) defined as the difference between the value of the oxygen consumption/heart rate (VO₂/HR) at anaerobic threshold and peak exercise. The synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score of all the CAD patients was calculated based on the complexity of the coronary lesions. The diagnostic performance of the CPET indicators was assessed by the area under the curve (AUC), sensitivity, and specificity.

Results

No significant differences in the CPET indicators were observed among the patients with or without CAD. The high SNYTAX score (≥22) group showed a significant reduction in the ΔVO₂/HR_(Peak-AT) compared to the low SNYTX score (<22) group (P=0.004). The AUC of the ΔVO₂/HR_(Peak-AT) was 0.804 (P=0.005), with the sensitivity of 95.7% and the specificity of 62.5%. The other CPET indicators did not differ significantly between the 2 groups. Oxygen pulse variation after the anaerobic threshold (AT) is superior to other CPET-derived variables in detecting intermediate to severe stenosis of the coronary artery in CAD patients.

Conclusions

The ΔVO₂/HR_(Peak-AT) is a quantitative indicator of the variation of the oxygen pulse response after the AT during incremental exercise. However, due to sample limitations, our results need to be interpreted with caution.

A novel 6-metabolite signature for prediction of clinical outcomes in type 2 diabetic patients undergoing percutaneous coronary intervention

Background

Outcome prediction tools for patients with type 2 diabetes mellitus (T2DM) undergoing percutaneous coronary intervention (PCI) are lacking. Here, we developed a machine learning-based metabolite classifier for predicting 1-year major adverse cardiovascular events (MACEs) after PCI among patients with T2DM.

Methods

Serum metabolomic profiling was performed in a nested case–control study of 108 matched pairs of patients with T2DM occurring and not occurring MACEs at 1 year after PCI, then the matched pairs were 1:1 assigned into the discovery and internal validation sets. External validation was conducted using targeted metabolite analyses in an independent prospective cohort of 301 patients with T2DM receiving PCI. The function of candidate metabolites was explored in high glucose-cultured human aortic smooth muscle cells (HASMCs).

Results

Overall, serum metabolome profiles differed between diabetic patients with and without 1-year MACEs after PCI. Through VSURF, a machine learning approach for feature selection, we identified the 6 most important metabolic predictors, which mainly targeted the nicotinamide adenine dinucleotide (NAD⁺) metabolism. The 6-metabolite model based on random forest and XGBoost algorithms yielded an area under the curve (AUC) of ≥ 0.90 for predicting MACEs in both discovery and internal validation sets. External validation of the 6-metabolite classifier also showed good accuracy in predicting MACEs (AUC 0.94, 95% CI 0.91–0.97) and target lesion failure (AUC 0.89, 95% CI 0.83–0.95). In vitro, there were significant impacts of altering NAD⁺ biosynthesis on bioenergetic profiles, inflammation and proliferation of HASMCs.

Conclusion

The 6-metabolite model may help for noninvasive prediction of 1-year MACEs following PCI among patients with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01561-1.

Risk Factors Predisposing to Angina in Patients with Non-Obstructive Coronary Arteries: A Retrospective Analysis

No hemodynamically significant atherosclerotic plaques are observed in up to 30% of patients reporting angina and undergoing coronary angiography. To investigate risk factors associated with non-obstructive coronary artery disease (NOCAD), we analyzed the medical records of, consecutively, 136 NOCAD subjects and 128 patients with significant stenosis in at least one coronary artery (the OCAD group). The blood concentrations of the TC (4.40 [3.78−5.63] mmol/L vs. 4.12 [3.42−5.01] mmol/L; p = 0.026), LDL-C (2.32 [1.80−3.50] mmol/L vs. 2.10 [1.50−2.70] mmol/L; p = 0.003), non-HDL-C (2.89 [2.29−4.19] mmol/L vs. 2.66 [2.06−3.39] mmol/L; p = 0.045), as well as the LDL-C/HDL-C ratio (1.75 [1.22−2.60] vs. 1.50 [1.10−1.95]; p = 0.018) were significantly increased in the NOCAD patients compared to the OCAD group due to the lower prevalence and intensity of the statin therapy in the NOCAD individuals (p < 0.001). Moreover, the abovementioned lipid parameters appeared to be valuable predictors of NOCAD, with the LDL-C (OR = 1.44; 95%CI = 1.14−1.82) and LDL-C/HDL-C (OR = 1.51; 95%CI = 1.13−2.02) showing the highest odds ratios. Furthermore, multivariable logistic regression models determined female sex as the independent risk factor for NOCAD (OR = 2.37; 95%CI = 1.33−4.20). Simultaneously, arterial hypertension substantially lowered the probability of NOCAD (OR = 0.21; 95%CI = 0.10−0.43). To conclude, female sex, the absence of arterial hypertension, as well as increased TC, LDL-C, non-HDL, and LDL-C/HDL-C ratio are risk factors for NOCAD in patients reporting angina, potentially as a result of poor hypercholesterolemia management.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

