Joint Association of Lipoprotein(a) and a Family History of Coronary Artery Disease with the Cardiovascular Outcomes in Patients with Chronic Coronary Syndrome

AIM

No data are currently available regarding the association between Lp(a) and the cardiovascular outcomes in patients with coronary artery disease (CAD) according to their family history (FHx) of CAD. This study aimed to evaluate the significance of Lp(a) in predicting major adverse cardiovascular events (MACEs) in patients with chronic coronary syndrome (CCS) with or without FHx.

METHODS

A total of 6056 patients with CCS were enrolled. Information on FHx was collected, and the plasma Lp(a) levels were measured. All patients were followed up regularly. The independent and joint associations of Lp(a) and FHx with the risk of MACEs, including cardiovascular death, nonfatal myocardial infarction, and stroke, were analyzed.

RESULTS

With over an average of 50.35±18.58 months follow-up, 378 MACEs were recorded. A Cox regression analysis showed an elevated Lp(a) level to be an independent predictor for MACEs in patients with [hazard ratio (HR): 2.77, 95% confidence interval (CI): 1.38-5.54] or without FHx (HR: 1.35, 95% CI: 1.02-1.77). In comparison to subjects with non-elevated Lp(a) and negative FHx, patients with elevated Lp(a) alone were at a nominally higher risk of MACEs (HR: 1.26, 95% CI: 0.96-1.67), while those with both had the highest risk (HR: 1.93, 95% CI: 1.14-3.28). Moreover, adding Lp(a) to the original model increased the C-statistic by 0.048 in subjects with FHx (p=0.004) and by 0.004 in those without FHx (p=0.391).

CONCLUSIONS

The present study is the first to suggest that Lp(a) could be used to predict MACEs in CCS patients with or without FHx; however, its prognostic significance was more noteworthy in patients with FHx.

Combined Assessment of Fractional Flow Reserve and Coronary Flow Velocity Reserve after Drug-Eluting Stent Implantation

BACKGROUND

Coronary flow velocity reserve (CFVR) can be measured noninvasively using stress transthoracic Doppler echocardiography (S-TDE). The prognostic significance of S-TDE-derived CFVR after percutaneous coronary intervention (PCI) remains unknown. The aim of this study was to investigate the prognostic value of post-PCI CFVR and its additional efficacy to fractional flow reserve (FFR) in patients undergoing elective PCI.

METHODS

A retrospective study was conducted involving 187 consecutive patients with chronic coronary syndrome who underwent elective PCI guided by FFR for the left anterior descending coronary artery. Pre- and post-PCI wire-based FFR and CFVR assessments of the left anterior descending coronary artery using S-TDE were performed in all patients. The association between post-PCI clinical and physiologic parameters and major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, heart failure, and unplanned remote target vessel revascularization, was evaluated.

RESULTS

Three-quarters of patients exhibited CFVR increase after PCI, while all patients showed FFR improvement. During a median follow-up period of 1.5 years, MACE occurred in 21 patients (11.2%). Among clinical demographics, patients with MACE had higher levels of N-terminal pro-brain natriuretic peptide compared with those without MACE (median, 615 pg/mL [interquartile range, 245-1,500 pg/mL] vs 180 pg/mL [interquartile range, 70-559 pg/mL]; P = .010). Post-PCI S-TDE-derived CFVR was lower in patients with MACE, while post-PCI FFR showed a nonsignificant tendency to be lower in patients with MACE. In a multivariable analysis, higher NT-proBNP (adjusted hazard ratio, 1.33; 95% CI, 1.02-1.74; P = .038), post-PCI CFVR ≤ 2.0 (adjusted hazard ratio, 2.93; 95% CI, 1.16-7.40; P = .023), and post-PCI FFR ≤ 0.82 (adjusted hazard ratio, 3.93; 95% CI, 1.52-10.18; P = .005) were independently associated with MACE.

CONCLUSIONS

In patients with chronic coronary syndrome who underwent successful elective PCI for left anterior descending coronary artery, the combined assessment of S-TDE-derived post-PCI CFVR and post-PCI FFR provided a significant association with the occurrence of MACE.

Characteristics and efficacy of traditional Chinese medicine in the therapeutic strategy of chronic coronary syndrome: A systematic review and meta-analysis

BACKGROUND AND AIMS

Chronic coronary syndrome (CCS) has always been controversial in its therapeutic strategy. Although invasive treatment and optimal medication therapy (OMT) are the most commonly used treatments, doctors continue to debate the best strategy. However, traditional Chinese medicine (TCM) for CCS is effective clinically.

METHODS

To identify potentially eligible observational and experimental studies, we searched Pubmed, the Web of Science, and the China National Knowledge Internet. To be eligible, studies had to report with end-of treatment outcomes, such as major adverse cardiac events (MACE), deaths from myocardial infarctions (MI), all-cause mortality, angina, cardiac mortality, the effectiveness rate of electrocardiographs, and the reduction rate of the Nitroglycerin tablets. Risk differences (RDs) and 95 % confidence intervals (95 % CIs) were calculated based on random-effects models or fixed-effects models. Citation screening, data abstraction, risk assessment, and strength-of-evidence grading were completed by 2 independent reviewers.

RESULTS

In Section 1 (13 studies, involving 17,287 patients), showed no significant difference between invasive treatment and medication treatment in MACE (RD = -0.04, 95% CI = -0.08 to 0.00, I2 = 76.4 %), all-cause mortality (RD = -0.01, 95%CI = -0.022 to 0.01, I2 = 73.44 %), MI (RD = 0.00, 95%CI = -0.00 to 0.01, I2 = 0.00 %) and cardiac mortality (RD = 0.00, 95 %CI = -0.01 to 0.01, I2 = 34.9 %). In Section 2 (21 studies, including 1820 patients), compared with WM treatment, TCM + WM treatment increased ECG effectiveness by 18 %, angina effectiveness by 20 %, and stopping or reducing Nitroglycerin tablets by 20 %. In Section 3 (25 studies, including 2859 patients) showed that TCM revealed a better electrocardiogram effective rate (RD = 0.10, 95 %CI = 0.05 to 0.14, I2 = 44.7 %) and angina effective rate (RD = 0.12, 95 %CI = 0.09 to 0.15, I2 = 44.9 %). We identified that TCM treatment properties of "Circulating blood and transforming stasis" and application of warm/heat-properties medicines were frequently used in CCS treatment.

CONCLUSIONS

TCM treatment has shown superior beneficial cardioprotective in CCS therapy strategy, among which "Circulating blood and transforming stasis" and the application of warm/heat-properties medicine are its characteristics.

Net clinical benefit of extended dual pathway inhibition according to Baseline risk in patients with chronic coronary syndrome: a COMPASS substudy

AIMS

Guidelines recommend extended dual pathway inhibition (DPI) with aspirin and rivaroxaban in patients with chronic coronary syndrome (CCS) at high ischemic risk. The CHADS-P2A2RC score improves risk prediction and enables antithrombotic treatment allocation in these patients. This study evaluated the net clinical benefit of DPI treatment according to baseline risk as classified by the CHADS-P2A2RC score in patients with CCS included in the COMPASS trial.

METHODS

COMPASS patients with CCS (n = 14 670), randomized to aspirin alone or DPI, were stratified according to cardiovascular risk using the CHADS-P2A2RC score. Endpoints were major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month risk difference of MACE and bleeding.

RESULTS

30-month incidences of MACE (7.9% vs 3.9%, HR 2.01, 95% CI 1.83-2.18) and fatal/critical organ bleeding (1.2% vs 0.8%, HR 1.49 [1.06-1.92]) were higher in high-risk (CHADS-P2A2RC ≥ 4) than low/moderate-risk (CHADS-P2A2RC < 4) patients. DPI reduced MACE (low/moderate-risk: HR 0.62 [0.47-0.82]; high-risk: HR 0.82 [0.68-0.99], p for interaction 0.09) and all-cause death (low/moderate-risk: HR 0.65 [0.46-0.91]; high-risk: HR 0.81 [0.65-1.00], p for interaction 0.29), without substantially increasing fatal/critical organ bleeding (low/moderate-risk: HR 1.35 [0.72-2.53]; high-risk: HR 1.18 [0.73-1.90], p for interaction 0.73). DPI provided net clinical benefit of similar magnitude in low/moderate-risk (-1.81% [-3.00 to -0.62]) and high-risk CCS patients (-1.96% [-3.60 to -0.33]).

CONCLUSIONS

As classified by the CHADS-P2A2RC score, low/moderate- and high-risk patients with CCS derived similar net clinical benefit and reduction in all-cause death from DPI treatment.

New-onset atrial fibrillation and chronic coronary syndrome in the CLARIFY registry

BACKGROUND AND AIMS

Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors, and impact on cardiovascular (CV) outcomes of NOAF in CCS patients.

METHODS

Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29 001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study.

RESULTS

The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patient-years (cumulative incidence at 5 years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, low estimated glomerular filtration rate, Caucasian ethnicity, alcohol intake, and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. New-onset atrial fibrillation was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.01 (95% CI 1.61-2.52) for the composite of CV death, non-fatal myocardial infarction, or non-fatal stroke, 2.61 (95% CI 2.04-3.34) for CV death, 1.64 (95% CI 1.07-2.50) for non-fatal myocardial infarction, 2.27 (95% CI 1.85-2.78) for all-cause death, 8.44 (95% CI 7.05-10.10) for hospitalization for heart failure, and 4.46 (95% CI 2.85-6.99) for major bleeding.

