Evolving Management Paradigm for Stable Ischemic Heart Disease Patients: JACC Review Topic of the Week

Coronary microvascular dysfunction and its role in heart failure with preserved ejection fraction for future prevention and treatment

Ischemic heart disease has long been established as the leading cause of heart failure, typically as a result of hemodynamically significant and obstructive coronary anatomy. Since, the role of dysfunctional coronary microvascular pathophysiologic mechanisms have also been associated with the development of congestive heart failure (CHF), most notably heart failure with preserved ejection fraction (HFpEF) although with limited clinical evidence. Conventional cardiometabolic and behavioral risk factors common to HFpEF such as diabetes mellitus (DM), obesity, hypertension, dyslipidemia, smoking, and chronic kidney disease foster a pro-inflammatory environment conducive to endothelial dysfunction and improper regulation of vasoactive substances. The impaired relaxation and increased vasoconstriction of damaged endothelium gives rise to impaired coronary blood flow and episodes of transient ischemia. Such coronary microvascular dysfunction (CMD) has its own implication on cardiovascular pathophysiologic mechanisms beyond symptomatic coronary and myocardial ischemia, and thus its own potential prevention goals and treatment targets for patients with HFpEF, where previous management had been limited. As such, we conducted a literature review to address the current landscape of data which links CMD to HFpEF. Furthermore, we considered the implications of biopsychosocial elements such as race, ethnicity, sex, gender, and the social determinants of health as they relate to the disparate health outcomes of those most at risk for CMD and HFpEF.

Effectiveness and Tolerability of Trimetazidine 80 mg Once Daily in Patients with Chronic Coronary Syndrome in Brazil: The V-GOOD Observational Study

INTRODUCTION

The V-GOOD study evaluated the effectiveness of trimetazidine modified-release (MR) 80 mg once daily (OD) in patients with chronic coronary syndrome (CCS) who remained symptomatic despite antianginal therapies in routine clinical practice.

METHODS

This prospective, observational study involved 1026 adult outpatients with symptomatic CCS from 70 sites in Brazil who were prescribed trimetazidine MR 80 mg OD plus background antianginal treatment. Data on number of angina attacks, short-acting nitrate consumption, prevalence of angina-free patients, severity of angina, patient-reported daily physical activity impairment, treatment adherence, tolerability, and cardiologist and patient satisfaction were collected at baseline (V1), then at 1 month (V2) and 3 months (V3).

RESULTS

Following the addition of trimetazidine MR 80 mg OD, the mean ± standard deviation number of angina attacks per week decreased from 3.1 ± 2.8 at V1 to 1.0 ± 2.1 at V2, and 0.7 ± 1.7 at V3, with concurrent reductions in short-acting nitrate consumption, patient-reported daily physical activity impairment and the proportion of patients with limiting angina (Canadian Cardiovascular Society class III or IV), and increases in the proportion of angina-free patients (all p < 0.001 vs. V1). Most cardiologists rated trimetazidine MR 80 mg OD as satisfactory/very satisfactory (90.7% for effectiveness and 94.8% for tolerability); most patients rated the treatment schedule as convenient/very convenient (97.2%) and satisfactory/very satisfactory (97.1%). Treatment was well tolerated.

CONCLUSIONS

These data support the symptomatic benefits and good tolerability associated with adding trimetazidine MR 80 mg OD to other antianginal therapies in patients with persistent symptoms. Graphical abstract available for this article.

TRIAL REGISTRATION NUMBER

NCT06464276.

Coronary computed tomography angiography in primary care patients with chest pain or dyspnea - a cross-sectional study

AIMS

Coronary Computed Tomography Angiography (CCTA) is recommended as a first-line investigation to exclude significant coronary artery stenosis in case of low to intermediate pre-test probability (PTP). The aim was to investigate CCTA findings in relation to the PTP of patients referred directly from primary health care centres.

METHODS/RESULTS

In this retrospective cohort study consecutive primary care CCTA referrals in a Swedish county 1st of June 2021 until 30th Nov. 2022 were included. CCTA reports were obtained for 483 patients ≥ 30 years old, without known CAD and stratified as no CAD, with atheromatosis or with suspected significant stenosis. For the 381 patients with eligible PTP data, the mean age was 60 years and 70% were women. While the median PTP was 11%, significant stenosis was suspected on CCTA in 18%. Among patients with PTP ≤ 15%, CCTA exposed no significant stenosis in 88%. No significant stenosis was found in patients with PTP < 5% true to patient age and gender in a sensitivity analysis (n = 25).

CONCLUSIONS

CCTA ruled out coronary stenosis as the cause of chest pain and dyspnea in 88% of patients referred from primary care with PTP 5-15%. PTP estimations by primary care physicians in CCTA referrals agreed with the occurrence of suspected significant stenosis among patients with PTP 5-15%, but underestimated it in PTP > 15%. The validity of PTP estimates < 5% was low.

Ischemic Myocardium Targeting Peptide-Guided Nanobubbles for Multimodal Imaging and Treatment of Coronary Microvascular Dysfunction

Coronary microvascular dysfunction (CMD) refers to clinical symptoms caused by structural and functional damage to coronary microcirculation. The timely and precise diagnosis of CMD-related myocardial ischemia is essential for improving patient prognosis. This study describes a method for the multimodal (fluorescence, ultrasonic, and photoacoustic) noninvasive imaging and treatment of CMD based on ischemic myocardium-targeting peptide (IMTP)-guided nanobubbles functionalized with indocyanine green (IMTP/ICG NBs) and characterizes their basic characteristics and in vitro imaging and targeting abilities. The IMTP/ICG NBs enable the accurate location of myocardial ischemia via photoacoustic imaging, and when loaded with tannic acid (TA), can be used to effectively treat myocardial ischemia and fibrosis in CMD mice, achieving an effect superior to that of free TA. The origin of this high therapeutic efficiency is revealed by transcriptomic and proteomic analyses. This investigation lays the groundwork for visual monitoring and the drug-targeted treatment of CMD.