The additive effect of essential hypertension on coronary artery plaques in type 2 diabetes mellitus patients: a coronary computed tomography angiography study

Background

The effect of comorbid hypertension and type 2 diabetes mellitus (T2DM) on coronary artery plaques examined by coronary computed tomography angiography (CCTA) is not fully understood. We aimed to comprehensively assess whether comorbid hypertension and T2DM influence coronary artery plaques using CCTA.

Materials and methods

A total of 1100 T2DM patients, namely, 277 normotensive [T2DM(HTN−)] and 823 hypertensive [T2DM(HTN +)] individuals, and 1048 normotensive patients without T2DM (control group) who had coronary plaques detected on CCTA were retrospectively enrolled. Plaque type, coronary stenosis, diseased vessels, the segment involvement score (SIS) and the segment stenosis score (SSS) based on CCTA data were evaluated and compared among the groups.

Results

Compared with patients in the control group, the patients in the T2DM(HTN−) and T2DM(HTN +) groups had more partially calcified plaques, noncalcified plaques, segments with obstructive stenosis, and diseased vessels, and a higher SIS and SSS (all P values < 0.001). Compared with the control group, T2DM(HTN +) patients had increased odds of having any calcified and any noncalcified plaque [odds ratio (OR) = 1.669 and 1.278, respectively; both P values < 0.001]; both the T2DM(HTN-) and T2DM(HTN +) groups had increased odds of having any partially calcified plaque (OR = 1.514 and 2.323; P = 0.005 and P < 0.001, respectively), obstructive coronary artery disease (CAD) (OR = 1.629 and 1.992; P = 0.001 and P < 0.001, respectively), multivessel disease (OR = 1.892 and 3.372; both P-values < 0.001), an SIS > 3 (OR = 2.233 and 3.769; both P values < 0.001) and an SSS > 5 (OR = 2.057 and 3.580; both P values < 0.001). Compared to T2DM(HTN−) patients, T2DM(HTN +) patients had an increased risk of any partially calcified plaque (OR = 1.561; P = 0.005), multivessel disease (OR = 1.867; P < 0.001), an SIS > 3 (OR = 1.647; P = 0.001) and an SSS > 5 (OR = 1.625; P = 0.001).

Conclusion

T2DM is related to the presence of partially calcified plaques, obstructive CAD, and more extensive coronary artery plaques. Comorbid hypertension and diabetes further increase the risk of partially calcified plaques, and more extensive coronary artery plaques.

Sex differences in coronary angiographic findings in patients with stable chest pain: analysis of data from the KoRean wOmen'S chest pain rEgistry (KoROSE)

Background

Focused evaluations on potential sex differences in the angiographic findings of the coronary arteries are scarce. This study was performed to compare the angiographic extent and localization of coronary stenosis between men and women.

Methods

A total of 2348 patients (mean age 62.5 years and 60% women) with stable chest pain undergoing invasive coronary angiography (CAG) were recruited from the database of the nation-wide chest pain registry. Obstructive coronary artery disease (CAD) was defined as ≥ 50% stenosis of the left main coronary artery and/or ≥ 70% stenosis of any other epicardial coronary arteries.

