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Lamb RJ, Griffiths K, Lip GYH, Sorokin V, Frenneaux MP, Feelisch M, Madhani M. ALDH2 polymorphism and myocardial infarction: From alcohol metabolism to redox regulation. Pharmacol Ther 2024; 259:108666. [PMID: 38763322 DOI: 10.1016/j.pharmthera.2024.108666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
Acute myocardial infarction (AMI) remains a leading cause of death worldwide. Increased formation of reactive oxygen species (ROS) during the early reperfusion phase is thought to trigger lipid peroxidation and disrupt redox homeostasis, leading to myocardial injury. Whilst the mitochondrial enzyme aldehyde dehydrogenase 2 (ALDH2) is chiefly recognised for its central role in ethanol metabolism, substantial experimental evidence suggests an additional cardioprotective role for ALDH2 independent of alcohol intake, which mitigates myocardial injury by detoxifying breakdown products of lipid peroxidation including the reactive aldehydes, malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE). Epidemiological evidence suggests that an ALDH2 mutant variant with reduced activity that is highly prevalent in the East Asian population increases AMI risk. Additional studies have uncovered a strong association between coronary heart disease and this ALDH2 mutant variant. It appears this enzyme polymorphism (in particular, in ALDH2*2/2 carriers) has the potential to have wide-ranging effects on thiol reactivity, redox tone and therefore numerous redox-related signaling processes, resilience of the heart to cope with lifestyle-related and environmental stressors, and the ability of the whole body to achieve redox balance. In this review, we summarize the journey of ALDH2 from a mitochondrial reductase linked to alcohol metabolism, via pre-clinical studies aimed at stimulating ALDH2 activity to reduce myocardial injury to clinical evidence for its protective role in the heart.
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Affiliation(s)
- Reece J Lamb
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, United Kingdom
| | - Kayleigh Griffiths
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | | | - Martin Feelisch
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton and NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom
| | - Melanie Madhani
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, United Kingdom.
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Ma XH, Chen Y, Huang XY, Jiang JR, Liu X, An DQ, He RR. Characteristics and efficacy of traditional Chinese medicine in the therapeutic strategy of chronic coronary syndrome: A systematic review and meta-analysis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 129:155579. [PMID: 38574427 DOI: 10.1016/j.phymed.2024.155579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND AND AIMS Chronic coronary syndrome (CCS) has always been controversial in its therapeutic strategy. Although invasive treatment and optimal medication therapy (OMT) are the most commonly used treatments, doctors continue to debate the best strategy. However, traditional Chinese medicine (TCM) for CCS is effective clinically. METHODS To identify potentially eligible observational and experimental studies, we searched Pubmed, the Web of Science, and the China National Knowledge Internet. To be eligible, studies had to report with end-of treatment outcomes, such as major adverse cardiac events (MACE), deaths from myocardial infarctions (MI), all-cause mortality, angina, cardiac mortality, the effectiveness rate of electrocardiographs, and the reduction rate of the Nitroglycerin tablets. Risk differences (RDs) and 95 % confidence intervals (95 % CIs) were calculated based on random-effects models or fixed-effects models. Citation screening, data abstraction, risk assessment, and strength-of-evidence grading were completed by 2 independent reviewers. RESULTS In Section 1 (13 studies, involving 17,287 patients), showed no significant difference between invasive treatment and medication treatment in MACE (RD = -0.04, 95% CI = -0.08 to 0.00, I2 = 76.4 %), all-cause mortality (RD = -0.01, 95%CI = -0.022 to 0.01, I2 = 73.44 %), MI (RD = 0.00, 95%CI = -0.00 to 0.01, I2 = 0.00 %) and cardiac mortality (RD = 0.00, 95 %CI = -0.01 to 0.01, I2 = 34.9 %). In Section 2 (21 studies, including 1820 patients), compared with WM treatment, TCM + WM treatment increased ECG effectiveness by 18 %, angina effectiveness by 20 %, and stopping or reducing Nitroglycerin tablets by 20 %. In Section 3 (25 studies, including 2859 patients) showed that TCM revealed a better electrocardiogram effective rate (RD = 0.10, 95 %CI = 0.05 to 0.14, I2 = 44.7 %) and angina effective rate (RD = 0.12, 95 %CI = 0.09 to 0.15, I2 = 44.9 %). We identified that TCM treatment properties of "Circulating blood and transforming stasis" and application of warm/heat-properties medicines were frequently used in CCS treatment. CONCLUSIONS TCM treatment has shown superior beneficial cardioprotective in CCS therapy strategy, among which "Circulating blood and transforming stasis" and the application of warm/heat-properties medicine are its characteristics.
