Acute coronary events

Plasma miR-122 and miR-3149 Potentially Novel Biomarkers for Acute Coronary Syndrome

OBJECTIVE

We evaluated the potentiality of plasma microRNAs (miRNAs, or miRs) that were considered as novel biomarkers for acute coronary syndrome (ACS), including acute myocardial infarction (AMI) and unstable angina (UA).

METHODS AND RESULTS

We initially identified plasma miR-122, -140-3p, -144, -720, -1225-3p, -2861, and -3149 as candidate miRNAs associated with AMI (≥2 fold and P < 0.05) by comparing expression differences of miRNAs among AMI, non-coronary heart disease (non-CHD) and stable angina (SA) groups, using miRNA microarrays (n = 8 independent arrays in each group). Those seven plasma miRNAs were further examined with qRT-PCR analyses in two replications including 111 and 428 patients separately, and the results demonstrated that plasma miR-122, -140-3p, -720, -2861, and -3149 were elevated in the ACS group vs. the non-ACS (non-CHD + SA) group (P < 0.01). The area under the receiver operating characteristic curve (AUC) of the five miRNAs for ACS classification was 0.838, 0.818, 0.865, 0.852, and 0.670, respectively (all P < 0.001), while the values reached 0.843 and 0.925 when simultaneously with miR-122 and -3149 or with miR-122, -2861, and -3149 together (all P < 0.001). In plasma of pigs after coronary ligation, miR-122 was increased from 180 min to 240 min and miR-3149 was augmented from 30 min to 240 min compared with the sham pigs (all P < 0.05).

CONCLUSION

Plasma miR-122, -140-3p, -720, -2861, and -3149 were associated with and potentially novel biomarkers for ACS.

Lack of association between epicardial fat volume and extent of coronary artery calcification, severity of coronary artery disease, or presence of myocardial perfusion abnormalities in a diverse, symptomatic patient population: results from the CORE320 multicenter study

BACKGROUND

Epicardial fat may play a role in the pathogenesis of coronary artery disease (CAD). We explored the relationship of epicardial fat volume (EFV) with the presence and severity of CAD or myocardial perfusion abnormalities in a diverse, symptomatic patient population.

METHODS AND RESULTS

Patients (n=380) with known or suspected CAD who underwent 320-detector row computed tomographic angiography, nuclear stress perfusion imaging, and clinically driven invasive coronary angiography for the CORE320 international study were included. EFV was defined as adipose tissue within the pericardial borders as assessed by computed tomography using semiautomatic software. We used linear and logistic regression models to assess the relationship of EFV with coronary calcium score, stenosis severity by quantitative coronary angiography, and myocardial perfusion abnormalities by single photon emission computed tomography (SPECT). Median EFV among patients (median age, 62.6 years) was 102 cm(3) (interquartile range: 53). A coronary calcium score of ≥1 was present in 83% of patients. Fifty-nine percent of patients had ≥1 coronary artery stenosis of ≥50% by quantitative coronary angiography, and 49% had abnormal myocardial perfusion results by SPECT. There were no significant associations between EFV and coronary artery calcium scanning, presence severity of ≥50% stenosis by quantitative coronary angiography, or abnormal myocardial perfusion by SPECT.

CONCLUSIONS

In a diverse population of symptomatic patients referred for invasive coronary angiography, we did not find associations of EFV with the presence and severity of CAD or with myocardial perfusion abnormalities. The clinical significance of quantifying EFV remains uncertain but may relate to the pathophysiology of acute coronary events rather than the presence of atherosclerotic disease.

Association of small dense LDL serum levels and circulating monocyte subsets in stable coronary artery disease

Objective

Atherosclerosis is considered to be an inflammatory disease in which monocytes and monocyte-derived macrophages play a key role. Circulating monocytes can be divided into three distinct subtypes, namely in classical monocytes (CM; CD14++CD16-), intermediate monocytes (IM; CD14++CD16+) and non-classical monocytes (NCM; CD14+CD16++). Low density lipoprotein particles are heterogeneous in size and density, with small, dense LDL (sdLDL) crucially implicated in atherogenesis. The aim of this study was to examine whether monocyte subsets are associated with sdLDL serum levels.

Methods

We included 90 patients with angiographically documented stable coronary artery disease and determined monocyte subtypes by flow cytometry. sdLDL was measured by an electrophoresis method on polyacrylamide gel.

Results

Patients with sdLDL levels in the highest tertile (sdLDL≥4mg/dL;T3) showed the highest levels of pro-inflammatory NCM (15.2±7% vs. 11.4±6% and 10.9±4%, respectively; p<0.01) when compared with patients in the middle (sdLDL=2-3mg/dL;T2) and lowest tertile (sdLDL=0-1mg/dL;T1). Furthermore, patients in the highest sdLDL tertile showed lower CM levels than patients in the middle and lowest tertile (79.2±8% vs. 83.9±7% and 82.7±5%; p<0.01 for T3 vs. T2+T1). Levels of IM were not related to sdLDL levels (5.6±4% vs. 4.6±3% vs. 6.4±3% for T3, T2 and T1, respectively). In contrast to monocyte subset distribution, levels of circulating pro- and anti-inflammatory markers were not associated with sdLDL levels.