Investigation of Myocardial Substrate for Sudden Arrhythmic Death in Coronary Artery Disease Without Acute Coronary Thrombosis or Myocardial Infarction

BACKGROUND

This cohort study aimed to evaluate the potential myocardial arrhythmic substrate in people with coronary artery disease who died from sudden arrhythmic death (SAD) without acute coronary thrombosis or myocardial infarction.

METHODS AND RESULTS

We performed histological analysis of the left ventricular free wall obtained at autopsy from decedents with ≥1 coronary artery and ≥75% area stenosis who died suddenly from either noncardiac causes (25 men, 23 women) or SAD (25 men, 25 women), matched for age and sex. Decedents with acute coronary thrombosis, myocardial infarction, or other myocardial abnormality were excluded. Decedents with either noncardiac death or SAD had similar height, weight, and heart weight. Decedents with SAD had higher cumulative area stenosis of coronary arteries (mean, 162% versus 134%; mean difference, 29% [95% CI, 1%-56%], P=0.042) and a higher proportion of decedents with SAD had diabetes (mean, 10% versus 0%; mean difference, 10% [95% CI, 2%-18%], P=0.025) and chronic, nonocclusive, organized coronary artery thrombus (mean, 16% versus 0%; mean difference, 16% [95% CI, 6%-26%], P=0.0040). Moreover, decedents with SAD had lower cardiomyocyte width (mean, 18.6 μm versus 19.6 μm; mean difference, 1.0 μm [95% CI, 0.2-1.8], P=0.014) and higher capillary length density (mean, 3618 mm/mm3 versus 3164 mm/mm3; mean difference, 453 mm/mm3 [95% CI, 210-697], P=0.0003) than decedents with noncardiac death.

CONCLUSIONS

SAD in people with coronary artery disease without acute coronary thrombosis or myocardial infarction was associated with greater coronary artery plaque burden and cardiomyocyte atrophy that may have contributed to myocardial substrate for arrhythmia.

Comparative outcomes of invasive versus conservative strategy in stable coronary artery disease patients: a risk-stratification-based hypothesis-generative study

BACKGROUND

Whether percutaneous coronary intervention (PCI) can improve the long-term prognosis of patients with stable coronary artery disease (SCAD) in comparison to conservative treatment remains controversial. The present study sought to evaluate the impacts of initial invasive versus conservative strategy on long-term clinical outcomes for patients with SCAD stratified by risk scores.

METHODS

This was a sub-analysis of the multicenter, observational Optimal antiPlatelet Therapy for Chinese patients with Coronary Artery Disease (OPT-CAD) study. Clinical outcomes were compared in SCAD patients who initially received PCI (invasive strategy) or conservative treatment according to risk stratification by OPT-CAD score. The primary outcome was ischemic events at 5 years, composed of cardiac death, myocardial infarction, and ischemic stroke. Secondary outcomes included all-cause death, Bleeding Academic Research Consortium (BARC) types 2, 3, or 5, and 3 or 5 bleeding.

RESULTS

The conservative group comprised 1767 (58.0%) patients and the invasive group comprised 1278 (42.0%) patients. Overall, invasive strategy did not reduce the risk of ischemic events compared with conservative strategy but was associated with an increased risk of BARC 2, 3, or 5 bleeding (adjusted hazard ratio (HR), 1.59; 95% confidence interval (CI), 1.13-2.26; P = 0.009). Similar results were observed in the low-risk patient subset (N = 2030). While in the moderate-to-high-risk subset (N = 1015), invasive strategy was associated with a reduced risk of ischemic events (HR, 0.67; 95% CI, 0.48-0.95; P = 0.02) and all-cause death (HR, 0.73; 95% CI, 0.51-1.03; P = 0.07), and with no excessive risk of bleeding.

CONCLUSIONS

Invasive strategy could not confer additional clinical benefits in patients with SCAD compared to conservative strategy, except in patients at moderate-to-high risk. The OPT-CAD risk score may be valuable to the guidance of optimal treatment strategy in SCAD patients.

Deep Learning-based Quantitative CT Myocardial Perfusion Imaging and Risk Stratification of Coronary Artery Disease

Background Precise assessment of myocardial ischemia burden and cardiovascular risk stratification based on dynamic CT myocardial perfusion imaging (MPI) is lacking. Purpose To develop and validate a deep learning (DL) model for automated quantification of myocardial blood flow (MBF) and ischemic myocardial volume (IMV) percentage and to explore the prognostic value for major adverse cardiovascular events (MACE). Materials and Methods This multicenter study comprised three cohorts of patients with clinically indicated CT MPI and coronary CT angiography (CCTA). Cohorts 1 and 2 were retrospective cohorts (May 2021 to June 2023 and January 2018 to December 2022, respectively). Cohort 3 was prospectively included (November 2016 to December 2021). The DL model was developed in cohort 1 (training set: 211 patients, validation set: 57 patients, test set: 90 patients). The diagnostic performance of MBF derived from the DL model (MBFDL) for myocardial ischemia was evaluated in cohort 2 based on the area under the receiver operating characteristic curve (AUC). The prognostic value of the DL model-derived IMV percentage was assessed in cohort 3 using multivariable Cox regression analyses. Results Across three cohorts, 1108 patients (mean age: 61 years ± 12 [SD]; 667 men) were included. MBFDL showed excellent agreement with manual measurements in the test set (segment-level intraclass correlation coefficient = 0.928; 95% CI: 0.921, 0.935). MBFDL showed higher diagnostic performance (vessel-based AUC: 0.97) over CT-derived fractional flow reserve (FFR) (vessel-based AUC: 0.87; P = .006) and CCTA-derived diameter stenosis (vessel-based AUC: 0.79; P < .001) for hemodynamically significant lesions, compared with invasive FFR. Over a mean follow-up of 39 months, MACE occurred in 94 (14.2%) of 660 patients. IMV percentage was an independent predictor of MACE (hazard ratio = 1.12, P = .003), with incremental prognostic value (C index: 0.86; 95% CI: 0.84, 0.88) over conventional risk factors and CCTA parameters (C index: 0.84; 95% CI: 0.82, 0.86; P = .02). Conclusion A DL model enabled automated CT MBF quantification and accurate diagnosis of myocardial ischemia. DL model-derived IMV percentage was an independent predictor of MACE and mildly improved cardiovascular risk stratification. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Zhu and Xu in this issue.

