Stable Coronary Artery Disease: Who Finally Benefits from Coronary Revascularization in the Modern Era? The ISCHEMIA and Interim ISCHEMIA-EXTEND Analysis

Coronary revascularization is one of the most studied treatment modalities in cardiology; however, there is no consensus among experts about its indications in patients with stable coronary artery disease (SCAD). Contemporary data regarding the role of revascularization in SCAD are in clear conflict with the current European guidelines. This article discusses the main statements of the most significant American and European Guidelines on myocardial revascularization of the last decade and also analyzes the appropriateness of revascularization to improve the prognosis and symptoms in SCAD in the light of new research data, primarily the ISCHEMIA study (NCT01471522) and the ACC/AHA 2021 Revascularization Guidelines based on them. Data on the revascularization in SCAD obtained after the completion of ISCHEMIA (including the interim analysis of ISCHEMIA-EXTEND) and their potential significance are discussed. The results of ISCHEMIA sub-analyses in the most important "controversial" subgroups (3-vessel disease, proximal left anterior descending artery disease, strongly positive stress test, etc.) are reviewed, as are the results of the ISCHEMIA-CKD substudy in patients with severe chronic kidney disease (CKD).

Use of cardiac imaging in chronic coronary syndromes: the EURECA Imaging registry

BACKGROUND

The prospective, multicentre EURECA registry assessed the use of imaging and adoption of the European Society of Cardiology (ESC) Guidelines (GL) in patients with chronic coronary syndromes (CCS).

METHODS

Between May 2019 and March 2020, 5156 patients were recruited in 73 centres from 24 ESC member countries. The adoption of GL recommendations was evaluated according to clinical presentation and pre-test probability (PTP) of obstructive coronary artery disease (CAD).

RESULTS

The mean age of the population was 64 ± 11 years, 60% of patients were males, 42% had PTP >15%, 27% had previous CAD, and ejection fraction was <50% in 5%. Exercise ECG was performed in 32% of patients, stress imaging as the first choice in 40%, and computed tomography coronary angiography (CTCA) in 22%. Invasive coronary angiography (ICA) was the first or downstream test in 17% and 11%, respectively. Obstructive CAD was documented in 24% of patients, inducible ischaemia in 19%, and 13% of patients underwent revascularization. In 44% of patients, the overall diagnostic process did not adopt the GL. In these patients, referral to stress imaging (21% vs. 58%; P < 0.001) or CTCA (17% vs. 30%; P < 0.001) was less frequent, while exercise ECG (43% vs. 22%; P < 0.001) and ICA (48% vs. 15%; P < 0.001) were more frequently performed. The adoption of GL was associated with fewer ICA, higher proportion of diagnosis of obstructive CAD (60% vs. 39%, P < 0.001) and revascularization (54% vs. 37%, P < 0.001), higher quality of life, fewer additional testing, and longer times to late revascularization.

CONCLUSIONS

In patients with CCS, current clinical practice does not adopt GL recommendations on the use of diagnostic tests in a significant proportion of patients. When the diagnostic approach adopts GL recommendations, invasive procedures are less frequently used and the diagnostic yield and therapeutic utility are superior.

Right ventricular diastolic dysfunction in patients with coronary artery disease: frequency and associated factors

Funding Acknowledgements

Type of funding sources: None.

Background. The prognostic value of right ventricle (RV) systolic dysfunction is known. Nearly all data on the importance of right ventricle function is notably focused on its systolic dysfunction, while right ventricle filling is far less studied, perhaps because of challenges in diastolic dysfunction assessment [1]. Independent prognostic value of RV diastolic dysfunction (RVDD) has been identified in certain clinical situations [2], but these studies are few in number. Therefore it is important to continue investigating the right ventricle diastolic function and clarify its possible clinical and prognostic significance in various groups of patients [3]. Thus, the purpose of this study was to assess the incidence of RVDD in patients with coronary artery disease (CAD) and to identify factors associated with its presence.