Conclusion

The atherogenic lipoprotein fraction sdLDL is associated with an increase of NCM and a decrease of CM. This could be a new link between lipid metabolism dysregulation, innate immunity and atherosclerosis.

Patterns and determinants of temporal change in high-sensitivity cardiac troponin-T: The Atherosclerosis Risk in Communities Cohort Study

BACKGROUND

Patterns and determinants of temporal change in highly-sensitivity troponin-T (hs-cTNT), a novel measure of subclinical myocardial injury, among asymptomatic persons have not been well characterized.

METHODS

We studied 8571 ARIC Study participants, free of cardiovascular disease, who had hs-cTNT measured at two time-points, 6 years apart (1990-1992 and 1996-1998). We examined the association of baseline 10-year atherosclerotic cardiovascular (ASCVD) risk-group (<5%, 5-7.4%, ≥ 7.5%) and individual cardiac risk-factors with change across hs-cTNT categories using Poisson and Multinomial Logistic regression and with mean continuous hs-cTNT change using linear regression.

RESULTS

Mean age was 57 years and 43% were male. Mean (SD) 6-year hs-cTNT change was higher across increasing ASCVD risk-groups; +1.2 (6.1) ng/L [<5%], +2.1 (5.4) ng/L [5-7.4%], and +2.8 (8.8) ng/L [≥ 7.5%]. Major baseline determinants of temporal hs-cTNT increases were: age, male gender, hypertension, diabetes, and obesity. In addition, the relative risk (RR) of incident elevated hs-cTNT (≥ 14 ng/L) was 1.46 (95% CI 1.1-2.0) for persons with sustained hypertension compared to those who remained normotensive. Results for sustained obesity (RR 1.65 [1.19-2.29]) and hyperglycemia (RR 1.76 [1.16-2.67]) were similar. These associations were generally stronger after accounting for survival bias. However, smoking, LDL-cholesterol and triglycerides were not associated with hs-cTNT change. HDL-cholesterol was associated with declining hs-cTNT.

CONCLUSIONS

Persons in higher ASCVD risk-groups were more likely to have increases in hs-cTNT over 6 years of follow-up. The modifiable risk-factors primarily driving this association were diabetes, hypertension, and obesity; particularly when they were persistently elevated over follow-up. Future studies are needed to determine whether modifying these risk factors can prevent progression of subclinical myocardial injury.

The role of T and B cells in human atherosclerosis and atherothrombosis

Far from being merely a passive cholesterol accumulation within the arterial wall, the development of atherosclerosis is currently known to imply both inflammation and immune effector mechanisms. Adaptive immunity has been implicated in the process of disease initiation and progression interwined with traditional cardiovascular risk factors. Although the body of knowledge regarding the correlation between atherosclerosis and immunity in humans is growing rapidly, a relevant proportion of it derives from studies carried out in animal models of cardiovascular disease (CVD). However, while the mouse is a well-suited model, the results obtained therein are not fully transferrable to the human setting due to intrinsic genomic and environmental differences. In the present review, we will discuss mainly human findings, obtained either by examination of post-mortem and surgical atherosclerotic material or through the analysis of the immunological profile of peripheral blood cells. In particular, we will discuss the findings supporting a pro-atherogenic role of T cell subsets, such as effector memory T cells or the potential protective function of regulatory T cells. Recent studies suggest that traditional T cell-driven B2 cell responses appear to be atherogenic, while innate B1 cells appear to exert a protective action through the secretion of naturally occurring antibodies. The insights into the immune pathogenesis of atherosclerosis can provide new targets in the quest for novel therapeutic targets to abate CVD morbidity and mortality.

Perfect storm: concurrent stress and depressive symptoms increase risk of myocardial infarction or death

BACKGROUND

Depression and stress have each been found to be associated with poor prognosis in patients with coronary heart disease. A recently offered psychosocial perfect storm conceptual model hypothesizes amplified risk will occur in those with concurrent stress and depressive symptoms. We tested this hypothesis in a large sample of US adults with coronary heart disease.

METHODS AND RESULTS

Participants included 4487 adults with coronary heart disease from the REasons for Geographic and Racial Differences in Stroke study, a prospective cohort study of 30,239 black and white adults. We conducted Cox proportional hazards regression with the composite outcome of myocardial infarction or death and adjustment for demographic, clinical, and behavioral factors. Overall, 6.1% reported concurrent high stress and high depressive symptoms at baseline. During a median 5.95 years of follow-up, 1337 events occurred. In the first 2.5 years of follow-up, participants with concurrent high stress and high depressive symptoms had increased risk for myocardial infarction or death (adjusted hazard ratio, 1.48 [95% confidence interval, 1.08-2.02]) relative to those with low stress and low depressive symptoms. Those with low stress and high depressive symptoms (hazard ratio, 0.92 [95% confidence interval, 0.66-1.28]) or high stress and low depressive symptoms (hazard ratio, 0.86 [95% confidence interval, 0.57-1.29]) were not at increased risk. The association on myocardial infarction or death was not significant after the initial 2.5 years of follow-up (hazard ratio, 0.89 [95% confidence interval, 0.65-1.22]).