Comparative Evaluation of Pre-Test Probability Models for Coronary Artery Disease with Assessment of a New Machine Learning-Based Model

PURPOSE

This study aimed to validate pivotal pre-test probability (PTP)-coronary artery disease (CAD) models (CAD consortium model and IJC-CAD model).

MATERIALS AND METHODS

Traditional PTP models-CAD consortium models: two traditional PTP models were used under the CAD consortium framework, namely CAD1 and CAD2. Machine learning (ML)-based PTP models: two ML-based PTP models were derived from CAD1 and CAD2, and used to enhance predictive capabilities [ML-CAD2 and ML-IJC (IJC-CAD)]. The primary endpoint was obstructive CAD. The performance evaluation of these PTP models was conducted using receiver-operating characteristic analysis.

RESULTS

The study included 238 participants, among whom 157 individuals (65.9% of the total sample) had CAD. The IJC-CAD model demonstrated the highest performance with an area under the curve (AUC) of 0.860 [95% confidence interval (CI): 0.812-0.909]. Following this, the ML-CAD2 model exhibited an AUC of 0.814 (95% CI: 0.758-0.870), CAD1 showed an AUC of 0.767 (95% CI: 0.705-0.830), and CAD2 had an AUC of 0.785 (95% CI: 0.726-0.845). Each of the PTP models was adjusted to have a CAD score cutoff that classified cases with a sensitivity of over 95%. The respective cutoff values were as follows: CAD1 and CAD2 >12, ML-CAD2 >0.380, and IJC-CAD >0.367. All PTP models achieved a CAD sensitivity of over 95%. Similar to the AUC performance, the accuracy of the PTP models was highest for IJC-CAD, reaching 80.3%. The accuracy of ML-CAD2 was 77.7%, while that for CAD1 and CAD2 was 74.8% and 75.2%, respectively.

CONCLUSION

ML-CAD2 and IJC-CAD showed superior performance compared to traditional existing models (CAD1 and CAD2).

Clinical, Economical, and Organizational Impact of Chronic Ischemic Cardiovascular Disease in Italy: Evaluation of 2019 Nationwide Hospital Admissions Data

BACKGROUND

Chronic ischemic cardiovascular disease (CICD) is a common cardiovascular disease and a frequent cause of hospitalization, with significant differences between men and women. It is also an important comorbidity, affecting hospitalization length and mortality. The purpose of this paper is to investigate the clinical and economic impact of CICD on hospital admissions of non-surgical patients.

METHODS

To conduct the study, hospital discharge data (SDO) from each public and private hospital facility regularly sent by the regions to the Ministry of Health were analyzed, focusing on internal medicine, cardiology, and geriatrics departments' 2019 discharged data coming from all Italian hospitals. Data were stratified according to age, gender, hospital charge ward, and costs.

RESULTS

The typical CICD patient is elderly (average age 80 years) and stays longer (+10.5 days) compared to the average one. They are also typically chronic patients with many comorbidities (respiratory and renal failure, as well as atrial fibrillation) in geriatrics and internal medicine departments, while in the cardiology departments, atrial fibrillation and outcomes of acute cardiovascular events predominate.

CONCLUSIONS

CICD is a condition that leads to more hospitalizations in internal medicine departments than in cardiology and geriatrics departments and generates an average hospitalization value in line with the average one in internal medicine and geriatrics departments. In cardiology, the average value level is higher than the department average. Gender differences were found in cardiology departments; this data could suggest that the existing guidelines are affected by studies carried out mainly on males which lead to fewer recommendations for interventional procedures on females.

Global, regional, and national epidemiology of ischemic heart disease among individuals aged 55 and above from 1990 to 2021: a cross-sectional study

BACKGROUND

The findings of the 2021 Global Burden of Disease (GBD) study can offer valuable insights for the development of screening and prevention strategies targeting ischemic heart disease (IHD). We aim to investigate trends in IHD incidence, mortality, and disability-adjusted life years (DALYs), while exploring associated risk factors for IHD-associated death from 1990 to 2021.

METHODS

The cross-sectional study utilized data from the GBD 2021, covering 204 countries and regions. The analysis included individuals aged 55 and above. We analyzed the trends in IHD incidence, all cause and cause-specific deaths, DALYs, and corresponding estimated annual percentage changes (EAPCs) from 1990 to 2021. These indicators were further stratified by geographical region, country, age group, gender, and sociodemographic index (SDI).

RESULTS

The global incidence rate, mortality rate, and DALYs rate for individuals aged 55 and above with IHD have shown a decreasing trend. However, the number of incident cases, death cases, and DALYs has been increasing from 1990 to 2021. Both the high-middle and high SDI regions exhibit a significant decline in these rates from 1990 to 2021. However, the low SDI, low-middle SDI, and middle SDI regions show less noticeable changes. The region with low-middle SDI experiences the largest increase in mortality rate (EAPC: 0.38; 95%CI, 0.33-0.44) and DALYs rate (EAPC: 0.17; 95%CI, 0.12-0.22). The region with middle SDI experiences the largest increase in incidence rate (EAPC: 0.37; 95%CI, 0.27-0.46). Regionally, East Asia exhibits the greatest increase in incidence rate (EAPC: 0.94; 95% CI, 0.79-1.10), mortality rate (EAPC: 1.68; 95% CI, 1.40-1.94), and DALYs rate (EAPC: 0.94; 95% CI, 0.69-1.20). Among the 12 risk factors associated with mortality from IHD, high systolic blood pressure, dietary risks, high low-density lipoprotein (LDL) cholesterol levels, and air pollution are identified as the primary contributors to global mortality.

CONCLUSIONS

This study reveals that in high SDI regions, the incidence, mortality, and DALYs rate of IHD are declining. Conversely, in low to middle SDI regions, the disease burden of IHD is increasing. It highlights global inequality in IHD burden. Recommendations include early screening, risk management, and strengthening primary care, especially in middle and low SDI regions. Countries should also invest in environmental governance and air pollution control. Future research should focus on evaluating the effects of health policies in different countries, exploring the impact of socio-economic and cultural factors on the burden of IHD, and developing big data-based prediction models to optimize resource allocation and intervention strategies.