CONCLUSIONS

Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.

Standardized angiographic projections allow evaluation of coronary artery side branches with quantitative flow ratio (QFR)

Quantitative flow ratio (QFR) is a novel, software-based noninvasive method for the quantitative evaluation of coronary physiology. QFR results correlate with invasive FFR measurements in the three main epicardial coronary arteries. However, QFR data for the evaluation of coronary side branches (SB) are scarce. The evaluation of QFR-performance of SB was retrospective and prospective. Eighty-seven patients with suspected chronic coronary syndrome, who received angiography using routine core lab projections, were retrospectively analyzed. On the second part 37 patients, who received angiography using recommended standardized coronary angiography projections, were prospectively analyzed. Quantitative analysis was performed for SB with a maximum lumen diameter proximal of ≥2 mm based on quantitative coronary angiography (QCA) by two certified experts with the software QAngio XA 3D 3.2. Using routine projections, QFR computation in 55 % of the SB were obtained (123 out of 224). Using standardized projections, 85 % of SB were computed by QFR (64 out of 75; p < 0.001 vs routine projections). The fluoroscopy time for recommended projections was not significantly different as opposed to routine projections (3.75 ± 2.2 vs. 4.58 ± 3.00 min, p = 2.6986). Using the standardized projections was associated with a higher amount of contrast medium (53.44 ± 24.23 vs. 87.95 ± 43.73 ml, p < 0.01), longer overall procedure time (23.23 ± 16.35 vs. 36.14 ± 17.21 min, p < 0.01) and a higher dose area product (1152.28 ± 576.70 vs. 2540.68 ± 1774.07 cGycm2, p < 0.01). Our study shows that the blood flow of the vast majority of coronary SB can be determined non-invasively by QFR in addition to the main epicardial coronary arteries when standardized projections are used.

Efficacy of Dyslipidemia Control by Combination Therapy with Rosuvastatin 10 Mg and Ezetimibe 10 Mg Compared with Rosuvastatin 20 Mg Monotherapy in Patients with Chronic Coronary Syndromes: A Randomized, Single-blind Controlled Trial

BACKGROUND

Studies have shown the combination treatment effectiveness of using rosuvastatin and ezetimibe in patients with chronic coronary artery disease. Our study aim to evaluate the effectiveness of dyslipidemia treatment with the combination of rosuvastatin and ezetimibe 10mg in patients with chronic coronary artery disease compared with 20 mg rosuvastatin.

OBJECTIVES

To evaluate the effectiveness of dyslipidemia treatment with the target of LDL-c < 1.4 mmol/L between combination therapy with rosuvastatin 10 mg and ezetimibe 10 mg in patients with chronic coronary artery disease compared with monotherapy increasing the dose of rosuvastatin 20 mg in Vietnam.

METHODS

A randomized controlled clinical trial, single-blind, parallel-group with a 1:1 randomized ratio in 103 outpatients with chronic coronary syndromes treated with rosuvastatin 10mg daily. Group A received the combination therapy with rosuvastatin 10 mg plus ezetimibe 10 mg daily, and group B received rosuvastatin 20 mg daily. The primary outcome was to assess the efficacy of low-density lipoprotein - cholesterol (LDL-c) control between rosuvastatin 10 mg plus ezetimibe 10 mg versus rosuvastatin 20 mg after 4 weeks and 8 weeks.

RESULTS

After 8 weeks of intervention, the proportion of archived treatment target patients with LDL-c < 1.4 mmol/L in groups A and B was 69.2% and 44.2%, respectively (Risk ratio (RR) = 1.57, p < 0.01), 50% LDL reduction was 27.9% and 55.8%, respectively (RR = 2.00, p < 0.01), and archived both targets were 51.9% and 25.6% (RR = 2.03, p < 0.01).

CONCLUSION

Group A's LDL-c reduction effect and target achievement proportion (Rosuvastatin 10mg + Ezetimibe 10 mg) were significantly higher than Group B's (Rosuvastatin 20 mg). Both medication therapies were safe in patients, and the increased dose of monotherapy showed more side effects than the combination therapy.

Contact with general practice in patients with suspected chronic coronary syndrome before and after CT angiography compared with the general population

BACKGROUND

Most patients undergoing coronary computed tomography angiography (CCTA) to diagnose coronary artery disease (CAD) are referred from general practitioners (GP). The burden in contacts to GP in relation to investigation on suspected CAD is unknown.

METHODS

All patients undergoing CCTA in Western Denmark from 2014-2022 were included. CCTA stenosis was defined as diameter stenosis of ≥ 50%. Patients with and without stenosis were matched, in each group, 1:5 to a reference population based on birth-year, gender and municipality using data from national registries. All GP visits were registered in up to five years preceding and one year after the CTA and stratified by gender and age. Charlson comorbidity index (CCI) were calculated in all groups.

RESULTS

Of the 62 512 patients included, 12 886 had a stenosis while 49 626 did not. Patients in both groups had a substantially higher GP visit frequency compared to reference populations. In the year of coronary CTA median GP contacts in patients with stenosis was 11 [6-17] vs. 6 [2-11] in the reference population (P < 0.001), in patients without stenosis 10 [6-17] vs. 5 [2-11] (P < 0.001). These findings were consistent across age and gender. CCI was higher among both patients with and without stenosis compared to reference groups.

CONCLUSION

In patients undergoing CCTA to diagnose CAD, a substantially increased frequency of contacts to GP was observed in the five-year period prior to examination compared to the reference populations regardless of the CCTA findings. Obtaining the CCTA result did not seem to substantially affect the GP visit frequency.

Chronic kidney disease's impact on revascularization and subsequent major adverse cardiovascular events in patients with chronic coronary syndrome

OBJECTIVE

To determine the impact of CKD on the completeness of revascularization and major adverse cardiovascular events (MACE) in patients with chronic coronary syndrome (CCS).

PATIENTS AND METHODS

The study enrolled 400 CCS patients who underwent revascularization by PCI. They were separated into two categories according to their eGFR levels: the control group: 200 patients with eGFR ≥60mL/min/1.73m2, and the CKD Group: 200 patients with eGFR< 60ml/min/1.73m.2 Patients were reclassified according to revascularization into complete and incomplete revascularization groups with one-year follow-up to assess the MACE.

RESULTS

CKD patients were significantly older (65.78 ± 6.41 vs. 56.70 ± 9.20 years, P=<0.001). They had higher syntax scores (P = 0.005), CIN (P = 0.001), all-cause mortality (P = 0.02), MACE (P = 0.037), and heart failure (P = 0.014). After reclassification according to revascularization. GFR was significantly reduced among patients with incomplete revascularization (51.08 ± 28.15 vs. 65.67 ± 26.62, respectively, P =<0.001). Repeated revascularization (P < 0.001), STEMI (P = 0.003), stent thrombosis (P = 0.015), MACE (P < 0.001), stroke (P < 0.001), and all-cause mortality (P < 0.001) were more prevalent among patients with incomplete revascularization. Multivariate regression analysis revealed eGFR (P = 0.001) and Syntax score (SS) (P=<0.001) as independent predictors of incomplete revascularization. The optimal eGFR cutoff value for predicting partial revascularization is 49.50mL/min/1.73m2, with 58.8% sensitivity and 69.3 % specificity.

CONCLUSION

Chronic kidney disease is associated with a higher syntax score and incomplete revascularization prevalence in CCS patients. Additionally, incomplete revascularization is associated with an increased incidence of major adverse cardiac events. In patients with CCS, CKD predicts partial revascularization and subsequent MACE.

Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

Exercise-based cardiac rehabilitation in stable angina pectoris: a narrative review on current evidence and underlying physiological mechanisms

Stable angina pectoris (SAP) is a prevalent condition characterised by a high disease burden. Based on recent evidence, the need for revascularisation in addition to optimal medical treatment to reduce mortality and re-events is heavily debated. These observations may be explained by the fact that revascularisation is targeted at the local flow-limiting coronary artery lesion, while the aetiology of SAP relates to the systemic, inflammatory process of atherosclerosis, causing generalised vascular dysfunction throughout the entire vascular system. Moreover, cardiovascular events are not solely caused by obstructive plaques but are also associated with plaque burden and high-risk plaque features. Therefore, to reduce the risk of cardiovascular events and angina, and thereby improve quality of life, alternative therapeutic approaches to revascularisation should be considered, preferably targeting the cardiovascular system as a whole with a physiological approach. Exercise-based cardiac rehabilitation fits this description and is a promising strategy as a first-line treatment in addition to optimal medical treatment. In this review, we discuss the role of exercise-based cardiac rehabilitation in SAP in relation to the underlying physiological mechanisms, we summarise the existing evidence and highlight future directions.

Clinical and prognostic incremental value of FFRCT in screening of patients with obstructive coronary artery disease

BACKGROUND

Coronary computed tomography angiography (CCTA) -derived fractional flow reserve (FFRCT) is recommended to evaluate the functional consequences of obstructive coronary artery disease (OCAD). Real-world incremental impacts of FFRCT use still remains under debate.