CONCLUSIONS

Our results provide initial support for a psychosocial perfect storm conceptual model; the confluence of depressive symptoms and stress on medical prognosis in adults with coronary heart disease may be particularly destructive in the shorter term.

The myth of the "vulnerable plaque": transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment

The cardiovascular science community has pursued the quest to identify vulnerable atherosclerotic plaque in patients for decades, hoping to prevent acute coronary events. However, despite major advancements in imaging technology that allow visualization of rupture-prone plaques, clinical studies have not demonstrated improved risk prediction compared with traditional approaches. Considering the complex relationship between plaque rupture and acute coronary event risk suggested by pathology studies and confirmed by clinical investigations, these results are not surprising. This review summarizes the evidence supporting a multifaceted hypothesis of the natural history of atherosclerotic plaque rupture. Managing patients at risk of acute coronary events mandates a greater focus on the atherosclerotic disease burden rather than on features of individual plaques.

PET imaging of atherosclerosis

ABSTRACT 

Atherosclerosis is a chronic, progressive, multifocal disease of the arterial wall, which is mainly fuelled by local and systemic inflammation, often resulting in acute ischemic events following plaque rupture and vessel occlusion. When assessing the cardiovascular risk of an individual patient, we must consider both global measures of disease activity and local features of plaque vulnerability, in addition to anatomical distribution and degree of established atherosclerosis. These parameters cannot be measured with conventional anatomical imaging techniques alone, which are designed primarily to identify the presence of organic intraluminal obstruction in symptomatic patients. However, molecular imaging with PET, using specifically targeted radiolabeled probes to track active in vivo atherosclerotic mechanisms noninvasively, may potentially provide a method that is better suited for this purpose. Vascular PET imaging can help us to further understand aspects of plaque biology, and current evidence supports a future role as an emerging clinical tool for the quantification of cardiovascular risk in order to guide and monitor responses to antiatherosclerosis treatments and to distinguish high-risk plaques.

Fluorescence lifetime imaging and intravascular ultrasound: co-registration study using ex vivo human coronaries

Fluorescence lifetime imaging (FLIM) has demonstrated potential for robust assessment of atherosclerotic plaques biochemical composition and for complementing conventional intravascular ultrasound (IVUS), which provides information on plaque morphology. The success of such a bi-modal imaging modality depends on accurate segmentation of the IVUS images and proper angular registration between these two modalities. This paper reports a novel IVUS segmentation methodology addressing this issue. The image preprocessing consisted of denoising, using the Wiener filter, followed by image smoothing, implemented through the application of the alternating sequential filter on the edge separability metric images. Extraction of the lumen/intima and media/adventitia boundaries was achieved by tracing the gray-scale peaks over the A-lines of the IVUS preprocessed images. Cubic spline interpolation, in both cross-sectional and longitudinal directions, ensured boundary smoothness and continuity. The detection of the guide-wire artifact in both modalities is used for angular registration. Intraluminal studies were conducted in 13 ex vivo segments of human coronaries. The IVUS segmentation accuracy was assessed against independent manual tracings, providing 91.82% sensitivity and 97.55% specificity. The proposed methodology makes the bi-modal FLIM and IVUS approach feasible for comprehensive intravascular diagnosis by providing co-registered biochemical and morphological information of atherosclerotic plaques.

Role of oral factor Xa inhibitors after acute coronary syndrome

Despite an early invasive strategy and the use of dual antiplatelet therapy, patients with acute coronary syndrome (ACS) continue to be at substantial risk for recurrent ischemic events. It is believed that this risk is, at least in part, due to an intrinsic coagulation pathway that remains activated for a prolonged period after ACS. Earlier studies using warfarin showed a reduction in ischemic events, but the overall benefits were offset by increased bleeding complications. Recently, there has been increased interest in the potential role of new oral anticoagulants, some of which target factor Xa, after ACS. Factor Xa is important for the coagulation pathway and also plays a role in cellular proliferation and inflammation. It may thus be an attractive target for therapeutic intervention in ACS. Recently, various oral factor Xa inhibitors have been studied as potential treatment options for ACS. This review will focus on currently available data to evaluate the possible role of factor Xa inhibitors in the management of patients with ACS.

Confluence of depression and acute psychological stress among patients with stable coronary heart disease: effects on myocardial perfusion

Background

Depression is prevalent in coronary heart disease (CHD) patients and increases risk for acute coronary syndrome (ACS) recurrence and mortality despite optimal medical care. The pathways underlying this risk remain elusive. Psychological stress (PS) can provoke impairment in myocardial perfusion and trigger ACS. A confluence of acute PS with depression might reveal coronary vascular mechanisms of risk. We tested whether depression increased risk for impaired myocardial perfusion during acute PS among patients with stable CHD.