Material and Methods

200 patients with stable CAD (153 men) were enrolled in the study. Echocardiography was performed on a Vivid S5 ultrasound scanner (GE). We studied clinical data, left ventricular indices, RV systolic and diastolic parameters (Et, At, et", a"t, s"t, TAPSE, and RV Tei index). Depending on the presence or absence of RVDD, all patients were divided into 2 groups: Group 1 - patients with RVDD (n = 92; 64 [61; 69] years; 73 (79.4%) men) and Group 2 - patients without RVDD (n = 108; 63 [60; 67] years; 80 (74.0%) men).

Results. The RV diastolic dysfunction is much more common than its systolic dysfunction in patients with stable CAD (46% and 7.5%, respectively, Fig. 1). Old myocardial infarction (MI) (p = 0.007), anterior MI (p = 0.001), congestive heart failure (p = 0.030) and peripheral arterial disease (p = 0.030) were more prevalent in patients with RVDD. The end-systolic dimension were higher (p = 0.010), while left ventricular (LV) ejection fraction (EF) (p = 0.044) and the mitral E/A ratio (p &lt; 0.001) were lower in this group. No significant differences were found between groups in the coronary artery stenosis. Independent predictors of the RVDD presence were increased age, old MI, hyperlipidemia, moderate chronic heart failure, peripheral arterial disease, and decreased LVEF. ROC-curves of studied left ventricular variables (LVEF, ratio E/A and E/e’) association with RVDD is presented in Fig. 2. The areas under the curves were less than 0.7 for all variables, which indicated an unacceptable ability to distinguish.

Conclusions. The RV diastolic dysfunction is much more common than its systolic dysfunction in patients with stable CAD. The RVDD presence was predominantly associated with an increase in age and LV systolic dysfunction, but not with coronary artery lesions. The predictive value of RVDD requires further research. Abstract Figure.  Abstract Figure.

Right ventricular diastolic dysfunction in breast cancer patients undergoing chemotherapy

Funding Acknowledgements

Type of funding sources: None.

Right ventricular (RV) diastolic dysfunction has been recognized as an independent predictor of adverse events and mortality in a wide range of diseases (1,2). Experimental and clinical data indicate that pathophysiological factors induce the development of RV diastolic dysfunction first, and only later - systolic dysfunction (3). The aim of the study was to assess the right ventricle diastolic function in patients with breast cancer undergoing chemotherapy.

Material and methods

The study included 40 women receiving anthracycline-based chemotherapy for cancer, and 25 age-matched and comorbidity-matched women without cancer as a control group. RV systolic (s"t, Tei-index, and TAPSE) and diastolic (Et, At, Et/At, e"t, a"t, e"t/a"t) function parameters at baseline and after treatment were compared and evaluated.

Results

In cancer patients during anthracycline-based chemotherapy, no signs of cardiotoxicity were detected according to the indicators of the left ventricular ejection fraction and global longitudinal strain. Progressive decline in RV diastolic function was noted in patients receiving anticancer therapy. Et was 53.0 (46.0; 62.0) sm/sec in control, 50.0 (41.0; 53.0) sm/sec in cancer group before treatment, and  45.0 (41.0; 51.0) sm/sec after one-year treatment (p = 0.017 for trend). Et/At was 1.4 (1.28; 1.6), 1.34 (1.23; 1.58), and 1.12 (0.81; 1.35), respectively (p = 0.002 for trend). RV systolic function was without changes during treatment. TAPSE was 2.5 (2.2; 2.8) sm in control, 2.3 (2.2; 2.5) sm in cancer group before treatment, and  2.3 (2.0; 2.4) sm after one-year treatment (p = 0.091 for trend). 

Conclusion

Patients undergoing chemotherapy experience a decline in right ventricular filling rates despite not showing clear signs of anthracycline-associated cardiotoxicity. More research is needed to indicate the clinical and prognostic significance of such changes.

Right ventricular diastolic dysfunction and postoperative cardiac complications in patients undergoing coronary artery bypass grafting

Background

Perioperative right ventricular (RV) dysfunction is associated with increased postoperative morbidity and mortality in patients undergoing heart surgery and large vessels. Almost all data on the importance of right ventricle function is specifically focused on its systolic dysfunction, which usually develops with severe left heart dysfunction. At the same time, the perioperative assessment of right ventricle filling during cardiac surgery has been far less studied.

