Incidence, Clinical Significance, and Longitudinal Signal Characteristics of Ischemic Lesions Related to Diagnostic Cerebral Catheter Angiography

PURPOSE

Cerebral DSA is a routine procedure with few complications. However, it is associated with presumably clinically inapparent lesions detectable on diffusion-weighted MRI imaging (DWI lesions). However, there are insufficient data regarding incidence, etiology, clinical relevance, and longitudinal development of these lesions. This study prospectively evaluated subjects undergoing elective diagnostic cerebral DSA for the occurrence of DWI lesions, potentially associated clinical symptoms and risk factors, and longitudinally monitored the lesions using state-of-the-art MRI.

MATERIALS AND METHODS

Eighty-two subjects were examined by high-resolution MRI within 24 h after elective diagnostic DSA and lesion occurrence was qualitatively and quantitatively evaluated. Subjects' neurological status was assessed before and after DSA by clinical neurological examination and a perceived deficit questionnaire. Patient-related risk factors and procedural DSA data were documented. Subjects with lesions received a follow-up MRI and were questioned for neurological deficits after a median of 5.1 months.

RESULTS

After DSA, 23(28%) subjects had a total of 54 DWI lesions. Significantly associated risk factors were number of vessels probed, intervention time, age, arterial hypertension, visible calcified plaques, and less examiner experience. Twenty percent of baseline lesions converted to persistent FLAIR lesions at follow-up. After DSA, none of the subjects had a clinically apparent neurological deficit. Self-perceived deficits were nonsignificantly higher at follow-up.

CONCLUSION

Cerebral DSA is associated with a considerable number of postinterventional lesions, some persisting as scars in brain tissue. Presumably because of the small lesion size and inconsistent location, no clinically apparent neurological deficits have been observed. However, subtle self-perceived changes may occur. Therefore, special attention is needed to minimize avoidable risk factors.

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BACKGROUND

The 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.

METHODS

In this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.

RESULTS

CAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.

CONCLUSION

The ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Resting Left Ventricular Global Longitudinal Strain to Identify Silent Myocardial Ischemia in Asymptomatic Patients with Diabetes Mellitus

BACKGROUND

Screening for silent coronary artery disease in asymptomatic patients with diabetes mellitus (DM) is challenging and controversial. In this context, it seems crucial to identify early markers of coronary artery disease.

METHODS

The aim of this study was to investigate the incremental value of resting left ventricular (LV) global longitudinal strain (GLS) for the prediction of positive results on stress (exercise or dobutamine) transthoracic echocardiography in 273 consecutive asymptomatic high-risk patients with DM. Positive results on stress transthoracic echocardiography were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities).

RESULTS

Compared with patients with negative stress results, those with positive stress results (n = 28 [10%]) more frequently had cardiovascular risk factors, complications of DM, vascular disease, moderate and severe calcification of the aortic valve and mitral annulus, and worse resting LV GLS (-16.7 ± 2.9% vs -19.0 ± 1.9%, P < .001). On multivariable logistic regression analysis, DM duration > 10 years, diabetic retinopathy, LV hypertrophy, and impaired LV GLS (odds ratio, 1.39 [95% CI, 1.14-1.70] per percentage increase; odds ratio, 5.16 [95% CI, 1.96-13.59] for LV GLS worse than -18%) were independently associated with positive results on stress transthoracic echocardiography. The area under the curve to predict positive results was 0.74 for LV GLS with a cutoff of -18.0% (sensitivity 68%, specificity 78%). The area under the curve of the multivariable model to predict test results was improved by the addition of LV GLS (P < .001), with a bias-corrected area under the curve after bootstrapping of 0.842 [95% CI, 0.753-0.893].

CONCLUSIONS

The present findings show that resting LV GLS is associated with the presence of silent ischemia and could be useful to better identify asymptomatic patients with DM who might benefit from coronary artery disease screening.