Methods and Results

Patients (N=146) completed the Beck Depression Inventory‐I (BDI‐I), a measure of depression linked to recurrent ACS and post‐ACS mortality, and underwent single‐photon emission computed tomography myocardial perfusion imaging at rest and during acute PS. The likelihood of new/worsening impairment in myocardial perfusion from baseline to PS as a function of depression severity was tested. On the BDI‐I, 41 patients scored in the normal range, 48 in the high normal range, and 57 in the depressed range previously linked to CHD prognosis. A BDI‐I score in the depressed range was associated with a significantly greater likelihood of new/worsening impairment in myocardial perfusion from baseline to PS (odds ratio =2.89, 95% CI: 1.26 to 6.63, P=0.012). This remained significant in models controlling ACS recurrence/mortality risk factors and medications. There was no effect for selective serotonin reuptake inhibitor medications.

Conclusions

Depressed patients with CHD are particularly susceptible to impairment in myocardial perfusion during PS. The confluence of PS with depression may contribute to a better understanding of the depression‐associated risk for ACS recurrence and mortality.

Greater collagen-induced platelet aggregation following cyclooxygenase 1 inhibition predicts incident acute coronary syndromes

Greater ex vivo platelet aggregation to agonists may identify individuals at risk of acute coronary syndromes (ACS). However, increased aggregation to a specific agonist may be masked by inherent variability in other activation pathways. In this study, we inhibited the cyclooxygenase-1 (COX1) pathway with 2-week aspirin therapy and measured residual aggregation to collagen and ADP to determine whether increased aggregation in a non-COX1 pathway is associated with incident ACS. We assessed ex vivo whole blood platelet aggregation in 1,699 healthy individuals with a family history of early-onset coronary artery disease followed for 6±1.2 years. Incident ACS events were observed in 22 subjects. Baseline aggregation was not associated with ACS. After COX1 pathway inhibition, collagen-induced aggregation was significantly greater in participants with ACS compared with those without (29.0 vs. 23.6 ohms, p < 0.001). In Cox proportional hazards models, this association remained significant after adjusting for traditional cardiovascular risk factors (HR = 1.10, 95%CI = 1.06-1.15; p < 0.001). In contrast, ADP-induced aggregation after COX1 inhibition was not associated with ACS. After COX1 pathway inhibition, subjects with greater collagen-induced platelet aggregation demonstrated a significant excess risk of incident ACS. These data suggest that platelet activation related to collagen may play an important role in the risk of ACS.

Difference of ruptured plaque morphology between asymptomatic coronary artery disease and non-ST elevation acute coronary syndrome patients: an optical coherence tomography study

BACKGROUND

Autopsy studies have reported that rupture of a thin-cap fibroatheroma and subsequent thrombus formation is the major mechanism leading to acute coronary syndrome (ACS). However, it is not clear why only some plaque ruptures lead to ACS. Optical coherence tomography (OCT) is a high-resolution imaging modality which is capable of investigating detailed coronary plaque morphology in vivo. The objective of this study was to determine whether ruptured plaque morphology assessed by OCT differs between asymptomatic coronary artery disease (CAD) and non-ST elevation acute coronary syndrome (NSTEACS).

METHODS

We examined ruptured plaque morphology using OCT in 80 patients, 33 with asymptomatic CAD and 47 with NSTEACS.

RESULTS

The frequency of lipid-rich plaque and intracoronary thrombus was significantly lower in asymptomatic CAD than in NSTEACS (61% vs. 85%, p = 0.013 and 9% vs. 83%, p < 0.001, respectively). Although maximal ruptured cavity cross-sectional area (CSA) was similar in both groups, lumen area at the rupture site and minimal lumen area were significantly larger in asymptomatic CAD than in NSTEACS (3.78 ± 1.50 mm(2) vs. 2.70 ± 1.55 mm(2), p = 0.003 and 2.75 ± 0.99 mm(2) vs. 1.72 ± 0.90 mm(2), p < 0.001, respectively).

CONCLUSIONS

OCT revealed that the morphology of ruptured plaques differs between asymptomatic CAD and NSTEACS in terms of lumen area and the frequency of lipid-rich plaques and thrombi. These morphological features may be associated with the clinical presentation of CAD.

Role of computed tomography for diagnosis and risk stratification of patients with suspected or known coronary artery disease

Cardiac computed tomographic angiography (CCTA) has emerged as a powerful imaging modality for the detection and prognostication of individuals with suspected coronary artery disease. Because calcification of coronary plaque occurs in proportion to the total atheroma volume, the initial diagnostic potential of CCTA focused on the identification and quantification of coronary calcium in low- to intermediate-risk individuals, a finding that tracks precisely with the risk of incident adverse clinical events. Beyond noncontrast detection of coronary calcium, CCTA using iodinated contrast yields incremental information about the degree and distribution of coronary plaques and stenosis, as well as vessel wall morphology and atherosclerotic plaque features. This additive information offers the promise of CCTA to provide a more comprehensive view of total atherosclerotic burden because it relates to myocardial ischemia and future adverse clinical events. Furthermore, emerging data suggest the prognostic and diagnostic importance of stenosis severity detection and atherosclerotic plaque features described by CCTA including positive remodeling, low-attenuation plaque, and spotty calcification, which have been associated with the vulnerability of plaque. We report a summary of the evidence supporting the role of CCTA in the detection of subclinical and clinical coronary artery disease in both asymptomatic and symptomatic patients and discuss the potential of CCTA to augment the identification of at-risk individuals. CCTA and coronary artery calcium scoring offer the ability to improve risk stratification, discrimination, and reclassification of the risk in patients with suspected coronary artery disease and to noninvasively determine the measures of stenosis severity and atherosclerotic plaque features.