Purpose

To evaluate whether the presence of preexisting RV diastolic dysfunction in patients undergoing coronary artery bypass grafting (CABG) is associated independently with higher incidents of postoperative cardiac complications. Design: one-center observational study.

Methods

The patient population consisted of those who underwent CABG in the cardiovascular surgery department from February 2017 to November 2018 (n=200, 153 males). Transthoracic echocardiography was performed on a Philips Clear Vue 550. Following RV systolic and diastolic parameters were studied: peak velocity of early (Et) and late (At) transtricuspid RV filling and their ratio. Tissue Doppler imaging was used to measure peak diastolic and systolic velocities at the tricuspid annulus (et', a't, s't), TAPSE, and RV Tei index. All patients were divided into 2 groups: with RV diastolic dysfunction (RVDD, n=92), and without RV diastolic dysfunction (control, n=108).

Results

Compared with those without RVDD, in patients with RVDD postoperative heart failure (HF, primary outcome) developed more frequently (p=0.026). The risk of developing postoperative HF was 3.39 in patients with RVDD compared with patients without RVDD (95% CI, 1.15–9.97; p=0.025). Left ventricular ejection fraction (LVEF) increase predicted a lower risk of postoperative HF with an OR = 0.95 (95% CI, 0.9–1.0; p=0.051). Female sex, cardiopulmonary bypass, increase of left ventricular mass index, and Et / At ratio also increased the risk of postoperative HF developing. But only RVDD, cardiopulmonary bypass and female sex were associated independently with development postoperative HF in the multivariate analyses.

Conclusion

Decreased preoperative RV diastolic function, cardiopulmonary bypass and female sex are independent risk factors for development postoperative HF after CABG in coronary artery disease patients. In contrast, LVEF and RV systolic dysfunction were not associated independently with this outcome. Therefore, assessment of preoperative RV diastolic function will be useful for predicting development postoperative HF following CABG. In addition, the Et / At ratio was the best echocardiographic marker associated with the postoperative HF development after CABG surgery.

Funding Acknowledgement

Type of funding sources: None.

Echocardiography indices in urbanized representatives of the Shor ethnic group with the presence of arterial hypertension

 

In patients with arterial hypertension, the detection of left ventricular hypertrophy has important clinical and prognostic significance. The use of published regulatory “control limits” remains limited and cannot be extended to other racial and ethnic groups. The aim of this study was to compare echocardiography indicators in patients with arterial hypertension from two ethnic groups living in the Gornaya Shoria region.

Methods

The study included patients with arterial hypertension: 58 indigenous and 50 non-indigenous urbanized residents, comparable in age, and divided by ethnicity and gender into 4 groups: men of indigenous nationality (n=20), women of indigenous nationality (n=38), men of non-indigenous nationality (n=15) and women of non-indigenous nationality (n=35). All of them underwent echocardiographic examination.

Results

The body weight and BSA were lower in men and women of Shor ethnicity than in men and women of non-indigenous ethnicity (p=0.0014 and p=0.004). LAi was significantly larger in men of Shor nationality (p=0.049), at the same time, the size of their RA was the smallest (p=0.04). The data of the longitudinal LV systolic function in the form of a systolic excursion of the septum (s'sept) were the highest in Shor men (p=0.004), and the LV performance index was the lowest in them (p=0.012). Also in this group, the minimum isovolumic relaxation time (p=0.03) and the highest rate of early diastolic filling of the LV (p=0.04) were noted. When assessing correlations independent factors associated with pronounced LVH were glucose, DBP, and urea in Shor patients. Non-indigenous nationality independent factors associated with pronounced LVH were waist circumference and DBP.

Conclusion

Echocardiographic examination of patients with hypertension revealed the features of structural and functional indicators in the representatives of the indigenous urbanized population of the Mountain Shoria in comparison with the representatives of the non-indigenous population. This study can be useful in assessing the impact of the development of arterial hypertension, as well as the impact of changing the lifestyle of the Shors when moving to the city from rural areas on ethnic differences in echocardiography.