METHODS

1601 patients with suspected OCAD on CCTA (>50 ​% stenosis), including 808 (50.5 ​%) patients evaluated by FFRCT, were included from a 2013-2021 registry. Propensity adjusted impacts of FFRCT use on rates of invasive coronary angiography (ICA), myocardial revascularization (MR) and post MR major adverse cardiac events (MACE) were reported, including a sensitivity analysis in severe OCAD (>70 ​% stenosis) (n ​= ​450). Accuracy of numerical and comprehensive FFRCT interpretations in selection of patients requiring a MR were also compared.

RESULTS

1160 (72,5 ​%) ICA, 559 (34.9 ​%) MR and 137 (24.5 ​%) post MR MACE occurred at 4.7 ​± ​1.9 years. FFRCT use was independently associated with decreased rate of ICA and MR (OR: 0.66; 95 ​% CI 0.53-0.83, p ​< ​0.001 and OR: 0.71; 95 ​% CI 0.58-0.88, p ​< ​0.01, respectively). Compared to the numerical interpretation, the FFRCT comprehensive assessment increased the ratio of MR per ICA (61.7 ​% vs 50.1 ​%, p ​< ​0.01) and was more accurate in selection of patients requiring MR. FFRCT reduced post MR MACE (OR: 0.64; 95 ​% CI 0.43-0.96, p ​< ​0.05). All these associations were no longer observed in severe OCAD.

CONCLUSION

Implementing FFRCT in OCAD patients reduces ICA use, improves selection of patients requiring MR and reduces post MR MACE. However, these incremental values of FFRCT were no longer observed in severe OCAD.

Association between endothelin-1, nitric oxide, and Gensini score in chronic coronary syndrome

BACKGROUND

Chronic coronary syndrome (CCS) is a major public health burden; its pathogenesis involves atherosclerosis and endothelial dysfunction. Endothelin-1 (ET-1) and nitric oxide (NO) are vasoactive substances synthesized by endothelial cells that play a crucial role in CCS development. The Gensini score (GS) is used for evaluating CCS severity based on lumen segment changes, stenosis degree, and coronary stenosis site.

METHODS

This prospective study included 71 patients with CCS; we evaluated the relationships between GS and ET-1 and NO serum levels were evaluated in these patients. The GS was calculated for all patients. Serum ET-1 & NO levels among other laboratory parameters were measured.

RESULTS

The high GS group had higher ET-1 and relatively NO expressions in the than the low GS group. GS was positively correlated with ET-1 and negatively correlated with NO, T4, and TSH levels. The results of the multiple linear regression analysis showed that ET-1 had the most significant effect on GS.

CONCLUSIONS

We found a strong association between ET-1, NO, and CCS severity. A combination of ET-1, NO, and GS is an essential predictor of CCS disease severity.

Sirolimus-coated balloon in acute and chronic coronary syndromes: subanalysis of the EASTBOURNE registry

INTRODUCTION AND OBJECTIVES

The PEACE study (Performance of a sirolimus-eluting balloon strategy in acute and chronic coronary syndromes) investigated for the first time whether a sirolimus-coated balloon (SCB) (Magic Touch, Concept Medical, India) is associated with different outcomes depending on whether it is used in acute coronary syndromes (ACS) or chronic coronary syndromes (CCS).

METHODS

This was a post-hoc analysis from the all-comers EASTBOURNE Registry (NCT03085823). Out of 2083 patients enrolled, an SCB was used to treat 968 (46.5%) ACS and 1115 (53.5%) CCS patients. The primary endpoint was target lesion revascularization at 12 months, while secondary endpoints were angiographic success and major adverse cardiovascular events.

RESULTS

Baseline demographics, mean reference vessel diameter and mean lesion length were comparable between ACS and CCS. Predilatation was more commonly performed in ACS (P=.007). SCB was inflated at a standard pressure in both groups with a slight trend toward longer inflation time in ACS. Angiographic success was high in both groups (ACS 97.4% vs CCS 97.7%, P=.820) with limited bailout stenting. Similarly, at 12 months the cumulative incidence of target lesion revascularization (ACS 6.6% vs CCS 5.2%, P=.258) was comparable between ACS and CCS. Conversely, a higher rate of major adverse cardiovascular events in acute presenters was mainly driven by myocardial infarction recurrencies (ACS 10.4% vs CCS 8.3%, P=.009). In-stent restenosis showed a higher proportion of target lesion revascularization and major adverse cardiovascular events than de novo lesions, independently of the type of presentation at the index procedure.

CONCLUSIONS

This SCB shows good performance in terms of acute and 1-year outcomes independently of the clinical presentation.

Evaluation of Incidence and Risk Factors of Sudden Cardiac Death in Patients with Chronic Coronary Syndrome Attending Physical Training

INTRODUCTION

Regular physical activity is recommended to patients with chronic coronary syndrome (CCS). However, vigorous physical exercise occurs as a risk factor of sudden cardiac death (SCD). The effect of short-term and irregular exercise is controversial. The aim of this research is to assess the role of regular training in the incidence of SCD and to identify risk factors among patients with CCS participating in a long-term training program.

METHODS

Data of risk factors, therapy, and participation were collected retrospectively for a 10-year period, assessing the length and regularity of participation. The incidence of SCD and related mortality was registered. ANOVA, χ2 test, and multinominal logistic regression and stepwise analysis were performed.

RESULTS

The Incidence of chronic kidney disease (CKD) was higher (p < 0.01) and taking beta-blockers (BBs) was lower (p = 0.04) in the SCD group. Irregular training, lack of BBs, smoking, and CKD increased the risk of SCD, while female sex, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ACEI/ARBs), and BBs decreased the risk of SCD.

CONCLUSIONS

Taking ACEI/ARBs and BBs proved to be a protective factor, emphasizing the use of optimal medical therapy. Assessment of cardiac risk factors and control of comorbidities also proved to be important. The occurrence of SCD was connected to irregular physical activity, probably relating to the adverse effects of ad hoc exercising.

The LIPL study: Postprandial lipid profile, inflammation, and platelet activity in patients with chronic coronary syndrome

Background and aims

It is suggested that the changes in atherosclerosis happen mainly under the influence of non-fasting lipids. To date, the studies in the postprandial state were primarily performed on healthy subjects. This exploratory, cross-sectional study investigates the change in lipid profile, inflammation, and platelet activation in patients with different cardiovascular risk profiles in the postprandial state.

Methods

The studied population consists of 66 patients with different cardiovascular risks: patients with a history of the chronic coronary syndrome (CCS) and diabetes mellitus type 2 (DM2) (n = 20), CCS without DM2 (n = 25), and a healthy control group (n = 21). Lipid variables and markers of platelet function and inflammation were assessed during the fasting state and three and 5 h after a standardized fat meal using a standardized oral fat tolerance test (OFTT), a milkshake with 90 g of fat.

Results

Patients with CCS and DM2 were significantly older and had the highest BMI. All patients with CCS were on acetylsalicylic acid, and 95% of CCS patients were on high-dose statins. The absolute leukocyte and neutrophile count increased significantly in the control group during the OFTT in comparison to CCS subjects. There was a significant decrease of HDL and increase of triglycerides during the OFTT, however with no difference between groups. There was no difference in the change of platelet activity between all groups.

Conclusion

This study showed that OFTT leads to an increased postprandial inflammation response in healthy group compared to CCS ± DM2 while there was no change in lipid profile and platelet activity.

Global and regional myocardial function assessment in symptomatic patients with chronic coronary syndrome using longitudinal strain and noninvasive myocardial work

Speckle tracking echocardiography (STE) derived longitudinal strain (LS) and noninvasive pressure-strain loop (PSL) derived myocardial work (MW) are more sensitive than conventional echocardiographic parameters in quantitative assessment of early myocardial dysfunction. The aim of this study was to assess left ventricular (LV) global and regional myocardial function in symptomatic chronic coronary syndrome (CCS) patients using the two promising methods. Transthoracic echocardiography was performed on patients with angina or equivalent symptoms before coronary angiography. STE-based LS and PSL-based MW analysis were carried out on each patient for global and regional myocardial function assessment. A total of 102 patients were classified into significant and nonsignificant coronary artery stenosis (CAS) groups. Among global myocardial function parameters, LS had the biggest area under the curve (AUC) of 0.735, with cutoff value of 18.4% (sensitivity, 79.6%; specificity, 72.9%), but remained statistically alike with all MW indices in predicting significant CAS (P>0.05 for all). Among regional myocardial function parameters, both LS and MW indices had predictive value for significant left anterior descending artery (LAD) or left circumflex artery (LCX) stenosis, while only myocardial work efficiency (MWE) for right coronary artery (RCA) stenosis. Both global and regional LS and MW have predictive value for significant CAS, but their value of regionalized assessment varies with specific coronary artery involvement.

Prognostic value of triglyceride-glucose index in patients with chronic coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

The triglyceride-glucose (TyG) index has been proposed as a reliable surrogate marker of insulin resistance and an independent predictor of major adverse cardiovascular events (MACEs). Several recent studies have shown the relationship between the TyG index and cardiovascular outcomes; however, the role of the TyG index in chronic coronary syndrome (CCS) progression has not been extensively assessed especially in population after revascularization. This study aimed to investigate the prognostic value of the TyG index in predicting MACEs in CCS patients undergoing percutaneous coronary intervention (PCI).