Assessing the prevalence and predicting factors of an abnormal gated myocardial perfusion SPECT in asymptomatic patients with type 2 diabetes

Considering the significant prevalence of silent myocardial ischemia and its related morbidity and mortality in asymptomatic type 2 diabetic patients, it is not well known whether early screening with MPI is cost-effective and predicting factors are not well elucidated. This was a cross-sectional study including 63 asymptomatic patients with type 2 diabetes mellitus (T2DM), with normal ECG and ejection fraction. Patients with any history of documented valvular, congestive or ischemic heart disease, renal or hepatic failure were excluded. At first all patients were interviewed and checked for risk factors and then patients underwent a two-day rest/stress 99mTc-MIBI gated MPI SPECT. Data was assessed by QPS/QGS and 4DM software and evaluated by a nuclear medicine specialist with summed stress score (SSS) of more than 4 defined as CAD. There were 42 females (67%) and 21 males (33%), with a mean age of 61.33 ± 6.98 years and 7.97 ± 4.86 years history of T2DM. CAD was detected in 26 (41.3%) patients and was significantly associated with male gender, smoking and requiring insulin therapy (P-value = 0.019, 0.046, 0.05, respectively). A significant association was found between the duration of diabetes, especially when > 15 years, and the probability of having CAD. Multivariable logistic regression revealed that smoking; male gender and diabetes duration were the strongest independent predictors of abnormal MPI results. We found a high (46%) prevalence of abnormal stress MPI SPECT in patients with type 2 diabetes mellitus, despite being asymptomatic. Asymptomatic patients with a history of smoking, long duration of diabetes, being under insulin treatment and male gender might benefit from MPI for early detection of silent ischemia.

Diabetes and the Risk of Sudden Cardiac Death

PURPOSE OF REVIEW

Persons with diabetes mellitus (DM) have increased morbidity and mortality rates compared with persons without DM. Sudden cardiac death (SCD) is a leading cause of death, and multiple studies have found an increased risk of SCD among individuals with DM. This review sought to collect the latest knowledge of the epidemiological and pathophysiological interplay between DM and SCD.

RECENT FINDINGS

Persons with DM have a two- to tenfold increased risk of SCD compared with persons without DM. The underlying mechanisms for the increased risk of SCD are complex and multifactorial. The main pathophysiological contributors are DM-induced cardiac autonomic neuropathy (CAN), metabolic changes, silent ischemia, and polypharmacy. Persons with DM have an increased risk of SCD. Future studies should focus on CAN and the combined risk of QT prolongation from the interplay between CAN, hypoglycemia, and polypharmacy. Genes and pathways involved in control of the autonomic nervous system and cardiac ion channels could be a future focal point.

Simulation Training in Neuroangiography: Transfer to Reality

PURPOSE

Endovascular simulation is an established and validated training method, but there is still no proof of direct patient's benefit, defined as lower complication rate. In this study, the impact of such a training was investigated for rehearsal of patient-specific cases as well as for a structured simulation curriculum to teach angiographer novices.

MATERIALS AND METHODS

A total of 40 patients undergoing a diagnostic neuroangiography were randomized in a training and control group. In all training group patients, the angiographer received a patient-anatomy-specific rehearsal on a high-fidelity simulator prior to the real angiography. Radiation exposure, total duration, fluoroscopy time and amount of contrast agent of the real angiography were recorded. Silent cerebral ischemia was counted by magnetic resonance diffusion-weighted imaging (DWI). Additionally, the first 30 diagnostic neuroangiographies of six novices were compared (n_total = 180). Three novices had undergone a structured simulation curriculum; three had acquired angiographic skills without simulation.

RESULTS

No differences were found in the number of DWI lesions or in other quality measures of the angiographies performed with and without patient-specific rehearsal. A structured simulation curriculum for angiographer novices reduced fluoroscopy time significantly and radiation exposure. The curriculum had no influence on the total duration of the examination, the amount of contrast medium or the number of catheters used.

CONCLUSION

There was no measurable benefit of patient-anatomy-specific rehearsal for an unselected patient cohort. A structured simulation-based curriculum to teach angiographic skills resulted in a reduction of fluoroscopy time and radiation dose in the first real angiographies of novice angiographers.

LEVEL OF EVIDENCE

Level 4, part 1: randomized trial, part 2: historically controlled study.