Funding Acknowledgement

Type of funding sources: None.

Coping strategies for stress in medical students with type D personality

Funding Acknowledgements

Type of funding sources: None.

Aim. To study the choice of coping strategies and coping adequacy in medical students with type D personality.

Material and methods. The study included 98 participants - 68 women and 30 men, studying at the General Medicine Faculty (Kemerovo State Medical University), aged 18 to 23 years (mean age 19.1 ± 2.0 years). All participants completed psychological questionnaires to identify predisposition to psychological distress and choice of coping strategies.

Results. All subjects (n = 98) were divided into two groups: subjects with type D personality (n = 44) and subjects without type D personality (n = 54). Type D personality in men was detected in 20.4%, in women in 79.6% (p = 0.03). In students with type D, the average scores on the negative affectivity (NA) and social inhibition (SI) scales were higher (16.0 and 13.5 points) than in students without type D (6.5 and 9.0 points), (p &lt; 0.001 in both cases). Subjects with type D had higher scores on the "Escape-avoidance" (p &lt; 0.001), "Accepting responsibility" (p = 0.009) and "Distancing" (p = 0.05) scales of the Ways of Coping Questionnaire (WSQ) and "Avoidance" (p = 0.007) scale of the Central Sensitisation Inventory (CSI) questionnaire. The indicator of coping strategies showed a very low level of use of avoidance strategies: with type D - 9.09%, without type D - 31.48% (p = 0.007). Students with type D had a pronounced preference for the "Escape-avoidance" strategy of 75.0% (p = 0.000018). According to univariate logistic regression analysis, an increase of 1 point in the values on the "Escape-avoidance" scale increased the chance of identifying type D by 1.15 times (95% CI 1.07-1.23; p &lt; 0.001). On the contrary, an increase in the score on the "Positive Reappraisal" scale reduced the probability of identifying type D personality (OR 0.98; 95% CI 0.86-0.98; p = 0.005). Receiver operating characteristic (ROC) analysis showed that the identified association between the "Escape-avoidance" strategy and type D personality has high values (AUC = 0.779; 95% CI 0.688-0.870).

Conclusion. Predominance of inadequate of coping strategies, such as "Escape-avoidance" and "Avoidance", was found in healthy medical students with type D personality. According to logistic regression analysis, the independent strategy associated with type D personality is the "Escape-avoidance" and without type D - "Positive Reappraisal".

Psychological status of patients after coronary artery bypass grafting: Data from a 5-year-follow-up study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Federal State Budgetary Scientific Institution “Research Institute for Complex Issues of Cardiovascular Diseases”

Negative psychological status is acknowledged as one of risk of development of cardiovascular pathology.  However, predictive value of type D personality (psychosocial distress) in different cultures and the countries are not fully understood. Purpose: Study aim was to investigate the association of type D personality and quality of life (QoL) with the development of cardiovascular complication in patients in five years after coronary artery bypass grafting (CABG). Materials and Methods: Evaluation of psychological status and combined risk of nonfatal (strokes, nonfatal myocardial infarctions, repeat procedures of revascularization and hospitalization due to relapse or progression of angina pectoris) and fatal (general and cardiovascular mortality) cases before and in five years after CABG. Patients with chronic ischemic heart disease (n = 602, 112 (18.5%) females and 490 (81.5%) males, mean age = 57.7 ± 7.3 years.) who had had CABG were included in the study. Who were formed in two groups: patients with the presence of type D (n= 134) and patients without type D (n = 468). The study of the psychological status was carried out using questionnaire DS-14.  Analysis of long-term results were assessed using the Kaplan–Meier method. Data was collected by a SF-36 questionnaire, comprising of 36 questions divided in 8 domains. The score was designated as 0 to 100; with the higher score being indicative of a better QoL.  Results: Frequency of fatal cases in both groups amounted 8.3% and 8.1% (p = 0.145), in turn nonfatal end-points in group with type D amounted 31.8%, and 15.9% in group without type D (p = 0.044) in during the 5 years. Presence of type D personality at initial examination increased 3.21 times combined risk of nonfatal and fatal cases (OR 3.21, 95%  CI 2.02-6.14, p = 0.002). In long term period there were no differences in survival between groups type D and without type D (95.5% vs. 96.8%), There were  differences in groups type D and without type D in nonfatal events (strokes, nonfatal myocardial infarctions, secondary endpoint: repeat procedures of revascularization and hospitalization due to relapse or progression of angina pectoris) (respectively, 97.1% vs 88.0%, (p = 0.341). Findings showed that 75% of subjects  reported well QoL, while the mean score regarding QoL in patients with type D personality, were higher than in patients without type D in all health related dimensions. Based on t-test difference, the of QoL in  in patients with type D and  in patients without type D for physical health (p &lt; 0.015), mental limitation (p &lt; 0.043), somatic pain (p &lt; 0.022) and mental health (p &lt; 0.041) was observed. Conclusion: Type D patients had a greater risk for nonfatal cardiac events and lower  QoL indicators, compared with non Type D patients.  Accumulated proofs indicate that in detection of patients at risk of development of stress induced cardiac complications after CABG  it is reasonable to use approach which involves consideration of personality type.