Imaging atherosclerosis and risk of plaque rupture

Atherosclerosis imaging strategies can delineate characteristics of plaques at risk of rupture and thrombosis. Structural plaque imaging identifies high-risk plaque features, including lipid pools, thin fibrous caps, and intraplaque hemorrhage. New molecular imaging techniques complement structural imaging approaches by illuminating important features of plaque biology, with a prominent focus on detecting inflammation as a high-risk phenotype. As we unravel the molecular and structural characteristics underlying thrombosis-prone plaques, there is significant promise for eventual early identification and prediction of atherosclerotic plaque complications before they occur. Here we focus on recent imaging insights into high-risk arterial plaques, the etiologic agent of acute myocardial infarction, stroke, and sudden cardiac death.

Current perspective on mental stress-induced myocardial ischemia

Mental stress and emotional arousal can act as triggers of myocardial infarction and other adverse cardiovascular outcomes. This editorial presents an overview of the research on mental stress-induced myocardial ischemia (MSIMI) and comments on two investigations examining MSIMI published in this journal. These studies confirm that MSIMI is frequently observed in patients with coronary artery disease and that characteristics, such as being a woman younger than 50 years and depression, may increase the relative risk of MSIMI. The method used for determining MSIMI (i.e., assessing cardiac function as determined by echocardiography versus measurement of myocardial perfusion using single-photon emission computed tomography), as well as the nature of the mental stress protocols (i.e., one stress task versus several repeated tasks), may have important effects on the findings of MSIMI research and on their interpretation. An overview of clinical characteristics of MSIMI is presented, and the article concludes with possible directions for future MSIMI research.

In search of serenity: religious struggle among patients hospitalized for suspected acute coronary syndrome

Hospitalization for a sudden cardiac event is a frightening experience, one that is often marked by uncertainty about health status, fear of recurrent cardiac problems, and related existential, religious, and spiritual concerns. Religious struggle, reflecting tension and strain regarding religious and spiritual issues, may arise in response to symptoms of acute coronary syndrome (ACS). The present study examined the prevalence and types of religious struggle using the Brief RCOPE, as well as associations between religious struggle, psychological distress, and self-reported sleep habits among 62 patients hospitalized with suspected ACS. Fifty-eight percent of the sample reported some degree of religious struggle. Questioning the power of God was the most frequently endorsed struggle. Those struggling religiously reported significantly more symptoms of anxiety, depression, and sleep disturbance. Non-White participants endorsed greater use of positive religious coping strategies and religious struggle. Results suggest that patients hospitalized for suspected ACS experiencing even low levels of religious struggle might benefit from referral to a hospital chaplain or appropriately trained mental health professional for more detailed religious and spiritual assessment. Practical means of efficiently screening for religious struggle during the often brief hospitalization period for suspected ACS are discussed.

Relation of myocardial bridge to myocardial infarction: a meta-analysis

BACKGROUND

Small case series have suggested an association of coronary myocardial bridge (MB) with myocardial infarction (MI). However, the relationship between MB and major adverse cardiac events (MACE) remains largely unknown. The aim of this study was to assess the relationship between MB and MACE involving MI.

METHODS

We performed a systematic search of MEDLINE, PreMEDLINE, and all EMB Reviews as well as a reference list of relevant articles according to the SPICO (Study design, Patient, Intervention, Control-intervention, and Outcome) criteria using the following keywords: myocardial bridging, myocardial bridge, intramural coronary artery, mural coronary artery, tunneled coronary artery, coronary artery overbridging, etc. Bibliographies of the retrieved publications were additionally hand searched. Studies were included for the meta-analysis if they satisfied the following criteria: (1) they evaluate the association of MB with cardiovascular endpoint event; (2) they included individuals with MB and those without MB; 3) they excluded individuals with obstructive coronary artery disease (CAD). Studies were reviewed by a predetermined protocol including quality assessment. Dates were pooled using a random effect model.

RESULTS

Seven observational studies that followed 5 486 patients eligible for the enrolled criteria were included from 7 136 initially identified articles. The prevalence of MB was 24.8% (1 363/5 486). During 0.5-7.0 years of follow-up of this cohort of population, crude outcome rates were 8.0% in the MB group and 7.7% in the non-MB group. The odds ratio of overall MACE and MI were 1.34 (95% confidence interval (CI): 0.57-3.17, P = 0.51, n = 7 studies) and 2.75 (95% CI: 1.08-7.02, P < 0.03, n = 5 studies) respectively for subjects of MB compared to non-MB.

CONCLUSION

Relationship between MB and MI appears to be a real one, although the study did not reveal a connection of MB to MACE, suggesting whether the necessity of antiplatelet therapy needs to be further studied in a larger cohort of patients with MB prospectively.