METHODS

The data for the study were taken from the Hospital Information System database in China-Japan Friendship Hospital over the period 2019-2021. Eligible participants were divided into groups according to the TyG index tertiles. The Boruta algorithm was performed for feature selection. Multivariate Cox proportional hazards models and restricted cubic spline (RCS) analysis were applied to examine the dose-response relationship between the TyG index and endpoint, and the results were expressed with hazard ratio (HR) and 95% confidence interval (CI) values. The area under the receiver operating characteristic (ROC) curve (AUC), decision curve analysis (DCA), and clinical impact curve (CIC) were plotted to comprehensively evaluate the predictive accuracy and clinical value of the model. The goodness-of-fit of models was evaluated using the calibration curve and χ2 likelihood ratio test.

RESULTS

After applying inclusion and exclusion criteria, 1353 patients with CCS undergoing PCI were enrolled in the study. After adjusting for all confounders, we found that those with the highest TyG index had a 59.5% increased risk of MACEs over the 1-year follow-up (HR 1.595, 95% CI 1.370 ~ 1.855). Using the lowest TyG index tertile as the reference (T1), the fully adjusted HRs (95% CIs) for endpoints was 1.343 (1.054 ~ 1.711) in the middle (T2) and 2.297 (1.842 ~ 2.864) in highest tertile (T3) (P for trend < 0.001). The TyG index had an excellent predictive performance according to the results of AUC 0.810 (0.786, 0.834) and χ2 likelihood ratio test (χ2 = 7.474, P = 0.486). DCA and CIC analysis also suggested a good overall net benefit and clinical impact of the multivariate model. The results in the subgroup analysis were consistent with the main analyses. RCS model demonstrated that the TyG index was nonlinearly associated with the risk of MACEs within one year (P for nonlinear < 0.001).

CONCLUSION

The elevated TyG index is associated with an increased risk of cardiovascular events and predicts future MACEs in patients with CCS undergoing PCI independently of known cardiovascular risk factors, indicating that the TyG index may be a potential marker for risk stratification and prognosis in CCS patients undergoing PCI.

Inflammation and renal function decline in chronic coronary syndrome: a prospective multicenter cohort study

BACKGROUND

Renal function decline is a frequently encountered complication in patients with chronic coronary syndrome. Aside from traditional cardiovascular risk factors, the inflammatory burden emerged as the novel phenotype that compromised renal prognosis in such population.

METHODS

A cohort with chronic coronary syndrome was enrolled to investigate the association between inflammatory status and renal dysfunction. Levels of inflammatory markers, including high-sensitivity C-reactive protein (hs-CRP), tumour necrosis factor-α (TNF-α), adiponectin, matrix metalloproteinase-9, interleukin-6, lipoprotein-associated phospholipase A2, were assessed. Renal event was defined as > 25% decline in estimated glomerular filtration rate (eGFR). Inflammatory scores were calculated based on the aggregate of hs-CRP, TNF-α, and adiponectin levels.

RESULTS

Among the 850 enrolled subjects, 145 patients sustained a renal event during an averaged 3.5 years follow-up. Multivariate analysis with Cox regression suggested elevations in hs-CRP, TNF-α, and adiponectin levels were independent risk factors for the occurrence of a renal event. Whereas, Kaplan-Meier curve illustrated significant correlation between high TNF-α (P = 0.005), adiponectin (P < 0.001), but not hs-CRP (P = 0.092), and eGFR decline. The aggregative effect of these biomarkers was also distinctly correlated with renal events (score 2: P = 0.042; score 3: P < 0.001).

CONCLUSIONS

Inflammatory burden was associated with eGFR decline in patients with chronic coronary syndrome.

Impact of biomarker type on periprocedural myocardial infarction in patients undergoing elective PCI

BACKGROUND

Periprocedural myocardial infarction (MI) according to the Society for Cardiovascular Angiography and Interventions (SCAI) criteria has prognostic relevance among patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether the type of cardiac biomarker used for the diagnosis of periprocedural MI plays a role in terms of event frequency and outcomes.

OBJECTIVES

To compare the characteristics of SCAI periprocedural MI based on creatine kinase-myocardial band fraction (CK-MB) vs. high-sensitivity cardiac troponin (hs-cTn) in patients undergoing elective PCI.

METHODS AND RESULTS

Between 2017 and 2021, periprocedural MI was assessed in a prospective study. The primary clinical outcome of interest was all-cause death at 1-year follow-up. A total of 1010 patients undergoing elective PCI were included. SCAI periprocedural MI based on CK-MB vs. hs-cTnI occurred in 1.8 and 13.5% of patients, respectively. hs-cTnI periprocedural MI in the absence of concomitant CK-MB criteria was associated with lower rates of ancillary criteria, including angiographic, ECG, and cardiac imaging criteria. At 1-year follow-up, periprocedural MI defined by CK-MB (adjusted hazard ratio, HR, 4.27, 95% confidence intervals, CI, 1.23-14.8; P = 0.022) but not hs-cTnI (adjusted HR 2.04, 95% CI 0.94-4.45; P = 0.072) was associated with a higher risk of all-cause death. Hs-cTnI periprocedural MI was not predictive of death unless accompanied by CK-MB criteria (adjusted HR 4.64, 95% CI 1.32-16.31; P = 0.017).

CONCLUSION

In the setting of elective PCI, using hs-cTn instead of CK-MB resulted in a substantial increase in SCAI periprocedural MI events, which were not prognostically relevant in the absence of concurrent CK-MB elevations.

Prognostic Implications of Fractional Flow Reserve and Coronary Flow Reserve After Drug-Eluting Stent Implantation

BACKGROUND

Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) provides prognostic information, but limited data are available regarding prognostication using post-PCI coronary flow reserve (CFR). In this study we aimed to assess the prognostic value of post-procedural FFR and CFR for target vessel failure (TVF) after PCI.Methods and Results: This lesion-based post-hoc pooled analysis of previously published registry data involved 466 patients with chronic coronary syndrome with single-vessel disease who underwent pre- and post-PCI FFR and CFR measurements, and were followed-up to determine the predictors of TVF. The prognostic value of post-PCI CFR and FFR was compared with that of FFR or CFR alone. Post-PCI FFR/CFR discordant results were observed in 42.5%, and 10.3% of patients had documented TVF. Receiver-operating characteristic curve analysis revealed that the optimal cutoff values of post-PCI FFR and CFR to predict the occurrence of TVF were 0.85 and 2.26, respectively. Significant differences in TVF were detected according to post-PCI FFR (≤0.85 vs. >0.85, P=0.007) and post-PCI CFR (<2.26 vs. ≥2.26, P<0.001). Post-PCI FFR ≤0.85 and post-PCI CFR <2.26 were independent prognostic predictors.

CONCLUSIONS

After PCI completion, discordant results between FFR and CFR were not uncommon. Post-PCI CFR categorization showed incremental prognostic value for predicting TVF independent of post-PCI FFR risk stratification.

Association of coronary plaque morphology with inflammatory biomarkers and target lesion revascularization in patients with chronic coronary syndrome: an optical coherence tomography study

BACKGROUND

The characteristics of high-risk coronary atherosclerosis evaluated using optical coherence tomography (OCT) can have a prognostic role. Inflammatory biomarkers may be related to the severity of coronary artery disease. This study investigated the association of high-risk morphological features of coronary plaques on OCT with circulating levels of inflammatory biomarkers and target lesion revascularization (TLR).

MATERIALS AND METHODS

We prospectively analyzed the data of 30 consecutive patients with chronic coronary syndrome who underwent percutaneous coronary intervention (PCI) using OCT. The levels of interleukin-6, tumor necrosis factor-alpha, high-sensitivity C-reactive protein, pentraxin 3, vascular endothelial growth factor, and monocyte chemoattractant protein-1 (MCP-1) were measured in plasma samples. Coronary plaque characteristics were scored quantitatively in the form of coronary plaque risk score (CPRS). The estimated high-risk plaque characteristics for TLR were plaque rupture, plaque erosion, calcified nodule, lipid-rich plaque, thin-cap fibroatheroma, cholesterol crystals, macrophage infiltration, microchannels, calcification angle >90°, and microcalcifications. Each high-risk feature carries 1 point. Patients were defined as having a low CPRS (CPRS ≤3) or a high CPRS (CPRS ≥4).

RESULTS

The primary outcome was TLR. TLR occurred in 6 (20%) patients within 15 months of PCI. High CPRS on OCT was directly correlated with TLR (P=0.029). In logistic regression analysis, CPRS was associated with TLR (odds ratio, 10.0; 95% confidence interval, 1.34-74.5). Serum MCP-1 level was significantly correlated with the CPRS (P=0.020).

CONCLUSIONS

In patients with chronic coronary syndrome, CPRS may be a surrogate predictor of TLR. Serum MCP-1 may aid in the detection of high-risk coronary atherosclerosis.