Preoperative status and in-hospital complications of coronary artery surgery in patients with pre-diabetes and type 2 diabetes mellitus

Aim

To assess the preoperative status and the rate of in-hospital complications of coronary artery surgery (CABG) in patients with pre-diabetes compared to patients with type 2 diabetes mellitus (type 2 DM) and normoglycemia.

Materials and methods

708 consecutive patients who underwent CABG between 2011 to 2012 were included in the study. All patients without positive history of diabetes underwent an oral glucose tolerance test (OGTT). The lab findings were interpreted in accordance with the recommended diagnostic criteria for diabetes and other glycemic disorders.

Results

DM screening before coronary artery bypass grafting allowed to diagnose type 2 diabetes in 8.9% (n=63) and prediabetes in 10.4% (n=74) of the study population. The preoperative screening increased the number of patients with DM from 15.2% (n=108) to 24.1% (n=171), and with prediabetes from 3.0% (n=21) to 13.4% (n=95). The total number of patients with carbohydrate metabolism disorders increased from 18.2% (n=129) to 37.5% (n=266). All patients were enrolled into 3 groups based on their glycemic status: Group 1 - without carbohydrate metabolism disorders (n=442), Group 2 - pre-diabetes (n=95), Group 3 - type 2 DM (n=171). The analysis of in-hospital complications reported that patients with pre-diabetes more often underwent urgent peripheral artery bypass compared to the other two groups (p1–2=0.002 vs. p1–3=0.023). The highest rate of wound complications was found in patients with pre-diabetes (p1–2=0.012). In addition, a clear trend towards the rate of other in-hospital complications of CABG in the groups with pre-diabetes and diabetes was found. The regression analysis shows that type 2 DM was associated with the total number of significant complications (odds ratio (OR) 1.731, 95% confidence interval (CI) 1.131–2.626, p=0.012), prolonged in-hospital stay (OR 2.2229, 95% CI 1.412- 3.519, p&lt;0.001), the risk of urgent peripheral artery bypass (OR 1.638, 95% CI 1.009–15.213, p=0.020), multiple organ dysfunction syndrome (OR 2.911, 95% CI 1.072–7.901, p=0.039) and the need for hemostasis correction using the extracorporeal methods (OR 3.472, 95% CI 1.042–11.556, p=0.044). All the associations described above remained significant when pre-diabetes was introduced into the regression model and any carbohydrate metabolism disorder was considered as a potential predictor of in-hospital complications. Additionally, an association between pre-diabetes and diabetes and the risk of acute renal damage (OR 1.700, 95% CI 1.067–2.612, p=0.024) and wound complications (OR 1.547, 95% CI 1.073–2.231, p=0.019) was observed.

Conclusion

Pre-diabetes affects the in-hospital outcomes after CABG as well as diabetes mellitus. Our findings emphasizes the relevance of active preoperative detection of carbohydrate metabolism disorders.

Funding Acknowledgement

Type of funding source: None