Coronary artery disease concomitant with chronic obstructive pulmonary disease

BACKGROUND

Numerous epidemiologic studies have linked the presence of chronic obstructive pulmonary disease (COPD) to coronary artery disease (CAD). However, prevalence, pathological processes, clinical manifestations and therapy are still debated, as progress towards uncovering the link between these two disorders has been hindered by the complex nature of multimorbidity.

METHODS

Articles targeting CAD in patients with COPD were identified from the searches of MEDLINE and EMBASE databases in July 2013. Three authors reviewed available evidence, focusing on the latest development on disease prevalence, pathogenesis, clinical manifestations and therapeutic strategies. Both clinical trial and previous reviews have been included in this work.

RESULTS

The most accredited hypothesis asserts that the main common risk factors, that is, cigarette smoke and ageing, elicit a chronic low-grade systemic inflammatory response, which affects both cardiovascular endothelial cells and airways/lung parenchyma. The development of CAD in patients with COPD potentiates the morbidity of COPD, leading to increased hospitalizations, mortality and health costs. Moreover, correct diagnosis is challenging and therapies are not clearly defined.

CONCLUSIONS

Evidence from recently published articles highlights the importance of multimorbidity in patient management and future research. Moreover, many authors emphasize the importance of low-grade systemic inflammation as a common pathological mechanism and a possible future therapeutic target.

Framework to co-register longitudinal virtual histology-intravascular ultrasound data in the circumferential direction

Considerable efforts have been directed at identifying prognostic markers for rapidly progressing coronary atherosclerotic lesions that may advance into a high-risk (vulnerable) state. Intravascular ultrasound (IVUS) has become a valuable clinical tool to study the natural history of coronary artery disease (CAD). While prospectively IVUS studies have provided tremendous insight on CAD progression, and its association with independent markers (e.g., wall shear stress), they are limited by the inability to examine the focal association between spatially heterogeneous variables (in both circumferential and axial directions). Herein, we present a framework to automatically co-register longitudinal (in-time) virtual histology-intravascular ultrasound (VH-IVUS) imaging data in the circumferential direction (i.e., rotate follow-up image so circumferential basis coincides with corresponding baseline image). Multivariate normalized cross correlation was performed on paired images (n = 636) from five patients using three independent VH-IVUS defined parameters: artery thickness, VH-IVUS defined plaque constituents, and VH-IVUS perivascular imaging data. Results exhibited high correlation between co-registration rotation angles determined automatically versus manually by an expert reader ( r(2) = 0.90). Furthermore, no significant difference between automatic and manual co-registration angles was observed ( 91.31 ±1.04(°) and 91.07 ±1.04(°), respectively; p = 0.48) and Bland-Altman analysis yielded excellent agreement ( bias = 0.24(°), 95% CI +/- 16.33(°)). In conclusion, we have developed, verified, and validated an algorithm that automatically co-registers VH-IVUS imaging data that will allow for the focal examination of CAD progression.

Inflammation and coagulation in atherosclerosis

Cardiovascular diseases remain to be the leading cause of death in Western societies. Despite major findings in vascular biology that lead to a better understanding of the pathomechanisms involved in atherosclerosis, treatment of the disease has only changed slightly within the last years. A big body of evidence suggests that atherosclerosis is a chronic inflammatory disease of the vessel wall. Accumulation and peroxidation of LDL-particles within the vessel wall trigger a strong inflammatory response, causing macrophage and T-cell accumulation within the vessel wall. Additionally, B-cells and specific antibodies against LDL-particles, as well as the complement system are implicated in atherogenesis. Besides data from clinical trials and autopsy studies it was the implementation of mouse models of atherosclerosis and the emerging field of direct gen-modification that lead to a thorough description of the pathophysiological mechanisms involved in the disease and created overwhelming evidence for a participation of the immune system. Recently, the cross-talk between coagulation and inflammation in atherogenesis has gained attention. Serious limitations and disparities in the pathophysiology of atherosclerosis in mice and men complicated the translation of experimental data into clinical practice. Despite these limitations, new anti-inflammatory medical therapies in cardiovascular disease are currently being tested in clinical trials.

Carotid intima-media thickness testing as an asymptomatic cardiovascular disease identifier and method for making therapeutic decisions

Cardiovascular disease (CVD) is the leading cause of death and disability in the United States. Although current therapies can reduce the risk for CVD, they are only given to patients who are considered to be at risk, and are therefore only beneficial if a patient's risk is accurately predicted before he or she sustains a cardiovascular (CV) event. Unfortunately, even relatively accurate risk factor analyses, such as the Reynolds Risk Score algorithm, fail to identify some patients who will sustain a CV event within 10 years. In contrast, the presence of an atheroma is an absolute predictor for the potential of an atherothrombotic event to occur, and it is therefore reasonable to anchor clinical decisions based on this knowledge. Carotid intima-media thickness (CIMT) testing via B-mode ultrasound is a safe, simple, and inexpensive method for evaluating CV risk by measuring the combined thickness of the intimal and medial layers of the arterial wall. Use of CIMT testing can also detect marked thickening of the arterial wall, possibly indicating plaques or atheromas that are associated with accelerated atherosclerotic disease and increased risk for coronary artery disease, myocardial infarction, and stroke. These characteristics make CIMT a practical supplemental method that physicians can use when making decisions. Moreover, the ability of CIMT testing to identify and quantify atherosclerotic disease has led to the adoption of CIMT as a surrogate endpoint in clinical trials, allowing the efficacy of new drugs to be assessed much more rapidly than would be possible by focusing solely on CV event or mortality rates. To date, several trials have provided evidence to indicate that some CVD therapies slow, stop, or reverse the progression of CIMT. Although many of these studies show that changes in CIMT predict future CV events, the value of CIMT testing in CVD risk assessment is still vigorously debated. In this article, we clarify the utility of CIMT testing for risk classification and reexamine its usefulness as a method for assessing therapeutic efficacy.