Myocardial Ischemic Syndromes: A New Nomenclature to Harmonize Evolving International Clinical Practice Guidelines

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction.

Association of Coronary Microvascular Rarefaction and Myocardial Fibrosis With Coronary Artery Disease

BACKGROUND

To evaluate, in a cohort study, whether coronary microvasculature and myocardial structure differ between people with and without coronary artery disease (CAD).

METHODS AND RESULTS

We performed histological analysis of left ventricle free wall obtained at autopsy from 25 men and 23 women with ≥1 coronary artery with ≥75% area stenosis, and 25 men and 25 women without (no or minimal) CAD, matched for sex and age, who died suddenly from noncardiac causes. Decedents with myocardial infarction or other cardiac abnormality were excluded. Decedents with and without CAD had similar height and weight. Heart weight of decedents with CAD was higher than that of decedents without CAD (mean, 391 versus 364 g; mean difference, 27 g [95% CI, 0.3-54.0], P=0.048). Decedents with CAD had lower arteriole density (mean, 1.4 per mm2 versus 1.8 per mm2; mean difference, -0.4 per mm2 [95% CI, -0.6 to -0.2], P=0.0001), lower capillary length density (mean, 3164 versus 3701 mm/mm3; mean difference, -537 [95% CI, -787 to -286], P<0.0001), and higher total myocardial fibrosis (mean, 7.5% versus 5.7%; mean difference, 1.7% [95% CI, 1.0-2.5], P<0.0001), than decedents without CAD.

CONCLUSIONS

CAD was associated with coronary microvascular rarefaction and increased myocardial fibrosis. The association of CAD with coronary microvascular rarefaction and increased myocardial fibrosis may contribute to the increased risks of death, myocardial infarction and heart failure that accompany CAD, and may attenuate the impact of percutaneous coronary intervention on cardiovascular risk in people with stable angina.

Myocardial ischaemic syndromes: a new nomenclature to harmonize evolving international clinical practice guidelines

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischaemia, various classifications have emerged over time, often with conflicting terminology-e.g. 'stable coronary artery disease' (CAD), 'stable ischaemic heart disease', and 'chronic coronary syndromes' (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with 'acute coronary syndromes' (ACS), the 2023 American guidelines endorsed the alternative term 'chronic coronary disease'. An unintended consequence of these competing classifications is perpetuation of the restrictive terms 'coronary' and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischaemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of 'acute myocardial ischaemic syndromes' and 'non-acute myocardial ischaemic syndromes', which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischaemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction.

Rebuilding the myocardial microenvironment to enhance mesenchymal stem cells-mediated regeneration in ischemic heart disease

Mesenchymal stem cells (MSCs) are naturally-derived regenerative materials that exhibit significant potential in regenerative medicine. Previous studies have demonstrated that MSCs-based therapy can improve heart function in ischemia-injured hearts, offering an exciting therapeutic intervention for myocardial ischemic infarction, a leading cause of worldwide mortality and disability. However, the efficacy of MSCs-based therapies is significantly disturbed by the myocardial microenvironment, which undergoes substantial changes following ischemic injury. After the ischemic injury, blood vessels become obstructed and damaged, and cardiomyocytes experience ischemic conditions. This activates the hypoxia-induced factor 1 (HIF-1) pathway, leading to the rapid production of several cytokines and chemokines, including vascular endothelial growth factor (VEGF) and stromal-derived factor 1 (SDF-1), which are crucial for angiogenesis, cell migration, and tissue repair, but it is not sustainable. MSCs respond to these cytokines and chemokines by homing to the injured site and participating in myocardial regeneration. However, the deteriorated microenvironment in the injured myocardium poses challenges for cell survival, interacting with MSCs, and constraining their homing, retention, and migration capabilities, thereby limiting their regenerative potential. This review discusses how the deteriorated microenvironment negatively affects the ability of MSCs to promote myocardial regeneration. Recent studies have shown that optimizing the microenvironment through the promotion of angiogenesis can significantly enhance the efficacy of MSCs in treating myocardial infarction. This approach harnesses the full therapeutic potential of MSCs-based therapies for ischemic heart disease.

Characterization of a novel mitophagy-related 5-genes signature for diagnosis of acute myocardial infarction

Myocardial infarction (MI) and the ensuing heart failure (HF) remain the main cause of morbidity and mortality worldwide. One of the strategies to combat MI and HF lies in the ability to accurately predict the onset of these disorders. Alterations in mitochondrial homeostasis have been reported to be involved in the pathogenesis of various cardiovascular diseases (CVDs). In this regard, perturbations to mitochondrial dynamics leading to impaired clearance of dysfunctional mitochondria have been previously established to be a crucial trigger for MI/HF. In this study, we found that MI patients could be classified into three clusters based on the expression levels of mitophagy-related genes and consensus clustering. We identified a mitophagy-related diagnostic 5-genes signature for MI using support vector machines-Recursive Feature Elimination (SVM-RFE) and random forest, with the area under the ROC curve (AUC) value of the predictive model at 0.813. Additionally, the single-cell transcriptome and pseudo-time analyses showed that the mitoscore was significantly upregulated in macrophages, endothelial cells, pericytes, fibroblasts and monocytes in patients with ischemic cardiomyopathy, while sequestosome 1 (SQSTM1) exhibited remarkable increase in the infarcted (ICM) and non-infarcted (ICMN) myocardium samples dissected from the left ventricle compared with control samples. Lastly, through analysis of peripheral blood from MI patients, we found that the expression of SQSTM1 is positively correlated with troponin-T (P < 0.0001, R = 0.4195, R2 = 0.1759). Therefore, this study provides the rationale for a cell-specific mitophagy-related gene signature as an additional supporting diagnostic for CVDs.

Patients With Non-Obstructive Coronary Artery Disease and Polyvascular Disease. Sub-Analysis of the Real-World Registry KAMMA (Clinical Registry on Patient Population With Polyvascular Disease in the Russian Federation and Eurasian Countries)

AIM

To study the clinical status and data of laboratory and instrumental examination of patients with non-obstructive ischemic heart disease (IHD) and multifocal atherosclerosis (MFA) included in the KAMMA registry.