Functional imaging after the "ISCHEMIA" trial

Previous randomized trials have shown a lack of benefits from the addition of revascularization to optimal medical therapy versus optimal medical therapy alone in patients with stable ischaemic heart disease at relatively low risk (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]), and in diabetic patients with stable ischaemic heart disease (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetics [BARI 2D]). More recently, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) randomized clinical trial showed similar results in patients with moderate-severe ischaemia on functional testing (imaging or stress electrocardiogram) and at least one significant (> 50%) coronary stenosis in a major epicardial coronary artery on coronarography computed coronary angiography. Although the ISCHEMIA trial adds pivotal knowledge regarding the management of and decision-making in stable patients, this study has prompted a great debate about the role of functional imaging for diagnosis, risk stratification and therapeutic decision-making. The objectives of this review are to summarize the results of the ISCHEMIA trial, to underline its limitations and to warn care providers about potential misinterpretation of this trial.

In-Hospital Outcomes and Conditions Associated With Coronary Artery Aneurysms in Chronic Coronary Syndrome

BACKGROUND

Coronary artery aneurysms (CAA) are infrequent findings among patients undergoing coronary angiography and may be associated with systemic diseases.

METHODS

We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the chronic coronary syndrome (CCS). We sought to determine the impact of CAA on in-hospital outcomes encompassing all-cause death, bleeding, cardiovascular complications, and stroke. Secondly, we examined the association of CAA with other relevant systemic conditions.

RESULTS

The presence of CAA was associated with a 3-fold increase in the odds of cardiovascular complications (OR 3.1, 95 % CI 2.9-3.8), however, it was associated with reduced odds of stroke (OR 0.7, 95 % CI 0.6-0.9). There was no significant impact on all-cause death and overall bleeding complications, although there appeared to be a reduction in the odds of gastrointestinal (GI) bleeding associated with CAA (OR 0.6, 95 % CI 0.4-0.8). Patients with CAA vs. those without CAA had a significantly greater prevalence of extracoronary arterial aneurysms (7.9 % vs. 1.4 %), systemic inflammatory disorders (6.5 % vs. 1.1 %), connective tissue disease (1.6 % vs. 0.6 %), coronary artery dissection (1.3 % vs. 0.1 %), bicuspid aortic valve (0.8 % vs. 0.2 %), and extracoronary arterial dissection (0.3 % vs. 0.1 %). In the multivariable regression, systemic inflammatory disorders, extracoronary aneurysms, coronary artery dissection, and connective tissue diseases were independent predictors of CAA.

CONCLUSIONS

CAA in patients with CCS is associated with greater odds of cardiovascular complications during hospitalization. These patients also had a substantially greater prevalence of extracardiac vascular and systemic abnormalities.

Medical care and biomarker-based assessment of mortality in two cohorts of patients with chronic coronary syndrome 10 years apart

BACKGROUND

This study aimed to describe the characteristics and mortality of two cohorts of patients with chronic coronary syndrome (CCS) recruited with identical study designs in the same rehabilitation clinics but approximately 10 years apart.

METHODS

The KAROLA cohorts included patients with CCS participating in an inpatient cardiac rehabilitation programme in Germany (KAROLA-I: years 1999/2000, KAROLA-II: 2009-2011). Blood samples and information on sociodemographic factors, lifestyle, and medical treatment were collected at baseline, at the end of rehabilitation, and after one year of follow-up. A biomarker-based risk model (ABC-CHD model) and Cox regression analysis were used to evaluate cardiovascular (CV) and non-CV mortality risk.

RESULTS

We included 1130 patients from KAROLA-I (mean age 58.7 years, 84.4% men) and 860 from KAROLA-II (mean age 60.4 years, 83.4% men). Patients in the KAROLA-I cohort had significantly higher concentrations of CV biomarkers and fewer patients were taking CV medications, except for statins. The biomarker-based ABC-CHD model provided a higher estimate of CV death risk for patients in the KAROLA-I cohort (median 3-year risk, 3.8%) than for patients in the KAROLA-II cohort (median 3-year risk, 2.7%, p-value for difference < 0.001). After 10 years of follow-up, 91 (8.1%) patients in KAROLA-I and 45 (5.2%) in KAROLA-II had died from a CV event.

CONCLUSIONS

Advances in disease management over the past 20 years may have led to modest improvements in pharmacological treatment during cardiac rehabilitation and long-term outpatient care for patients with CCS. However, modifiable risk factors such as obesity have increased in the more recent cohort and should be targeted to further improve the prognosis of these patients.

Long-Term Change in Flow Rates in Patients with Coronary Slow Flow

INTRODUCTION

Coronary slow flow (CSF) is a condition characterized by impaired blood flow rates in the coronary arteries. It can result in severe cardiovascular outcomes. There is no sufficient evidence regarding the certain etiology and reversibility of slow flow patterns and changes in frame counts with long-term management.

METHODS

We retrospectively enrolled 48 patients with chronic coronary syndrome and CSF who underwent a second angiography. A corrected coronary frame rate (CFR) >27 was defined as CSF. We created 3 groups according to the change in CSF status as the improved, not changed, and worsened groups. We compared the CFR and CSF status of the patients between the first and second angiographies within a median of 2.6 years.

RESULTS

We determined a nonsignificant change in cCFR in left anterior descending (LAD) artery (34.4 [18.9] vs. 31.59 [10.3], p = 0.35), circumflex (Cx) artery (42.84 [12.56] vs. 40.66 [13.2], p = 0.35), and right coronary artery (RCA) (57.80 [30.13] vs. 50.32 [19.5], p = 0.11). In the comparison of CSF status of LAD (75% vs. 63%, p = 0.27), Cx (96% vs. 83%, p = 0.09), RCA (94% vs. 94%, p = 1.0) between first and second angiographies, there was no significant change. In the comparison of the 3 groups according to the improvement of CSF status, there was no significant difference in demographic features, change in laboratory parameters, and time between the groups.

CONCLUSION

There was no significant change in the median CFR and CSF status in the overall group between the two angiographies after 3 years.

Comparison of two diagnostic strategies for patients with stable chest pain suggestive of chronic coronary syndrome: rationale and design of the double-blind, pragmatic, randomized and controlled OPERATE Trial

BACKGROUND

To achieve potential financial savings and avoid exposing the patients to unnecessary risk, an optimal diagnostic strategy to identify low risk individual who may derive minimal benefit from further cardiac imaging testing (CIT) is important for patients with stable chest pain (SCP) suggestive of chronic coronary syndrome (CCS). Although several diagnostic strategies have been recommended by the most recent guidelines, few randomized controlled trials (RCTs) have prospectively investigated the actual effect of applying these strategies in clinical practice.

METHODS

OPERATE (OPtimal Evaluation of stable chest pain to Reduce unnecessAry utilization of cardiac imaging TEsting) trial is an investigator-initiated, multicenter, coronary computed tomography angiography (CCTA)-based, 2-arm parallel-group, double-blind, pragmatic and confirmative RCT planning to include 800 subjects with SCP suggestive of CCS. After enrollment, all subjects will be randomized to two arms (2016 U.K. National Institute of Health and Care Excellence guideline-determined and 2019 European Society of Cardiology guideline-determined diagnostic strategy) on a 1:1 basis. According to each strategy, CCTA should be referred and deferred for a subject in high and low risk group, respectively. The primary (effectiveness) endpoint is CCTA without obstructive coronary artery disease. Safety of each strategy will be mainly assessed by 1-year major adverse cardiovascular event rates.

DISCUSSION

The OPERATE trial will provide comparative effectiveness and safety evidences for two different diagnostic strategies for patients with SCP suggestive of CCS, with the intension of improving the diagnostic yield of CCTA at no expense of safety.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.org Identifier NCT05640752.

Association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease: Analysis from the CLARIFY registry

BACKGROUND

Conflicting data exist on the association between consumption of coffee or tea and cardiovascular outcomes, and few focus on patients with established coronary artery disease.

AIM

To describe the association between coffee or tea consumption and cardiovascular outcomes in patients with stable coronary artery disease, using an extensive contemporary international registry, allowing the identification of multiple potential confounders.

METHODS

The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled in 2009 and 2010 in 45 countries, with a 5-year follow-up. Patients were categorized according to daily consumption of coffee or tea, and were compared with those declaring neither. The primary composite outcome of myocardial infarction, stroke or cardiovascular death was analysed at 5years, as well as all-cause mortality. Sensitivity analyses were performed with a multivariable model.

RESULTS

A total of 15,459 and 10,029 patients declared coffee or tea consumption, respectively. At 5years, after full adjustment, no association was found between coffee consumption and the primary outcome: hazard ratio 1.04 (95% confidence interval 0.89-1.21) for 1 cup; 0.94 (0.82-1.08) for 2-3 cups; and 1.04 (0.86-1.27) for ≥4 cups (P=0.51). Drinking tea was not associated with a different incidence of the primary outcome before or after adjustment, with fully adjusted hazard ratios of 1.08 (95% confidence interval 0.84-1.38) for 1 cup, 1.12 (0.96-1.31) for 2-3 cups and 0.95 (0.79-1.14) for ≥4 cups (P=0.30). After full adjustment, neither coffee nor tea drinking was associated with all-cause mortality.

CONCLUSIONS

In outpatients with stable coronary artery disease, there was no association between coffee or tea consumption and ischaemic outcomes or all-cause mortality.

Comprehensive Assessment of Myocardial Ischemia Mechanisms in the Catheterization Laboratory: Design and Rationale of the Advanced Invasive Diagnosis Strategy for Patients with Stable Coronary Syndromes Undergoing Coronary ANGIOgraphy - the AID-ANGIO Study

BACKGROUND

The diagnostic yield of invasive coronary angiography (ICA) to identify obstructive coronary artery disease in the context of chronic coronary syndromes (CCS) is very low. Furthermore, myocardial ischemia may have a non-obstructive origin, which cannot be detected by ICA.