The association between cortisol response to mental stress and high-sensitivity cardiac troponin T plasma concentration in healthy adults

Objectives

The objective of this study was to examine the association between cortisol response to mental stress and high-sensitivity cardiac troponin T (hs-cTnT) in healthy older individuals without history of cardiovascular disease (CVD).

Background

Mental stress is a recognized risk factor for CVD, although the mechanisms remain unclear. Cortisol, a key stress hormone, is associated with coronary atherosclerosis and may accentuate structural and functional cardiac disease.

Methods

This cross-sectional study involved 508 disease-free men and women aged 53 to 76 years drawn from the Whitehall II epidemiological cohort. We evaluated salivary cortisol response to standardized mental stress tests (exposure) and hs-cTnT plasma concentration using a high-sensitivity assay (outcome). We measured coronary calcification using electron-beam dual-source computed tomography and Agatston scores.

Results

After adjustment for demographic and clinical variables associated with CVD as well as for inflammatory factors, we found a robust association between cortisol response and detectable hs-cTnT (odds ratio [OR]: 3.98; 95% confidence interval [CI]: 1.60 to 9.92; p = 0.003). The association remained when we restricted the analysis to participants without coronary calcification (n = 222; OR: 4.77; 95% CI: 1.22 to 18.72; p = 0.025) or when we further adjusted for coronary calcification in participants with positive Agatston scores (n = 286; OR: 7.39; 95% CI: 2.22 to 26.24; p = 0.001).

Conclusions

We found that heightened cortisol response to mental stress was associated with detectable plasma levels of cTnT using high-sensitivity assays in healthy participants, independently of coronary atherosclerosis. Further research is needed to understand the role of psychosocial stress in the pathophysiology of cardiac cell damage.

Increase in cardiac myosin binding protein-C plasma levels is a sensitive and cardiac-specific biomarker of myocardial infarction

Earlier studies have shown that cardiac myosin binding protein-C (cMyBP-C) is easily releasable into the circulation following myocardial infarction (MI) in animal models and patients. However, since its release kinetics has not been clearly demonstrated, no parameters are available to judge its efficacy as a bona fide biomarker of MI in patients with MI. To make this assessment, plasma levels of cMyBP-C and six known biomarkers of MI were determined by sandwich enzyme-linked immunosorbent assay in patients with MI who had before and after Percutaneous Transcoronary Angioplasty (PTCA), as well as healthy controls. Compared to healthy controls (22.3 ± 2.4 ng/mL (n=54)), plasma levels of cMyBP-C were significantly increased in patients with MI (105.1 ± 8.8 ng/mL (n=65), P<0.001). Out of 65 patients, 24 had very high levels of plasma cMyBP-C (116.5 ± 13.3 ng/mL), indicating high probability of MI. Importantly, cMyBP-C levels were significantly decreased in patients (n=40) at 12 hours post-PTCA (41.2 ± 9.3 ng/mL, P<0.001), compared to the patients with MI. Receiver operating characteristic analysis revealed that a plasma cMyBP-C reading of 68.1 ng/mL provided a sensitivity of 66.2% and a specificity of 100%. Also, myoglobin, carbonic anhydrase and creatine kinase-MB levels were significantly increased in MI patients who also had higher cMyBP-C levels. In contrast, levels of cardiac troponin I, glycogen phosphorylase and heart-type fatty acid binding protein were not significantly changed in the samples, indicating the importance of evaluating the differences in release kinetics of these biomarkers in the context of accurate diagnosis. Our findings suggest that circulating cMyBP-C is a sensitive and cardiac-specific biomarker with potential utility for the accurate diagnosis of MI.

Biological imaging of atherosclerosis: moving beyond anatomy

Biological or molecular imaging is now providing exciting new strategies to study atherosclerosis in both animals and humans. These technologies hold the promise to provide disease-specific, molecular information within the context of a systemic or organ-specific disease beyond traditional anatomical-based imaging. By integration of biological, chemical, and anatomical imaging knowledge into diagnostic strategies, a more comprehensive and predictive picture of atherosclerosis is likely to emerge. As such, biological imaging is well positioned to study different stages of atherosclerosis and its treatment, including the sequence of atheroma initiation, progression, and plaque rupture. In this review, we describe the evolving concepts in atherosclerosis imaging with a focus on coronary artery disease, and we provide an overview of recent exciting translational developments in biological imaging. The illuminated examples and discussions will highlight how biological imaging is providing new clinical approaches to identify high-risk plaques, and to streamline the development process of new atherosclerosis therapies.