MATERIAL AND METHODS

The subanalysis included 1,893 IHD patients who underwent coronary angiography (CAG) and ultrasonic examination of peripheral arteries. Based on the CAG data, patients were divided into two groups: group 1, patients with obstructive coronary atherosclerosis (CA) (maximum stenosis ≥50% and/or history of percutaneous coronary intervention/coronary artery bypass grafting, n=1728; 91.3%) and group 2, patients with non-obstructive CA (maximum stenosis <50%, n = 165; 8.7%).

RESULTS

A comparative analysis based on the degree of coronary obstruction in patients with verified IHD who were included in the KAMMA registry showed that 8.7% of them had coronary artery stenosis of less than 50%. The overwhelming majority of patients with non-obstructive CA had MFA affecting the brachiocephalic arteries in 94.3% and the lower extremity arteries in 40.2%. Among patients with non-obstructive IHD, women predominated; risk factors such as smoking and type 2 diabetes mellitus were less frequent in this group than in the obstructive IHD group. Patients with non-obstructive CA more frequently had a history of dyslipidemia; they had higher total cholesterol and non-high-density lipoprotein cholesterol; and they more frequently received moderate-intensity statin therapy than patients with obstructive CA (55.8% vs. 34.5%). Characteristic features of patients with non-obstructive CA were less severe IHD and less frequent history of acute coronary syndrome. However, the incidence of stroke, peripheral arterial thrombosis, and chronic arterial insufficiency of the lower extremities did not differ in groups 1 and 2, whereas the incidence of paroxysmal atrial fibrillation was higher in the non-obstructive IHD group.

CONCLUSION

IHD patients without coronary obstruction also require assessment of the peripheral arterial status, as they may have advanced MFA, which should be taken into account when choosing the "aggressiveness" of therapy.

Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions

Angina pectoris may arise from obstructive coronary artery disease (CAD) or in the absence of significant CAD (ischemia with nonobstructed coronary arteries [INOCA]). Therapeutic strategies for patients with angina and obstructive CAD focus on reducing cardiovascular events and relieving symptoms, whereas in INOCA the focus shifts toward managing functional alterations of the coronary circulation. In obstructive CAD, coronary revascularization might improve angina status, although a significant percentage of patients present angina persistence or recurrence, suggesting the presence of functional mechanisms along with epicardial CAD. In patients with INOCA, performing a precise endotype diagnosis is crucial to allow a tailored therapy targeted toward the specific pathogenic mechanism. In this expert opinion paper, we review the evidence for the management of angina, highlighting the complementary role of coronary revascularization, optimal medical therapy, and lifestyle interventions and underscoring the importance of a personalized approach that targets the underlying pathobiology.

Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome

PURPOSE OF REVIEW

This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences.

RECENT FINDINGS

The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.

Psychological burden in patients with angina and unobstructed coronary arteries-underestimated, underexplored, undertreated

Patients with angina and unobstructed coronary arteries (ANOCA) are frequently encountered in clinical practice. These cases represent a diagnostic and therapeutic challenge and are often characterized by a long patient journey until a diagnosis of coronary vasomotor disorders is established. Moreover, the unsatisfactory management of such patients leads to insecurity, ongoing symptoms, and psychological sequelae such as anxiety or depression. Currently, the psychological burden in patients with ANOCA is underestimated, underexplored, and undertreated. This review gives a new perspective on the pathophysiology of coronary vasomotor disorders including psychological risk factors and calls for comprehensive care by interdisciplinary ANOCA clinics.

New Electrocardiographic Score for Predicting the Site of Coronary Artery Occlusion in Inferior Wall Acute Myocardial Infarction

Background

An electrocardiogram (ECG) was used to determine the type of acute myocardial infarction (MI) and locate the culprit vessel. Inferior wall myocardial infarction (IWMI) patients with the right coronary artery (RCA) as the culprit vessel may have a worse clinical prognosis than the left circumflex artery (LCx). We aimed to develop a new, simple, accurate scoring system to localize the RCA.

Methods

From January 2018 to January 2020, patients were admitted to the Department of Cardiology of TEDA International Cardiovascular Hospital and the Second Hospital of Tianjin Medical University due to IWMI and coronary angiography confirmed that the infarct-related vessel was a single RCA or LCx. ECG of patients before percutaneous coronary intervention (PCI) was collected to quantitatively analyze the characteristics of ST-segment deviation in non-inferior wall leads (N-IWL) and establish the RCA score in N-IWL.

Results

149 patients were enrolled, including 83 in the RCA group and 66 in the LCx group. Finally, ST-segment depression (ST↓) lead I, aVR, V1, and V6, and ST↓≥ 1mm in lead V4 were found to be associated with the location of the RCA. The sensitivity, specificity, and area under the curve (AUC) of the N-IWL RCA scoring system were 77.1%, 72.7%, and 0.83, respectively. The diagnostic ability of the scoring system was better than that of other algorithms and scoring systems.

Conclusion

ECG helps identify the RCA in patients with IWMI before PCI. The N-IWL RCA score may help identify the culprit vessel as the RCA in patients with IWMI.

A Systematic Approach to the Evaluation of the Coronary Microcirculation Using Bolus Thermodilution: CATH CMD

Coronary microvascular dysfunction (CMD) can cause myocardial ischemia in patients presenting with angina without obstructive coronary artery disease (ANOCA). Evaluating for CMD by using the thermodilution technique offers a widely accessible means of assessing microvascular resistance. Through this technique, 2 validated indices, namely coronary flow reserve and the index of microcirculatory resistance, can be computed, facilitating investigation of the coronary microcirculation. The index of microcirculatory resistance specifically estimates minimum achievable microvascular resistance within the coronary microcirculation. We aim to review the bolus thermodilution method, outlining the fundamental steps for conducting measurements and introducing an algorithmic approach (CATH CMD) to systematically evaluate the coronary microcirculation. Embracing a standardized approach, exemplified by the CATH CMD algorithm, will facilitate adoption of this technique and streamline the diagnosis of CMD.