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

BACKGROUND

Up to two-thirds of patients with obstructive coronary artery disease (CAD) have silent ischemia (SI), which predicts an adverse prognosis and can be a treatment target in obstructive CAD. Over 50% of women with ischemia and no obstructive CAD have coronary microvascular dysfunction (CMD), which is associated with adverse cardiovascular outcomes. We aimed to investigate the prevalence of SI in CMD in order to consider it as a potential treatment target.

METHODS

36 women with CMD by coronary reactivity testing and 16 age matched reference subjects underwent 24-h 12-lead ambulatory ECG monitoring (Mortara Instruments) after anti-ischemia medication withdrawal. Ambulatory ECG recordings were reviewed by two-physician consensus masked to subject status for SI measured by evidence of ≥1 minute horizontal or downsloping ST segment depression ≥1.0 mm, measured 80 ms from the J point.

RESULTS

Demographics, resting heart rate, and systolic blood pressure were similar between CMD and reference subjects. Thirty-nine percent of CMD women had a total of 26 SI episodes vs. 0 episodes in the reference group (p = 0.002). Among these women 13/14 (93%) had SI, and few episodes (3/26, 12%) were symptomatic. Mean HR at the onset of SI was 96 ± 13 bpm and increased to 117 ± 16 bpm during the ischemic episodes. 87% reported symptoms that were not associated with ST depressions.

CONCLUSIONS

Ambulatory ischemia is prevalent in women with CMD, with a majority being SI, while most reported symptoms were not accompanied by ambulatory ischemia. Clinical trials evaluating anti-ischemic medications should be considered in the CMD population.

Risk of undiagnosed coronary artery disease associated with infrapopliteal artery occlusion from a multicenter study

Peripheral artery disease (PAD) is associated with high cardiovascular mortality. Which part of PAD with lower extremities is related to coronary artery disease (CAD) remains unknown. We hypothesized that PAD including infrapopliteal artery (IPA) occlusion was associated with CAD. A total of 260 patients who have no history of CAD or the anginal symptom, complain of the claudication or critical limb ischemia and underwent peripheral angiography were retrospectively analyzed. IPA occlusion was diagnosed with peripheral angiography, and CAD was diagnosed with the coronary angiography. A multivariate logistic regression analysis was performed to determine the predictors of silent CAD. Among them, a total of 146 patients (56.2%) had IPA occlusion. Baseline characteristics were significantly different between two groups as to the proportions of age, male, dyslipidemia (with vs. without IPA occlusion; 72.4 ± 10.8 vs. 69.1 ± 10.2; 62.3% vs. 75.4%; 38.6% vs. 52.6%, respectively, all comparisons P < 0.05). Notably, the prevalence of CAD was significantly higher in patients with IPA occlusion (50.7% vs. 34.2%, P = 0.008). On a multivariate analysis, IPA occlusion was an independent predictor for the presence of silent CAD (OR, 1.94; CI, 1.09-3.44, P = 0.024), but aortoiliac artery occlusion (OR, 1.16; CI, 0.53-2.56, P = 0.71) and femoropopliteal artery occlusion (OR, 1.02; CI, 0.57-1.83, P = 0.96) were not. IPA occlusion was associated with silent CAD. Vascular surgeons, interventional radiologists, as well as interventional cardiologists should recognize IPA occlusion as a risk factor of silent CAD.

[Comparative Study Of Coronary Artery Disease In Diabetics And Non-Diabetics In The Department Of Cardiology Of Aristide Le Dantec University Hospital]

The aim of this study was to compare the features of coronary artery disease between diabetic and non-diabetic patients.

PATIENTS AND METHODS

A case-control study was carried out from 1 May 2013 to 31 July 2015 in the department of cardiology of Aristide le Dantec university hospital. Forty-five diabetic patients and forty-five non-diabetic patients who underwent coronary angiography and / or angioplasty were included.

RESULTS

There was a male predominance with a sex ratio of 1.6 in both groups. The mean age was 62.26 years for diabetics and 59.06 years for non-diabetics (p = 0.6). In diabetics, symptomatology was dominated by silent ischemia (48.9%) versus typical angina pain (68.9%) in non-diabetics. Myocardial infarction was the most common indication of coronary angiography in both groups. Coronary angiography revealed one-vessel disease (46.6% versus 41.7% p = 0.822), double vessel disease (26.7% versus 41.7% p = 0.091) and triple vessel disease (26.7% versus 16.6% p = 0.561). Angioplasty was indicated in 37.8% of diabetics versus 63.9% of non-diabetics. Nine diabetic patients and three non-diabetic patients had an indication of coronary artery bypass grafting.