METHODS

AID-ANGIO is an observational, prospective, single-cohort, multicenter study, intended to evaluate the diagnostic yield of adopting a hierarchical strategy to assess obstructive and non-obstructive causes of myocardial ischemia in an all-comers population of patients with CCS at the time of ICA. The primary endpoint will investigate the additional diagnostic value of such strategy over angiography alone regarding the identification of ischemia-generating mechanisms.

SUMMARY

An estimated sample of consecutive 260 patients with CCS referred by their clinicians to ICA, will be enrolled. In a stepwise manner, a conventional ICA will be performed as the initial diagnostic tool. Those patients with severe-grade stenosis will not undergo further assessment and an obstructive origin for myocardial ischemia will be assumed. Subsequently, the remainder with intermediate-grade stenosis will be assessed with pressure guidewires. Those with a negative result from physiological evaluation and those without epicardial coronary stenosis will be further studied for ischemia of non-obstructive origin, including microvascular dysfunction and vasomotor disorders. The study will be conducted in two steps. Firstly, ICA images will be displayed to patient's referring clinicians, who will be asked to identify the existent epicardial stenosis, their angiographic severity and probable physiological relevance, together with a tentative therapeutic approach. Then, the diagnostic algorithm will continue to be applied and, considering the whole gathered information, a definite therapeutic plan will be consensually established by the interventional cardiologist and patient's referring clinicians.

CONCLUSION

The AID-ANGIO study will assess the additional diagnostic yield of a hierarchical strategy over ICA alone to identify ischemia-generating mechanisms in patients with CCS and its impact on therapeutic approach. Positive results of the study might support a streamlined invasive diagnostic process for patients with CCS.

Factors influencing adherence to clinical practice guidelines in patients with suspected chronic coronary syndrome: a qualitative interview study in the ambulatory care sector in Germany

BACKGROUND

Chronic coronary syndrome (CCS) is a potentially progressive clinical presentation of coronary artery disease (CAD). Clinical practice guidelines (CPGs) are available for prevention, diagnosis, and treatment. Embedded in the "ENLIGHT-KHK" healthcare project, a qualitative study was conducted to identify factors that influence guideline adherence from the perspective of general practitioners (GPs) and cardiologists (CA) in the ambulatory care sector in Germany.

METHODS

GPs and CAs were surveyed via telephone using an interview guide. The respondents were first asked about their individual approach to caring for patients with suspected CCS. Subsequently, the accordance of their approach with guideline recommendations was addressed. Finally, potential measures for assisting with guideline adherence were discussed. The semi-structured interviews were transcribed verbatim and analysed using a qualitative content analysis in accordance with Kuckartz and Rädiker. Factors influencing adherence to CPGs were categorised by assessing whether they (i) inhibited or facilitated guideline adherence, (ii) played a role in patients at risk of CCS or with suspected or known CCS, (iii) were mentioned in implicit or explicit thematic reference to CPGs, and (iv) were declared a practical problem.

RESULTS

Based on interviews with ten GPs and five CAs, 35 potential influencing factors were identified. These emerged at four levels: patients, healthcare providers, CPGs, and the healthcare system. The most commonly cited barrier to guideline adherence among the respondents was structural aspects at the system level, including reachability of providers and services, waiting times, reimbursement through statutory health insurance (SHI) providers, and contract offers. There was a strong emphasis on interdependencies between factors acting at different levels. For instance, poor reachability of providers and services at the system level may result in inexpedience of guideline recommendations at the CPG level. Likewise, poor reachability of providers and services at the system level may be aggravated or alleviated by factors such as diagnostic preferences at the patient level or collaborations at the provider level.

CONCLUSIONS

To assist with adherence to CPGs regarding CCS, promoting measures may be needed that account for interdependencies between barriers and facilitators at various healthcare levels. Respective measures should consider medically justified deviations from guideline recommendations in individual cases.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00015638; Universal Trial Number (UTN): U1111-1227-8055.

Evaluation of the guideline-adherence of coronary angiography in patients with suspected chronic coronary syndrome - Results from the German prospective multicentre ENLIGHT-KHK project

Background

With 900'000 coronary angiographies (CA) per year, Germany has the highest annual per capita volume in Europe. Until now there are no prospective clinical data on the degree of guideline-adherence in the use of CA in patients with suspected chronic coronary syndrome (CCS) in Germany.

Methods

Between January 2019 and August 2021, 458 patients with suspected CCS were recruited in nine German centres. Guideline-adherence was evaluated according to the current European Society of Cardiology and German guidelines. Pre-test probability (PTP) for CAD was determined using age, gender, and a standardized patient questionnaire to identify symptoms. Data on the diagnostic work-up were obtained from health records.

Results

Patients were in mean 66.6 years old, male in 57.3 %, had known CAD in 48.4 % and presented with typical, atypical, non-anginal chest pain or dyspnoea in 35.7 %, 41.3 %, 23.0 % and 25.4 %, respectively. PTP according to the European guidelines was in mean 24.2 % (11.9 %-36.5 % 95 % CI). 20.9 % of the patients received guideline-recommended preceding non-invasive image guided testing. The use of CA was adherent to the European and German guideline recommendations in 20.4 % and 25.4 %, respectively. In multivariate-analysis, arterial hypertension and prior revascularization were predictors of guideline non-adherence.

Conclusion

These are the first prospective clinical data which demonstrated an overall low degree of guideline-adherence in the use of CA in patients with suspected CCS in the German health care setting. To improve adherence rates, the availability of and access to non-invasive image guided testing needs to be strengthened. (German Clinical Trials Registry DRKS00015638 - Registration Date: 19.02.2019).

Role of galectin-3 in diagnosis and severity assessment of epicardial artery lesions in patients with suspected coronary artery disease

BACKGROUND

This study aimed to investigate the possible role of serum galectin-3 (Gal-3) levels in the diagnosis and assessment of significant epicardial artery lesions in patients with suspected coronary artery disease (CAD).

METHODS

This was a single-center cross sectional cohort study including 168 subjects with suspected CAD and indications for coronary angiography divided into three groups: percutaneous coronary intervention (PCI) group (N 64), coronary artery bypass graft surgery (CABG) group (N 57), and group with no coronary stenosis (N 47). Gal-3 levels were measured and the syntax score (Ss) was calculated.

RESULTS

The mean value of Gal-3 in the PCI and CABG group was 19.98 ng/ml, while in the control group, it was 9.51 ng/ml (p < 0.001). The highest value of Gal-3 was found in the group of subjects with three-vessel disease (p < 0.001). When subgroups were analyzed by Gal-3 levels (< 17.8 ng/ml low, 18.8-25.9 ng/ml intermediate, > 25 ng/ml high risk) there was a significant difference between at least two Gal-3 groups for the arithmetic mean of Syntax score (p < 0.001). The syntax I's arithmetic mean at low and intermediate-risk Gal-3 levels was significantly lower than at high-risk Gal-3 levels (p < 0.001).

CONCLUSION

Gal-3 could be used as an additional tool for diagnosis and severity assessment of atherosclerotic disease in patients with suspected CAD. Furthermore, it could help identify high-risk subjects in patients with stable CAD.

Association between the triglyceride-glucose index and the presence and prognosis of coronary microvascular dysfunction in patients with chronic coronary syndrome

BACKGROUND

Coronary microvascular dysfunction (CMD) is a strong determinant of prognosis in patients with chronic coronary syndrome (CCS). The triglyceride-glucose index (TyG index), an alternative method to evaluate insulin resistance, is positively correlated with the incidence and adverse outcomes of cardiovascular diseases. However, the relationship between the TyG index and the presence and prognosis of CMD in CCS patients has not been investigated. Therefore, we aimed to evaluate the association between the TyG index and the presence and clinical outcomes of CMD among CCS patients.

METHODS

CCS patients who underwent coronary angiography between June 2015 to June 2019 were included. The TyG index was calculated as Ln[fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2]. Coronary angiography‑derived index of microvascular resistance (caIMR) was used to measure microvascular function, and CMD was defined as caIMR ≥ 25U. Patients with CMD were divided into three groups (T1, T2, and T3 groups) according to TyG tertiles. The primary endpoint was major adverse cardiac event (MACE).

RESULTS

Of 430 CCS patients, 221 patients had CMD. CMD patients had significantly higher TyG index than those without CMD. Sixty-three MACE was recorded during the follow-up duration among CMD patients, and the incidence rate of MACE was higher in the T3 group compared to T1/T2 groups (39.2% vs. 20.5% vs. 25.7%; P = 0.035). Multivariable logistic regression analysis showed that the TyG index was an independent predictor of CMD (OR, 1.436; 95% CI, 1.014-2.034; P = 0.042). Compared to the T1 group, the T3 group strongly correlated with the risk of MACE in CMD patients even after adjusting for additional confounding risk factors (HR, 2.132; 95%CI, 1.066-4.261; P = 0.032).

CONCLUSION

TyG index is significantly associated with the risk of CMD, and it is an independent predictor of MACE among CMD patients with CCS. This study suggests that the TyG index has important clinical significance for the early prevention and risk stratification of CMD.