Results

Although women were older than men (64.4 ± 10.3 vs. 59.5 ± 11.4 years, P < 0.001), men had worse risk profiles including high blood pressure, more frequent smoking and elevated triglyceride and C-reactive protein. The prevalence of obstructive CAD was significantly higher in men than in women (37.0% vs. 28.4%, P < 0.001). Men had a higher prevalence of LM disease (10.3% vs. 3.5%, P < 0.001) and three-vessel disease (16.1% vs. 9.5%, P = 0.007) compared to women. In multiple binary logistic regression analysis, the risk of men having LM disease or three-vessel disease was 7.4 (95% confidence interval 3.48–15.97; P < 0.001) and 2.7 (95% confidence interval 1.57–4.64; P < 0.001) times that of women, respectively, even after controlling for potential confounders.

Conclusions

In patients with chest pain undergoing invasive CAG, men had higher obstructive CAD prevalence and more high-risk angiographic findings such as LM disease or three-vessel disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-021-00411-1.

Focused evaluation on sex differences in the angiographic findings of the coronary arteries is limited.

We evaluated sex differences in the angiographic extent and localization of coronary stenosis in 2348 patients.

Men had higher prevalence of obstructive coronary artery disease and more high-risk angiographic findings such as left main disease or three-vessel disease.

This sex difference could be applied in the clinical evaluation and management of patients with suspected coronary artery disease.

Sex-Specific Plaque Signature: Uniqueness of Atherosclerosis in Women

PURPOSE OF REVIEW

Cardiovascular disease is a leading cause of morbidity and mortality in both men and women, although there are notable differences in presentation between men and women. Atherosclerosis remains the predominant driver of coronary heart disease in both sexes; however, sex differences in atherosclerosis should be investigated further to understand clinical manifestations between men and women.

RECENT FINDINGS

There are sex differences in the prevalence, progression, and prognostic impact of atherosclerosis. Furthermore, developing evidence demonstrates unique differences in atherosclerotic plaque characteristics between men and women on both noninvasive and invasive imaging modalities. Coronary microvascular dysfunction may be present even if no obstructive lesions are found. Most importantly, non-obstructive coronary artery disease is associated with a heightened risk of future adverse cardiovascular events and should not be ignored. The distinct plaque signature in women should be recognized, and optimal preventive strategies should be performed for both sexes.

Serum Complement C1q Activity Is Associated With Obstructive Coronary Artery Disease

Background: Complement C1q plays a dual role in the atherosclerosis. Previous studies showed inconsistent results about the association of serum C1q levels and coronary artery disease (CAD). Here, we explored the associations of serum C1q activity with CAD, coronary stenosis severity, cardiovascular biomarkers, and 1-year restenosis after coronary artery revascularization.

Methods: We enrolled 956 CAD patients and 677 controls to evaluate the associations of serum complement C1q activity to the presence and severity of obstructive CAD and non-obstructive CAD. Serum C1q activity and the concentrations of laboratory markers were measured in all subjects. All the data were analyzed using SPSS22.0 software.

Results: Serum C1q activity in Obstructive CAD and Non-Obstructive CAD groups was significantly higher than the control group (195.52 ± 48.31 kU/L and 195.42 ± 51.25 kU/L vs. 183.44 ± 31.75 kU/L, P < 0.05). Greater C1q activity was significantly correlated with higher total cholesterol (TC) and triglyceride (TG) levels. C1q activity was associated with an increased Odds Ratio (OR) of CAD (OR = 1.322, 95% CI 1.168–1.496, P < 0.05) and 1-year restenosis after revascularization (the highest OR = 3.544, 95% CI 1.089–12.702, P < 0.05). Complement C1q activity was not correlated with Gensini score in the Obstructive CAD group after adjustment for confounders. C1q activity has low value in predicting the incidence of CAD.

Conclusion: Serum complement C1q activity is associated with obstructive CAD.