New avenues for the assessment of stable ischemic heart disease

Myocardial ischemia is a complex condition which may result from epicardial and/or microvascular causes involving functional and structural mechanisms. These mechanisms may overlap in a given patient illustrating the difficulties for appropriate management. Assessment of myocardial ischemia can be performed using noninvasive and invasive tools. However, despite living in the era of individualized precision medicine, these tools are not yet used in a broader fashion. Emerging noninvasive techniques such as quantitative perfusion cardiac magnetic resonance imaging (CMR) and stress perfusion computed tomography (CT) or photon-counting CT techniques may contribute to new standards in the assessment of stable angina patients. Invasive evaluation of myocardial ischemia should not only focus on hemodynamically relevant epicardial disease but also involve coronary vasomotor function testing (coronary spasm, coronary flow reserve, and microvascular resistance) where appropriate. Optimal patient management will depend on accurate and comprehensive diagnostic evaluation of myocardial ischemia and development of new treatment options in the future.

Angina pectoris 2023: With and without obstructive coronary artery disease: Epidemiology, diagnosis, prognosis, and treatment

Angina contributes to significant morbidity worldwide. The evaluation of angina is variable and complicated by multiple factors. The diagnosis is often focussed on epicardial disease despite the knowledge that chest pain can be due to cardiac, non-cardiac, macro, and microvascular causes. Standardised diagnostic pathways and novel approaches to angina assessment may offer the opportunity to improve our understanding of angina and apply a personalised approach to treatment.

Effects of Ivabradine on Myocardial Perfusion in Chronic Angina: A Prospective, Preliminary, Open-Label, Single-Arm Study

INTRODUCTION

Ivabradine reduces heart rate (HR), episodes of angina, and nitrate consumption, and increases exercise capacity in patients with chronic angina (CA). In this exploratory study, myocardial perfusion scintigraphy (MPS) was used to evaluate changes in the percentage of myocardial ischemia after ivabradine therapy in patients with CA.

METHODS

This prospective, open-label, single-arm study included patients with CA receiving maximum tolerated doses of beta blockers, who had a resting HR ≥ 70 bpm and had experienced ischemia according to MPS during an exercise test at baseline. Participants received ivabradine 5 mg twice daily (titrated according to HR) concomitant with beta blockers. A second MPS was performed after 3 months, without interruption of treatment with beta blockers or ivabradine. The primary outcome was change in the percentage of myocardial ischemia from baseline to 3 months. Time to ischemia during the exercise test, the proportion of patients presenting angina during the exercise test, and health status, assessed using the seven-item Seattle Angina Questionnaire-7 (SAQ-7), were also evaluated.

RESULTS

Twenty patients (3 females) with a mean (± standard deviation [SD]) age of 62.2 ± 6.5 years were included in the study, of whom 55% had diabetes, 70% had previous myocardial revascularization, and 45% had previous myocardial infarction. The percentage of patients with myocardial ischemia significantly decreased from baseline to 3 months after initiation of treatment with ivabradine (- 2.9%; 95% confidence interval [CI] - 0.3 to - 5.5; p = 0.031). Mean time to appearance of ischemia increased from 403 ± 176 s at baseline to 466 ± 136 s at 3 months after initiation of ivabradine (Δ62 s; 95% CI 18-106 s; p = 0.008), and the proportion of patients experiencing angina during the exercise test decreased from 40% at baseline to 5% also at 3 months (p = 0.016). Mean resting HR decreased from 76 ± 7 bpm at baseline to 55 ± 8 bpm at 3 months (p < 0.001). The mean SAQ-7 summary score improved from 69 ± 21 at baseline to 83 ± 12 at 3 months (p = 0.001). No serious adverse effects were reported.

CONCLUSION

Ivabradine added to beta blockers was associated with a reduction in detectable myocardial ischemia by MPS in patients with CA. Infographic available for this article.

TRIAL REGISTRATION

The trial has been retrospectively registered with the Brazilian Registry of Clinical Trials (REBEC) under the following number RBR-5fysqrh (date of registration: 30 November 2023).

Racial and Ethnic Disparities in the Management of Chronic Coronary Disease

Chronic coronary disease (CCD) comprises a continuum of conditions that include obstructive and non-obstructive coronary artery disease with or without prior acute coronary syndrome. Racial and ethnic representation disparities are pervasive in CCD guideline-informing clinical trials and evidence-based management. These disparities manifest across the entire spectrum of CCD management, spanning from non-pharmacological lifestyle changes to guideline-directed medical therapy, and cardiac rehabilitation to invasive procedures. Recognizing and addressing the historical factors underlying these disparities is crucial for enhancing the quality and equity of CCD management within an increasingly diverse population.

Plasma Metabolic Profiling and Multiclass Diagnostic Model Development for Stable Angina Pectoris and Acute Myocardial Infarction

Coronary heart disease remains a major global health challenge, with a clear need for enhanced early risk assessment. This study aimed to elucidate metabolic signatures across various stages of coronary heart disease and develop an effective multiclass diagnostic model. Using metabolomic approaches, gas chromatography-mass and liquid chromatography-tandem mass spectrometry were used to analyze plasma samples from healthy controls, patients with stable angina pectoris, and those with acute myocardial infarction. Pathway enrichment analysis was conducted on metabolites exhibiting significant differences. The key metabolites were identified using Random Forest and Recursive Feature Elimination strategies to construct a multiclass diagnostic model. The performance of the model was validated through 10-fold cross-validation and evaluated using confusion matrices, receiver operating characteristic curves, and calibration curves. Metabolomics was used to identify 1491 metabolites, with 216, 567, and 295 distinctly present among the healthy controls, patients with stable angina pectoris, and those with acute myocardial infarction, respectively. This implicated pathways such as the glucagon signaling pathway, d-amino acid metabolism, pyruvate metabolism, and amoebiasis across various stages of coronary heart disease. After selection, testosterone isobutyrate, N-acetyl-tryptophan, d-fructose, l-glutamic acid, erythritol, and gluconic acid were identified as core metabolites in the multiclass diagnostic model. Evaluating the diagnostic model demonstrated its high discriminative ability and accuracy. This study revealed metabolic pathway perturbations at different stages of coronary heart disease, and a precise multiclass diagnostic model was established based on these findings. This study provides new insights and tools for the early diagnosis and treatment of coronary heart disease.