Impact of a comprehensive cardiac rehabilitation programme versus coronary revascularisation in patients with stable angina pectoris: study protocol for the PRO-FIT randomised controlled trial

BACKGROUND

Currently, in the majority of patients with stable angina pectoris (SAP) treatment consists of optimal medical treatment, potentially followed by coronary angiography and subsequent coronary revascularisation if necessary". Recent work questioned the effectiveness of these invasive procedures in reducing re-events and improving prognosis. The potential of exercise-based cardiac rehabilitation on clinical outcomes in patients with coronary artery disease is well-known. However, in the modern era, no studies compared the effects of cardiac rehabilitation versus coronary revascularisation in patients with SAP.

METHODS

In this multicentre randomised controlled trial, 216 patients with stable angina pectoris and residual anginal complaints under optimal medical treatment will be randomised to: 1) usual care (i.e., coronary revascularisation), or 2) a 12-month cardiac rehabilitation (CR) programme. CR consists of a multidisciplinary intervention, including education, exercise training, lifestyle coaching and a dietary intervention with a stepped decline in supervision. The primary outcome will be anginal complaints (Seattle Angina Questionnaire-7) following the 12-month intervention. Secondary outcomes include cost-effectiveness, ischemic threshold during exercise, cardiovascular events, exercise capacity, quality of life and psychosocial wellbeing.

DISCUSSION

In this study, we will examine the hypothesis that multidisciplinary CR is at least equally effective in reducing anginal complaints as the contemporary invasive approach at 12-months follow-up for patients with SAP. If proven successful, this study will have significant impact on the treatment of patients with SAP as multidisciplinary CR is a less invasive and potentially less costly and better sustainable treatment than coronary revascularisations.

TRIAL REGISTRATION

Netherlands Trial Register, NL9537. Registered 14 June 2021.

A prospective, randomized, controlled, multicentre trial for secondary prevention in patients with chronic coronary syndrome using a smartphone application for digital therapy: the CHANGE study protocol

Aims

Coronary artery disease (CAD) remains the leading cause of death worldwide. 'Stable' CAD is a chronic progressive condition, which recent European guidelines recommend referring to as 'chronic coronary syndrome' (CCS). Despite therapeutic advances, morbidity and mortality among patients with CCS remain high. Optimal secondary prevention in patients with CCS includes optimization of modifiable risk factors with behavioural changes and pharmacological therapy. The CHANGE study aims to provide evidence for optimization of secondary prevention in CCS patients by using a smartphone application (app).

Methods and results

The CHANGE study is designed as a prospective, randomized, controlled trial with a 1:1 allocation ratio, which is currently performed in nine centres in Germany in a parallel group design. 210 patients with CCS will be randomly allocated either to the control group (standard-of-care) or to the intervention group, who will be provided the VantisTherapy* app in addition to standard-of-care to incorporate secondary prevention into their daily life. The study will be performed in an open design. Outcomes will be assessed using objective data from three in-person visits (0, 12, and 24 weeks). Primary outcomes will involve adherence to secondary prevention recommendations and quality of life (QoL). The recruitment process started in July 2022.

Conclusion

The CHANGE study will investigate whether a smartphone-guided secondary prevention app, combined with a monitor function compared with standard-of-care, has beneficial effects on overall adherence to secondary prevention guidelines and QoL in patients with CCS.

Trial registration

The study is listed at the German study registry (DRKS) under the registered number DRKS00028081.

Single-pill combination in the management of chronic coronary syndromes: A strategy to improve treatment adherence and patient outcomes?

Chronic coronary syndrome (CCS) represents a major challenge for physicians, particularly in the context of an increasing aging population. Additionally, CCS is often underestimated and under-recognised, particularly in female patients. As patients are frequently affected by several chronic comorbidities requiring polypharmacy, this can have a negative impact on patients' adherence to treatment. To overcome this barrier, single-pill combination (SPC), or fixed-dose combination, therapies are already widely used in the management of conditions such as hypertension, dyslipidaemia, and diabetes mellitus. The use of SPC anti-anginal therapy deserves careful consideration, as it has the potential to substantially improve treatment adherence and clinical outcomes, along with reducing the failure of pharmacological treatment before considering other interventions in patients with CCS.

The clinical significance of osteopontin on the cardiovascular outcomes in patients with stable coronary artery disease

BACKGROUND

Osteopontin (OPN) is a noncollagenous matricellular protein which is mainly present in bone matrix. A high OPN level has been associated with heart failure and acute coronary syndrome, however data on patients with chronic coronary syndrome (CCS) are lacking. The present study aimed to evaluate the association between OPN and the prognosis of Taiwanese patients with CCS.

METHODS

We enrolled participants from the Biosignature Registry, a nationwide prospective cohort study conducted at nine different medical centers throughout Taiwan. The inclusion criteria were participants who had received successful percutaneous coronary intervention at least once previously, and stable under medical therapy for at least 1 month before enrollment. They were followed for at least 72 months. Logistic regression and Cox proportional hazard model were used to investigate the association between OPN and clinical outcomes. The outcomes of this study were the first occurrence of hard cardiovascular events and composite cardiovascular outcomes including cardiovascular mortality, revascularization, hospitalization for acute myocardial infarction (AMI) or heart failure.

RESULTS

A total of 666 patients with both hs-CRP and osteopontin measurements were enrolled and followed for 72 months. OPN was correlated positively with AMI-related hospitalization, where the highest tertile (Tertile 3) of baseline OPN had the highest risk of AMI-related hospitalization, which remained significant after multivariate adjustments (HR 3.20, p = 0.017). In contrast, combining OPN and hs-CRP did not improve the prediction of CV outcomes.

CONCLUSION

OPN may be a potentially valuable biomarker in predicting CV outcomes. During 6 years of follow-up period, an OPN level >4810 pg/ml was associated with a significantly higher incidence of AMI-related hospitalization in CCS patients who received successful PCI before the enrollment.

Periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention

Percutaneous coronary intervention (PCI) in addition to guideline-directed medical therapy reduces the risk of spontaneous myocardial infarction (MI), urgent revascularization, and improves angina status; however, PCI is associated with an increased risk of periprocedural myocardial injury and MI. Numerous studies have investigated the mechanisms, predictors, and therapeutic strategies for periprocedural MI. Various definitions of periprocedural MI have been proposed by academic groups and professional societies requiring different cardiac biomarker thresholds and ancillary criteria for myocardial ischemia. The frequency and clinical significance of periprocedural MI substantially varies according to the definitions applied. In daily practice, accurate diagnosis of clinically-relevant periprocedural MI is essential because it may have a substantial impact on subsequent patient management. In the clinical trial setting, only clinically relevant periprocedural MI definitions should be applied as a clinical endpoint in order to avoid obscuring meaningful outcomes. In this review, we aim to summarize the mechanisms, predictors, frequency, and prognostic impact of periprocedural MI in patients undergoing PCI and to provide the current perspective on this issue.

De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy?

Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y₁₂ inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y₁₂ inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.

Relationship between coronary artery calcium score and bleeding events after percutaneous coronary intervention in chronic coronary syndrome

The relationship between coronary artery calcium (CAC) and bleeding events after percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome (CCS) is not well established. This study aimed to examine the association between CAC scores and clinical outcomes after PCI in patients with CCS. This retrospective observational study included 295 consecutive patients who underwent multidetector computer tomography and were scheduled for their first elective PCI. Patients were categorized into two groups based on the CAC scores (low: ≤ 400 or high: > 400). The bleeding risk was evaluated using the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria. The primary clinical outcome was a major bleeding event within 1 year after PCI, defined as Bleeding Academic Research Consortium (BARC) 3 or 5. The high CAC score group had a higher proportion of patients meeting the ARC-HBR criteria than the low CAC score group (52.7% vs. 31.3%, p < 0.001). Kaplan-Meier survival analysis showed that the incidence of major bleeding events was higher in the high CAC score group as compared to the low CAC score group (p < 0.001). Furthermore, multivariate Cox regression anal ysis revealed that a high CAC score was an independent determinant of major bleeding events during the first year after PCI. A high CAC score is significantly associated with the incidence of major bleeding events after PCI in CCS patients.

Sex Differences in Long-Term Outcomes in Patients With Chronic Coronary Syndrome After Percutaneous Coronary Intervention - Insights From a Japanese Real-World Database Using a Storage System

BACKGROUND

Several studies have reported some sex differences in patients with coronary artery diseases. However, the results regarding long-term outcomes in patients with chronic coronary syndrome (CCS) are inconsistent. Therefore, the present study investigated sex differences in long-term outcomes in patients with CCS after percutaneous coronary intervention (PCI).Methods and Results: This was a retrospective, multicenter cohort study. We enrolled patients with CCS who underwent PCI between April 2013 and March 2019 using the Clinical Deep Data Accumulation System (CLIDAS) database. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, or hospitalization for heart failure. In all, 5,555 patients with CCS after PCI were included in the analysis (4,354 (78.4%) men, 1,201 (21.6%) women). The median follow-up duration was 917 days (interquartile range 312-1,508 days). The incidence of MACE was not significantly different between the 2 groups (hazard ratio [HR] 1.20; 95% confidential interval [CI] 0.97-1.47; log-rank P=0.087). After performing multivariable Cox regression analyses on 4 different models, there were still no differences in the incidence of MACE between women and men.