Prognostic Implication of Non-Obstructive Coronary Lesions: A New Classification in Different Settings

The clinical significance of non-obstructive coronary artery disease is the subject of debate. Our objective was to evaluate the long-term cardiovascular prognosis associated with non-obstructive coronary artery disease in patients undergoing coronary angiography, and to conduct a stratification by sex, diabetes, and clinical indication. We designed a multi-centre retrospective longitudinal observational study of 3265 patients that were classified into three groups: normal coronary arteries (lesion <20%, 1426 patients), non-obstructive coronary artery disease (20–50%, 643 patients), and obstructive coronary artery disease (>70%, 1196 patients). During a mean follow-up of 43 months, we evaluated a combined cardiovascular event: acute myocardial infarction, stroke, hospitalization for heart failure, or cardiovascular death. Multivariable-adjusted Cox proportional hazard models showed a worse prognosis in patients with non-obstructive coronary artery disease, in comparison with patients of normal coronary arteries group, in the total population (hazard ratio 1.72, 95% confidence interval 1.23–2.39; p for trend <0.001), in non-diabetics (hazard ratio 2.12, 95% confidence interval: 1.40–3.22), in women (hazard ratio 1.75, 95% confidence interval 1.10–2.77), and after acute coronary syndrome (hazard ratio 2.07, 95% confidence interval 1.25–3.44). In conclusion, non-obstructive coronary artery disease is associated with an impaired long-term cardiovascular prognosis. This association held for non-diabetics, women, and after acute coronary syndrome.

Invasive assessment of myocardial bridging in patients with angina and no obstructive coronary artery disease

AIMS

Angina and no obstructive coronary artery disease (ANOCA) is common. A potential cause of angina in this patient population is a myocardial bridge (MB). We aimed to study the anatomical and haemodynamic characteristics of an MB in patients with ANOCA.

METHODS AND RESULTS

Using intravascular ultrasound (IVUS), we identified 184 MBs in 154 patients. We evaluated MB length, arterial compression, and halo thickness. MB muscle index (MMI) was defined as MB length×halo thickness. Haemodynamic testing of the MB was performed using an intracoronary pressure/Doppler flow wire at rest and during dobutamine stress. We defined an abnormal diastolic fractional flow reserve (dFFR) as ≤0.76 during stress. The median MB length was 22.9 mm, arterial compression 30.9%, and halo thickness 0.5 mm. The median MMI was 12.1. Endothelial and microvascular dysfunction were present in 85.4% and 22.1%, respectively. At peak dobutamine stress, 94.2% of patients had a dFFR ≤0.76 within and/or distal to the MB. MMI was associated with an abnormal dFFR.

CONCLUSIONS

In select patients with ANOCA who have an MB by IVUS, the majority have evidence of a haemodynamically significant dFFR during dobutamine stress, suggesting the MB as being a cause of their angina. A comprehensive invasive assessment of such patients during coronary angiography provides important diagnostic information that can guide management.

High-frequency QRS analysis to supplement ST evaluation in exercise stress electrocardiography: Incremental diagnostic accuracy and net reclassification

BACKGROUND

Exercise stress electrocardiography (ECG) alone is underutilized in part due to poor diagnostic accuracy. High-frequency QRS analysis (HF-QRS) is a novel tool to supplement ST evaluation during stress ECG. We compared the diagnostic accuracy and net reclassification of HF-QRS analysis compared with ST evaluation for substantial myocardial ischemia by exercise SPECT myocardial perfusion imaging (MPI).

METHODS AND RESULTS

Exercise SPECT MPI was performed in 257 consecutive eligible patients (mean age 59 ± 12, 67% male). An ischemic HF-QRS pattern was defined as a ≥ 1 µV absolute reduction and a ≥ 50% relative reduction of the root-mean-square of the 150-250 Hz band signal in ≥ 3 leads. Left ventricular ischemia of ≥ 10% on SPECT MPI was the diagnostic standard for substantial myocardial ischemia. HF-QRS analysis demonstrated incremental diagnostic value to ST evaluation plus clinical risk factors (AUC 0.804 vs 0.749, P < .0001). A HF-QRS + ST -analysis strategy identified 92.3% of subjects with substantial ischemia and no abnormality in 59.9% of the cohort. No cardiac events occurred in patients without substantial ischemia identified by HF-QRS analysis.

CONCLUSIONS

In this prospective analysis, exercise stress ECG with HF-QRS analysis identified any and substantial ischemia with high diagnostic accuracy and may allow more than half of referred patients to safely avoid imaging.