Antiplatelet and anticoagulant strategies in acute coronary syndrome: where we are in 2013

Multiple antiplatelet and anticoagulant therapies are available for the treatment of acute coronary syndromes. The combination of agents should be tailored to the individual patient carefully considering the balance between ischemic and bleeding risk, as well as the planned revascularization strategy. Despite multiple large-scale, rigorously designed and conducted randomized controlled trials, it can be difficult to select the correct pharmacotherapy for each patient and many unanswered questions remain, such as the safety and optimal doses of differing combinations of antiplatelet/anticoagulant therapy, as well as the timing and duration of therapies. In addition, the headline results of many trials report improved efficacy outcomes at the cost of increased bleeding risk; however, very few show a clear mortality benefit. It is therefore difficult to weigh up the risk–benefit profile of emerging therapies.

Comparing the new European cardiovascular disease prevention guideline with prior American Heart Association guidelines: an editorial review

Atherosclerotic heart disease and stroke remain the leading causes of death and disability worldwide. Cardiovascular disease (CVD) prevention can improve the well-being of a population and possibly cut downstream healthcare spending, and must be the centerpiece of any sustainable health economy model. As lifestyle and CVD risk factors differ among ethnicities, cultures, genders, and age groups, an accurate risk assessment model is the critical first step for guiding appropriate use of testing, lifestyle counseling resources, and preventive medications. Examples of such models include the US Framingham Risk Score and the European SCORE system. The European Society of Cardiology recently published an updated set of guidelines on CVD prevention. This review highlights the similarities and differences between European and US risk assessment models, as well as their respective recommendations on the use of advanced testing for further risk reclassification and the appropriate use of medications. In particular, we focus on head-to-head comparison of the new European guideline with prior American Heart Association statements (2002, 2010, and 2011) covering risk assessment and treatment of asymptomatic adults. Despite minor disagreements on the weight of recommendations in certain areas, such as the use of coronary calcium score and non-high-density lipoprotein cholesterol in risk assessment, CVD prevention experts across the 2 continents agree on 1 thing: prevention works in halting the progression of atherosclerosis and decreasing disease burden over a lifetime.

The 'perfect storm' and acute coronary syndrome onset: do psychosocial factors play a role?

The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk.

Cardiac Magnetic Resonance: One Slice, Two Different LGE Patterns

A 56-years-old man with previous myopericarditis (10 months earlier, coronary angiography not performed) was admitted because of pericarditis pain and ST segment elevation, together with myocardial necrosis markers rise. Electrocardiogram (EKG) showed negative T waves in lateral and inferior leads; echocardiogram showed mild pericardial effusion and inferior and lateral basal hypokinesis. Cardiac magnetic resonance imaging (CMRI) on day 7 post-admission showed increased T2-short tau inversion recovery (T2-STIR) signal of inferior wall and two different noncontiguous late gadolinium enhancement (LGE) areas: Ischemic-like with about 75% transmural extension (inferior wall) and subepicardial (inferolateral wall) along with pericardial LGE (inferior and inferolateral wall). Coronary angiography showed three vessel disease. Pathogenetic hypothesis of these unexpected findings are discussed. This case shows again the ability of CMRI to unreveal unusual and unexpected pathologic patterns.

Reduced antiplatelet effect of aspirin is associated with low-grade inflammation in patients with coronary artery disease

Inflammation has been proposed to modify platelet function. This may lead to increased platelet reactivity and reduced antiplatelet drug efficacy in patients with coronary artery disease (CAD). However, this hypothesis has not been investigated in stable CAD patients receiving aspirin as mono antiplatelet therapy. It was the objective of this study to investigate the association between platelet reactivity, the inflammatory markers high-sensitive C-reactive protein (hs-CRP) and interleukin-6 (IL-6), and platelet activation. We performed a cross-sectional study on 524 stable high-risk CAD patients. Among these, 91% had a history of myocardial infarction, 23% had type 2 diabetes, and 13% had both. All patients received 75 mg aspirin daily as mono antiplatelet therapy. Platelet reactivity was assessed by multiple electrode aggregometry (Multiplate®, MEA) and VerifyNow®. Inflammation was evaluated by hs-CRP and IL-6. Platelet activation was assessed by soluble P-selectin (sP-selectin), and cyclooxygenase-1 inhibition was evaluated by measurement of serum thromboxane B2. Hs-CRP levels were significantly higher in upper platelet reactivity tertile patients than in lower platelet reactivity tertile patients (p≤0.02). Similar results were obtained with IL-6, though not statististically significant (p≥0.15). Platelet activation evaluated by sP-selectin was significantly higher in patients with MEA reactivity levels in the upper tertile than in the lower tertile (p=0.0001). Optimal compliance was confirmed by low serum thromboxane B2 levels in all patients. In conclusion, increased levels of hs-CRP were associated with augmented platelet reactivity in stable high-risk CAD patients receiving aspirin as mono antiplatelet therapy. These findings may suggest that chronic low-grade inflammation reduce the antiplatelet effect of aspirin.