CONCLUSION

Our study confirms the greater frequency of silent ischemia and multiple-vessel disease in diabetics as well as a more frequent indication of coronary artery bypass grafting in these patients.

Stable Ischemic Heart Disease

Classical angina refers to typical substernal discomfort triggered by effort or emotions, relieved with rest or nitroglycerin. The well-accepted pathogenesis is an imbalance between oxygen supply and demand. Goals in therapy are improvement in quality of life by limiting the number and severity of attacks, protection against future lethal events, and measures to lower the burden of risk factors to slow disease progression. New pathophysiological data, drugs, as well as conceptual and technological advances have improved patient care over the past decade. Behavioral changes to improve diets, increase physical activity, and encourage adherence to cardiac rehabilitation programs, are difficult to achieve but are effective.

Endothelial Dysfunction is Associated with Occult Coronary Artery Disease Detected by Positron Emission Tomography

OBJECTIVE

Silent myocardial ischemia is common in asymptomatic subjects without a prior history of coronary artery disease (CAD) and is associated with increased morbidity and mortality. Our objective was to determine whether endothelial dysfunction is associated with silent myocardial ischemia and whether the association is independent of genetic and familial factors.

MATERIAL AND METHODS

We examined 416 male monozygotic and dizygotic twins aged 47 to 63 years, free of symptomatic CAD. Subclinical ischemia was diagnosed by [13N] ammonia positron emission tomography at rest and after adenosine stress. Endothelial function was measured by flow-mediated dilation (FMD) of the brachial artery. Generalized estimating equations were used for analysis.

RESULTS

Fixed perfusion defects were found in 24 (6%) twins and reversible perfusion defects in 90 (22%) twins, indicating subclinical ischemia. There was an inverse correlation between FMD and the reversible perfusion defect score (r = - 0.14, p=0.01) but not the fixed defect score (r= -0.017, p=0.73). From the lowest to the highest quartile of FMD, the prevalence of reversible defects decreased 28% to 14%, p=0.008. In multivariable analysis, reversible defects were significantly associated with each quartile of decreasing FMD (OR =1.3; 95% 1.1, 2.5). In 54 twin pairs discordant for endothelial dysfunction (FMD ≤ 7% dilation from baseline), twins with endothelial dysfunction had 9% higher likelihood of having perfusion defects than their co-twins without endothelial dysfunction (p=0.041).

CONCLUSIONS

Endothelial dysfunction is independently associated with silent ischemia and this association is not confounded by genetic or other shared familial factors.

Stable ischemic heart disease

Classical angina refers to typical substernal discomfort triggered by effort or emotions, relieved with rest or nitroglycerin. The well-accepted pathogenesis is an imbalance between oxygen supply and demand. Goals in therapy are improvement in quality of life by limiting the number and severity of attacks, protection against future lethal events, and measures to lower the burden of risk factors to slow disease progression. New pathophysiological data, drugs, as well as conceptual and technological advances have improved patient care over the past decade. Behavioral changes to improve diets, increase physical activity, and encourage adherence to cardiac rehabilitation programs, are difficult to achieve but are effective.

The clinical significance of continuous ECG (ambulatory ECG or Holter) monitoring of the ST-segment to evaluate ischemia: a review

Silent ischemia is a common manifestation of coronary artery disease (CAD). Continuous ECG (cECG) monitoring is an effective tool for assessing the frequency and duration of silent ischemic episodes for patients with CAD and for risk stratifying asymptomatic patients or those after an acute coronary syndrome by identifying those at increased risk for future cardiovascular events or death. cECG also allows monitoring of the effectiveness of therapy in patients with CAD. Treatment strategies targeted toward the elimination of silent ischemia have shown that revascularization was better than medical therapy in eliminating silent ischemia, but large scale, prospective studies targeting silent ischemia as a treatment endpoint are still lacking. Future research is warranted to study the effects of newer medical agents or the selected use of revascularization in those patients with persistent silent ischemia despite current medical regiments.