Extracellular Vesicles in Diagnosing Chronic Coronary Syndromes the Bumpy Road to Clinical Implementation

Coronary artery disease (CAD), comprising both acute coronary syndromes (ACS) and chronic coronary syndromes (CCS), remains one of the most important killers throughout the entire world. ACS is often quickly diagnosed by either deviation on an electrocardiogram or elevated levels of troponin, but CCS appears to be more complicated. The most used noninvasive strategies to diagnose CCS are coronary computed tomography and perfusion imaging. Although both show reasonable accuracy (80-90%), these modalities are becoming more and more subject of debate due to costs, radiation and increasing inappropriate use in low-risk patients. A reliable, blood-based biomarker is not available for CCS but would be of great clinical importance. Extracellular vesicles (EVs) are lipid-bilayer membrane vesicles containing bioactive contents e.g., proteins, lipids and nucleic acids. EVs are often referred to as the "liquid biopsy" since their contents reflect changes in the condition of the cell they originate from. Although EVs are studied extensively for their role as biomarkers in the cardiovascular field during the last decade, they are still not incorporated into clinical practice in this field. This review provides an overview on EV biomarkers in CCS and discusses the clinical and technological aspects important for successful clinical application of EVs.

Temporal Trends Analysis of the Characteristics, Management, and Outcomes of Women With Acute Coronary Syndrome (ACS): ACS Israeli Survey Registry 2000-2016

Background Cardiovascular disease remains a leading cause of death among women. Despite improvements in the management of patients with acute coronary syndrome (ACS), women with an ACS remain at higher risk. Methods and Results We performed a time-dependent analysis of the management and outcomes of women admitted with ACS who enrolled in the prospective biennial ACS Israeli Surveys between 2000 and 2016. Surveys were divided into 3 time periods (2000-2004, 2006-2010, and 2013-2016). Outcomes included 30-day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Overall, 3518 women were admitted with an ACS. Their mean age (70±12 years) was similar among the time periods. Over the time course of the study, more women were admitted with non-ST-elevation ACS (51.9%, 59.6%, and 66.1%, respectively; P<0.001), and statins and percutaneous coronary intervention were increasingly utilized (66%, 91%, 93%, and 42%, 60%, and 68%, respectively; P<0.001 for each). Among women with ST-segment-elevation myocardial infarction, more primary percutaneous coronary interventions were performed (48.5%, 84.7%, and 95.3%, respectively; P<0.001). The rate of 30-day major adverse cardiac events has significantly decreased over the years (24.6%, 18.6%, and 13.5%, respectively; P<0.001). However, 1-year mortality rates declined only from 2000 to 2004 (16.9%, 12.8%, and 12.3%; P=0.007 for the overall difference), and this change was not significant after propensity matching or multivariate analysis. Conclusions Over more than a decade, 30-day major adverse cardiac events have decreased among women with ACS. Advances in pharmacological treatments and an early invasive approach may have accounted for this improvement. However, the lack of further reduction in 1-year mortality rates among women suggests that more measures should be provided in this high-risk population.

Functional and Anatomical Imaging in Patients with Ischemic Symptoms and Known Coronary Artery Disease

PURPOSE OF REVIEW

This review is aimed at summarizing recent advances in functional, anatomical, and hybrid imaging techniques used in the assessment of ischemic complaints in patients with known coronary artery disease (CAD).

RECENT FINDINGS

Cardiovascular imaging has seen significant growth over the last decade in the fields of coronary computed tomography angiography (CCTA), FFR derived from CCTA, cardiac magnetic resonance, radionuclide myocardial perfusion imaging, and hybrid imaging for the purposes of evaluating symptoms concerning for ischemia. This growth stems from refinement of imaging techniques and hardware and software advances that have made current techniques more accurate with less acquisition time. However, every anatomic and functional imaging modality has important technical and patient-specific limitations. This review assesses these issues, guides a patient-centered imaging approach, and identifies important research questions to resolve. Recent advances in non-invasive cardiovascular imaging can provide important information in patients with known CAD beyond traditional imaging techniques; the use of these novel tools refines the clinical management of complex patients with ischemic symptoms and known CAD.