Do Clinical Outcomes and Quality of Life Differ by the Number of Antianginals for Stable Ischemic Heart Disease? Insights from the BARI 2D Trial

Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was β blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.

Myocardial energy balance and metabolism as causes of myocardial ischemia

The current approach to myocardial ischemia has been influenced by the misconception of a close link between ischemia and coronary atherosclerotic obstructions. Recent guidelines have, however, acknowledged the multifactorial nature of this condition, with an identifiable cause present in less than half of angina patients, and a large fraction with angina of unknown origin. Because of this background, focusing on cardiac energy metabolim offers new opportunities to manage myocardial ischemia even when its cause is unknown.

Optimal medical therapy vs revascularization in chronic coronary syndromes: Does ISCHEMIA move the needle toward or away from revascularization??

The optimal management of chronic coronary syndrome (CCS) patients has been a source of debate for several decades. Herein, we describe the evidence base comprising several landmark clinical trials including the most recent ISCHEMIA Trial, which, in aggregate, does not demonstrate a conclusive, incremental benefit of revascularization combined with optimal medical therapy (OMT) versus OMT alone in reducing prognostically-important clinical outcomes during long-term follow-up. For CCS patients with symptoms or quality of life not deemed refractory or unacceptable on medical therapy, a conservative approach to the judicious and selective use of revascularization plus OMT remains a justifiable evidence-based management strategy.

Treatment Strategies for Chronic Coronary Heart Disease with Left Ventricular Systolic Dysfunction or Preserved Ejection Fraction-A Systematic Review and Meta-Analysis

In this meta-analysis, we examine the advantages of invasive strategies for patients diagnosed with chronic coronary heart disease (CHD) and preserved left ventricular (LV) function, as well as those with significant LV systolic dysfunction (LV ejection fraction (EF) < 45%).

MATERIAL AND METHODS

We conducted a systematic search to identify all randomized trials directly comparing invasive strategies with optimal medical therapy (OMT) in patients diagnosed with chronic CHD. Data from these trials were pooled using a random-effects meta-analysis. The primary outcome assessed was the all-cause mortality, while secondary endpoints included cardiovascular (CV) death, stroke, myocardial infarction (MI), and unplanned revascularization. This study was designed to assess the benefits of both invasive strategies and OMT in patients with preserved LV function and in those with LV systolic dysfunction. The statistical analysis of the data was conducted using the Review Manager (RevMan) software, version 5.4.1 (The Cochrane Collaboration, 2020).

RESULTS

Twelve randomized studies enrolling 13,912 patients were included in the final analysis. Among the patients with chronic CHD and preserved LV systolic function, revascularization did not demonstrate a reduction in all-cause mortality (8.52% vs. 8.45%, p = 0.45), CV death (3.41% vs. 3.62%, p = 0.08), or the incidence of MI (9.88% vs. 10.49%, p = 0.47). However, the need for unplanned myocardial revascularization was significantly lower in the group following the initial invasive approach compared to patients undergoing OMT (14.75% vs. 25.72%, p < 0.001). In contrast, the invasive strategy emerged as the preferred treatment modality for patients with ischemic LV systolic dysfunction. This approach demonstrated lower rates of all-cause mortality (40.61% vs. 46.52%, p = 0.004), CV death (28.75% vs. 35.82%, p = 0.0004), and MI (8.19% vs. 10.8%, p = 0.03).

CONCLUSIONS

In individuals diagnosed with chronic CHD and preserved LV EF, the initial invasive approach did not demonstrate a clinical advantage over OMT. Conversely, in patients with ischemic LV systolic dysfunction, myocardial revascularization was found to reduce the risks of CV events and enhance the overall outcomes. These findings hold significant clinical relevance for optimizing treatment strategies in patients with chronic CHD, contingent upon myocardial contractility status.

Stent, balloon and hybrid in de novo PCI: could the whole be greater than the sum of its parts?

Andreas Grüntzig, an ardent angiologist crafted an indeflatable sausage-shaped dual-lumen balloon- catheter, designed its delivery to the heart, launched minimally invasive coronary intervention and taught by beaming live demonstration. Subsequent advances are just incremental tweaks and tinkers around this fully formed framework from 1978. The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug- eluting stent, drug-coated balloon, or both in different combinations and permutations. Now with Grüntzig's balloon armed with an antiproliferative drug, it could dominate the field once more, as he originally envisaged.

A bibliometric analysis of efferocytosis in cardiovascular diseases from 2001 to 2022

INTRODUCTION

In recent years, efferocytosis in cardiovascular diseases has become an intense area of research. However, only a few bibliometric analyses have been conducted in this area. In this review, we used CiteSpace 5.7. R2 and VOSviewer 1.6.17 software to perform text mining and knowledge map analysis. This study summarizes the latest progress, development paths, frontier research hotspots, and future research trends in this field.

MATERIALS AND METHODS

Studies on efferocytosis in cardiovascular diseases were downloaded from the Web of Science Core Collection.

RESULTS

In total, 327 studies published by 506 institutions across 42 countries and regions were identified. The number of studies on efferocytosis in cardiovascular diseases has increased over time. Arteriosclerosis Thrombosis and Vascular Biology published the highest number of articles and was the top co-cited journal. Tabas Ira. was the most prolific researcher and co-cited the most. The most productive countries were the United States and China. Columbia University, Harvard Medical School, and Brigham Women's Hospital were the 3 most productive institutions in the field of research. Keyword Co-occurrence, Clusters, and Burst analyses showed that inflammation, atherosclerosis, macrophages, and phagocytosis appeared with the highest frequency in these studies.

CONCLUSION

Multinational cooperation and multidisciplinary intersections are characteristic trends of development in the field, and the immune microenvironment, glycolysis, and lipid metabolism will be the focus of future research.