CONCLUSIONS

There were no significant sex differences in MACE in patients with CCS who underwent PCI and underwent multidisciplinary treatments.

Cost Change of Elective Percutaneous Coronary Artery Intervention for Chronic Coronary Syndrome in Japan From 2010 to 2019

BACKGROUND

Because of revisions to insurance reimbursement costs, medical fees have changed for investigations and percutaneous coronary intervention (PCI) treatment of chronic coronary syndrome (CCS). In this retrospective study, we investigated these changes and their effects on mortality and cardiovascular events.Methods and Results: We included 1,483 patients who underwent elective PCI for CCS between April 2010 and September 2019. The primary outcomes were changes in PCI procedure fees and all included hospitalization fees due to the biennial revisions of reimbursement costs across 5 time periods (~2 years each). Secondary outcomes were rates of survival and freedom from major adverse cerebral and cardiovascular events (MACCE) in each time period. Patient characteristics were generally unchanged over the study period; however, treatment procedures changed significantly, with changes in the approach site (from transfemoral to transradial access; P<0.0001) and final device (from bare-metal stents to drug-eluting stents; P<0.0001), and an increase in the use of imaging modalities (P<0.0001). Medical fee parameters (primary outcomes) decreased significantly from 2010 to 2019 (P<0.001): PCI procedure fees decreased by 25%, whereas all included hospitalization fees decreased by 20%. There were no significant differences in survival or freedom-from-MACCE rates between periods.

CONCLUSIONS

Because of revisions to reimbursement prices, there were rapid and significant decreases in PCI procedure and hospitalization fees for CCS. These changes had no effect on mortality or cardiovascular events.

Epicardial fat accumulation and left heart remodelling in patients with chronic coronary syndrome

AIMS

Patients with chronic coronary syndrome (CCS) suffer from subsequent cardiovascular events, even after complete revascularization; thus, elucidation of the underlying pathophysiological mechanisms is required. Epicardial adipose tissue (EAT) is increasingly recognized as a metabolically active organ with a key role in the pathogenesis of metabolic-related cardiac diseases. The present study investigated the association between EAT burden and left heart remodelling in patients with CCS.

METHODS AND RESULTS

We studied 267 CCS patients (210 men; 71 ± 9 years) with complete revascularization and normal left ventricular (LV) ejection fraction who underwent follow-up echocardiography. All patients underwent the measurement of EAT thickness and speckle-tracking analysis to evaluate LV global longitudinal strain (LVGLS) and left atrial (LA) phasic strain. The mean EAT thickness was 5.0 ± 1.8 mm. Age, sex, body mass index, and diabetes mellitus were independently associated with EAT thickness (all P < 0.05). Multivariable linear regression analysis demonstrated that EAT thickness was significantly associated with LV mass index, early diastolic mitral annular velocity, and LA conduit strain independent of age, sex, and cardiovascular risk factors (all P < 0.05). On the other hand, there was no relationship between EAT thickness and LV systolic parameters including LV ejection fraction and LVGLS.

CONCLUSION

CCS patients with increased EAT thickness had unfavourable left heart remodelling. The assessment of EAT thickness by echocardiography may have clinical utility as a simple surrogate to aid in risk stratification for impaired left heart function in CCS patients.

[Contribution of coroscanner in chronic coronary syndrome]

Cardiac division imaging by coroscanner has progressed a lot in 20 years to gradually become an important and potentially indispensable tool of chronic coronary cardiology. The European and American recommendations are Grade I for the assessment of symptomatic patients at intermediate to high risk, at the same level as traditional functional tests. The development of sophisticated post-treatment algorithms that apply the equations of fluid mechanics makes it possible to calculate an FFR value at any point from the CT image of the coronary artery. This FFR-CT is correctly correlated with invasive FFR compared to a threshold value of 0.80 and helps guide therapeutic choices. Thus, the coroscanner is a complement or an alternative to traditional functional tests and is positioned as a filter of access to coronary angiography, especially since it combines, from the same examination, a precise anatomical description, and a functional evaluation of the various possible lesions. Which is the Holy Grail of coronary cardiology.

Real-World Data on Potent P2Y12 Inhibition in Patients with Suspected Chronic Coronary Syndrome, Referred for Coronary Angiography

INTRODUCTION

Potential benefit with potent platelet inhibition in patients with chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) has been discussed. The aim of this study was to compare a potent P2Y12 inhibition strategy using ticagrelor with clopidogrel in CCS patients referred for coronary angiography (CA) and PCI if feasible.

METHODS

In this retrospective real-world study, patients referred for outpatient CA due to suspected CCS were included. To adjust for group differences, a propensity score reflecting the probability of being treated with ticagrelor was calculated and added to the logistic regression outcome model.

RESULTS

In total, 1,003 patients were included in the primary analysis (577 treated with clopidogrel and 426 with ticagrelor). Among clopidogrel-treated patients, 132 (22.9%) experienced a bleeding complication compared with 93 (21.8%) among ticagrelor-treated patients, with no significant difference between the groups (p = 0.70). There was no difference in bleeding severity. Furthermore, we observed no statistically significant difference in major adverse cardiovascular events (MACE [death, stent thrombosis, myocardial infarction, or stroke]) (1.2% vs. 2.3%, p = 0.17). A subgroup analysis restricted to patients undergoing PCI ad hoc displayed a similar pattern. Also, patients undergoing CA without PCI ad hoc frequently experienced a bleeding complication, with no difference between the two treatments (21.0% vs. 17.3%, p = 0.27). Propensity score adjusted analyses confirmed the results.

DISCUSSION

In patients with CCS referred for CA and PCI if feasible, a more potent P2Y12 inhibition strategy with ticagrelor was not associated with bleeding complications or MACE compared with clopidogrel.

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.

Improved pre-test likelihood estimation of coronary artery disease using phonocardiography

Aims

Current early risk stratification of coronary artery disease (CAD) consists of pre-test probability scoring such as the 2019 ESC guidelines on chronic coronary syndromes (ESC2019), which has low specificity and thus rule-out capacity. A newer clinical risk factor model (risk factor-weighted clinical likelihood, RF-CL) showed significantly improved rule-out capacity over the ESC2019 model. The aim of the current study was to investigate if the addition of acoustic features to the RF-CL model could improve the rule-out potential of the best performing clinical risk factor models.

Methods and results

Four studies with heart sound recordings from 2222 patients were pooled and distributed into two data sets: training and test. From a feature bank of 40 acoustic features, a forward-selection technique was used to select three features that were added to the RF-CL model. Using a cutoff of 5% predicted risk of CAD, the developed acoustic-weighted clinical likelihood (A-CL) model showed significantly (P < 0.05) higher specificity of 48.6% than the RF-CL model (specificity of 41.5%) and ESC 2019 model (specificity of 6.9%) while having the same sensitivity of 84.9% as the RF-CL model. Area under the curve of the receiver operating characteristic for the three models was 72.5% for ESC2019, 76.7% for RF-CL, and 79.5% for A-CL.

Conclusion

The proposed A-CL model offers significantly improved rule-out capacity over the ESC2019 model and showed better overall performance than the RF-CL model. The addition of acoustic features to the RF-CL model was shown to significantly improve early risk stratification of symptomatic patients suspected of having stable CAD.

Risk of death associated with incident heart failure in patients with known or suspected chronic coronary syndrome

AIMS

Traditional adverse events in chronic coronary syndrome (CCS) include atherothrombotic events but usually exclude heart failure (HF). Data are scarce about how new-onset HF modifies mortality risk. We aimed to determine the incidence of HF and compare its long-term mortality risk with myocardial infarction (MI) and stroke in patients with known or suspected CCS.

METHODS

We prospectively evaluated 5811 consecutive HF-free patients submitted to vasodilator stress cardiac magnetic resonance (CMR) for known or suspected CCS. Ischaemic burden and left ventricular ejection fraction were assessed by CMR. HF included outpatient diagnosis or acute HF hospitalization. The mortality risk for the incident events and their cross-comparisons were evaluated using a Markov illness-death model with transition-specific survival models.

RESULTS

The mean age was 55 ± 11 years, and 38.9% were female. At a median follow-up of 5.44 (IQR = 2.53-8.55) years, 591 deaths were registered (1.79 per 100 P-Y). The rates of new-onset HF were higher compared with MI and stroke [1.02, 0.62, and 0.51, respectively (P < 0.05)]. The adjusted association between new-onset HF, MI, and stroke, and subsequent mortality was time dependent. The risk increased almost linearly for HF and became significant by the third year. By Year 10, the mortality risk attributable to new-onset HF was more than 2.5-fold (HR: 2.68, 95% CI = 1.74-4.12). For MI, there was a significant increase in mortality risk up to the second year, followed by a monotonic decrease. For stroke, the mortality risk increased for the entire follow-up but became significant by the third year. A cross-comparison among incident endpoints HF outnumbers risk for those with MI by the sixth year (HR_year6.3 : 1.88, 95% CI = 1.03-3.43). There was no difference in mortality risk between incident HF and stroke.

CONCLUSIONS

In patients with CCS, long-term rates of incident HF were higher than MI and stroke. Patients with new-onset HF showed a higher risk of long-term mortality.