Towards refining of the proposed ECG-based index of coronary microvascular resistance (ECGMVR)

Assessment of the coronary microcirculation via noninvasive indices of coronary microvascular resistance (MVR), based on coronary angiography (AngioMVR) is currently implemented in patients undergoing coronary angiography, and it is employed by many laboratories. Recently, a proposal has been presented of a new index of MVR, based on the duration of the transient electrocardiogram repolarization and depolarization changes emerging during coronary angiography (ECGMVR). It is paramount that the ECGMVR, which does not require any special expertise, new equipment, additional personnel and costs, or prolongation of the catheterization procedure, undergoes correlation with currently utilized indices of AngioMVR, the TIMI frame count index, and the invasive indices assessing the coronary epicardial and microvasculature states, for its validation. Some additional insights are also included in the present communication for the refinement of ECGMVR implementation.

Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management

INTRODUCTION

In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks.

AREAS COVERED

This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications.

EXPERT OPINION

Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.

Pre-test probability for coronary artery disease in patients with chest pain based on machine learning techniques

BACKGROUND

A correct and prompt diagnosis of coronary artery disease (CAD) is a crucial component of disease management to reduce the risk of death and improve the quality of life in patients with CAD. Currently, the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC) guidelines recommend selecting an appropriate pre-diagnosis test for an individual patient according to the CAD probability. The purpose of this study was to develop a practical pre-test probability (PTP) for obstructive CAD in patients with chest pain using machine learning (ML); also, the performance of ML-PTP for CAD is compared to the final result of coronary angiography (CAG).

METHODS

We used a database from a single-center, prospective, all-comer registry designed to reflect real-world practice since 2004. All subjects underwent invasive CAG at Korea University Guro Hospital in Seoul, South Korea. We used logistic regression algorithms, random forest (RF), supporting vector machine, and K-nearest neighbor classification for the ML models. The dataset was divided into two consecutive sets according to the registration period to validate the ML models. ML training for PTP and internal validation used the first dataset registered between 2004 and 2012 (8631 patients). The second dataset registered between 2013 and 2014 (1546 patients) was used for external validation. The primary endpoint was obstructive CAD. Obstructive CAD was defined as having a stenosis diameter of >70% on the quantitative CAG of the main epicardial coronary artery.

RESULTS

We derived an ML-based model consisting of three different models according to the subject used to obtain the information, such as the patient himself (dataset 1), the community's first medical center (dataset 2), and doctors (dataset 3). The performance range of the ML-PTP models as the non-invasive test had C-statistics of 0.795 to 0.984 compared to the result of invasive testing via CAG in patients with chest pain. The training ML-PTP models were adjusted to have 99% sensitivity for CAD so as not to miss actual CAD patients. In the testing dataset, the best accuracy of the ML-PTP model was 45.7% using dataset 1, 47.2% using dataset 2, and 92.8% using dataset 3 and the RF algorithm. The CAD prediction sensitivity was 99.0%, 99.0%, and 98.0%, respectively.

CONCLUSION

We successfully developed a high-performance model of ML-PTP for CAD which is expected to reduce the need for non-invasive tests in chest pain. However, since this PTP model is derived from data of a single medical center, multicenter verification is required to use it as a PTP recommended by the major American societies and the ESC.

Percutaneous Coronary Intervention Is Not Superior to Optimal Medical Therapy in Chronic Coronary Syndrome: A Meta-Analysis

(1) Background and Aim: Conflicting evidence exists regarding the benefits of percutaneous coronary intervention (PCI) on survival and symptomatic relief of patients with chronic coronary syndrome (CCS) compared with optimal medical therapy (OMT). This meta-analysis is to evaluate the short- and long-term clinical benefit of PCI over and above OMT in CCS. (2) Methods: Main endpoints were major adverse cardiac events (MACEs), all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), urgent revascularization, stroke hospitalization, and quality of life (QoL). Clinical endpoints at very short (≤3 months), short- (<12 months), and long-term (≥ 12 months) follow-up were evaluated. (3) Results: Fifteen RCTs with a total of 16,443 patients with CCS (PCI n = 8307 and OMT n = 8136) were included in the meta-analysis. At mean follow-up of 27.7 months, the PCI group had similar risk of MACE (18.2 vs. 19.2 %; p < 0.32), all-cause mortality (7.09 vs. 7.88%; p = 0.56), CV mortality (8.74 vs. 9.87%; p = 0.30), MI (7.69 vs. 8.29%; p = 0.32), revascularization (11.2 vs. 18.3%; p = 0.08), stroke (2.18 vs. 1.41%; p = 0.10), and hospitalization for anginal symptoms (13.5 vs. 13.9%; p = 0.69) compared with OMT. These results were similar at short- and long-term follow-up. At the very short-term follow-up, PCI patients had greater improvement in the QoL including physical limitation, angina frequency, stability, and treatment satisfaction (p < 0.05 for all) but such benefits disappeared at the long-term follow-up. (4) Conclusions: PCI treatment of CCS does not provide any long-term clinical benefit compared with OMT. These results should have significant clinical implications in optimizing patient's selection for PCI treatment.

ANOCA/INOCA/MINOCA: Open artery ischemia

Ischemic heart disease continues to represent a major health threat for death, disability, and poor quality of life as it also consumes enormous health-related resources. For over a century, the major clinical phenotype was taken to be obstructive atherosclerosis involving the larger coronary arteries (e.g., coronary artery disease [CAD]). However, evolving evidence now indicates that nonobstructive CAD is the predominant phenotype. Patients within this phenotype have been termed to have angina with no obstructive CAD (ANOCA), ischemia with no obstructive CAD (INOCA), or myocardial infarction with no obstructive coronary arteries (MINOCA). But as methods to assess cardiomyocyte injury evolve, these phenotypic distinctions have begun to merge, raising concern about their usefulness. Also, considerable evidence has suggested several endotypes that link to potential mechanisms. These include coronary microvascular dysfunction, augmented vasoreactivity (failure to relax appropriately, exaggerated constriction ["spasm"], etc.), nonobstructive atherosclerosis, pre-heart failure with preserved ejection fraction, hypercoagulable states, and several others, alone or in combination. This review summarizes these syndromes and their associated clinical outcomes with an emphasis on potential mechanistic signals. These involve the endothelium, the microvasculature, and cardiomyocyte function. Biomarkers of injury/dysfunction involving these structures are discussed along with a hypothetical construct for management being tested in an ongoing trial.