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Affiliation(s)
- Xiao-Hui Ma
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China; Key Laboratory of High Incidence Diseases in Xinjiang Region, Ministry of Education (MOE), Xinjiang Medical University, Urumqi 830054, China; Guangdong Engineering Research Center of Chinese Medicine & Disease Susceptibility, Jinan University, Guangzhou 510632, China; Guangdong Province Key Laboratory of Pharmacodynamic Constituents of TCM and New Drugs Research, College of Pharmacy, Jinan University, Guangzhou 510632, China; International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Jinan University, Guangzhou 510632, China.
| | - Yang Chen
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China; Key Laboratory of High Incidence Diseases in Xinjiang Region, Ministry of Education (MOE), Xinjiang Medical University, Urumqi 830054, China
| | - Xiao-Yao Huang
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China; Key Laboratory of High Incidence Diseases in Xinjiang Region, Ministry of Education (MOE), Xinjiang Medical University, Urumqi 830054, China
| | - Jia-Rong Jiang
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China; Key Laboratory of High Incidence Diseases in Xinjiang Region, Ministry of Education (MOE), Xinjiang Medical University, Urumqi 830054, China
| | - Xin Liu
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China; Key Laboratory of High Incidence Diseases in Xinjiang Region, Ministry of Education (MOE), Xinjiang Medical University, Urumqi 830054, China
| | - Dong-Qing An
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi 830054, China; National Traditional Chinese Medicine Inheritance and Innovation Center, Xinjiang Medical University, Urumqi 830054, China.
| | - Rong-Rong He
- Institute of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi 830054, China; Guangdong Engineering Research Center of Chinese Medicine & Disease Susceptibility, Jinan University, Guangzhou 510632, China; Guangdong Province Key Laboratory of Pharmacodynamic Constituents of TCM and New Drugs Research, College of Pharmacy, Jinan University, Guangzhou 510632, China; International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Development of Chinese Ministry of Education (MOE), Jinan University, Guangzhou 510632, China.
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Quintana RA, von Knebel Doeberitz P, Vatsa N, Liu C, Ko YA, De Cecco CN, van Assen M, Quyyumi AA. Intra- and inter-reader reproducibility in quantitative coronary plaque analysis on coronary computed tomography angiography. Curr Probl Cardiol 2024; 49:102585. [PMID: 38688396 PMCID: PMC11146670 DOI: 10.1016/j.cpcardiol.2024.102585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Coronary artery plaque burden, low attenuation non-calcified plaque (LAP), and pericoronary adipose tissue (PCAT) on coronary CT angiography (CCTA), have been linked to future cardiac events. The purpose of this study was to evaluate intra- and inter reader reproducibility in the quantification of coronary plaque burden and its characteristics using an artificial intelligence-enhanced semi-automated software. MATERIALS AND METHODS A total of 10 women and 6 men, aged 52 (IQR 49-58) underwent CCTA using a Siemens Somatom Force, Somatom Definition AS and Somatom Definition Flash scanners. Two expert readers utilized dedicated semi-automatic software (vascuCAP, Elucid Bioimaging, Wenham, MA) to assess calcified plaque, low attenuation plaque and PCAT. Readers were blinded to all clinical information and repeated their analysis at 6 weeks in random order to minimize recall bias. Data analysis was performed on the right and left coronary arteries. Intra- and inter-reader reproducibility was compared using Pearson correlation coefficient, while absolute values between analyses and readers were compared with paired non-parametric tests. This is a sub-study of the Specialized Center of Research Excellence (SCORE) clinical trial (5U54AG062334). RESULTS A total of 64 vessels from 16 patients were analyzed. Intra-reader Pearson correlation coefficients for calcified plaque volume, LAP volume and PCAT volumes were 0.96, 0.99 and 0.92 for reader 1 and 0.94, 0.94 and 0.95 for reader 2, respectively, (all p < 0.0001). Inter-reader Pearson correlation coefficients for calcified plaque volume, LAP and PCAT volumes were 0.92, 0.96 and 0.78, and 0.99, 0.99 and 0.93 on the second analyses, all had a p value <0.0001. There was no significant bias on the corresponding Bland-Altman analyses. CONCLUSION Volume measurement of coronary plaque burden and PCAT volume can be performed with high intra- and inter-reader agreement.
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Affiliation(s)
- Raymundo A Quintana
- Cardiovascular Imaging Section, Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Philipp von Knebel Doeberitz
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nishant Vatsa
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Chang Liu
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Carlo N De Cecco
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, USA
| | - Marly van Assen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, USA
| | - Arshed A Quyyumi
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
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Toftholm MH, Højstrup S, Talleruphuus U, Marner L, Bjerking L, Jakobsen L, Christiansen EH, Bouchelouche K, Galatius S, Prescott E, Skak-Hansen KW. 82-rubidium positron emission tomography determined myocardial flow reserve and outcomes following cardiac revascularisation - A multicentre registry study. Int J Cardiol 2024; 405:131865. [PMID: 38365013 DOI: 10.1016/j.ijcard.2024.131865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/21/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Finding patients with chronic coronary syndromes (CCS) whom revascularization could benefit, is complicated. Myocardial flow reserve (MFR), a measurement of myocardial perfusion, has proven prognostic value on survival and risk of major adverse cardiac events (MACE). We investigated if MFR identifies who may benefit from revascularization. METHODS Among 7462 patients from Danish hospitals examined with 82Rb PET between January 2018 and August 2020, patients with ≥5% reversible perfusion defects were followed for MACE and all-cause mortality. Associations between revascularisation (within 90 days) and outcomes according to MFR (< and ≥ 2) was assessed by Cox regression adjusted by inverse probability weighting for demographics, cardiovascular risk factors, comorbidities, and 82Rb PET variables. RESULTS Of 1806 patients with ≥5% reversible perfusion defect, 893 (49%) had MFR < 2 and 491 underwent revascularisation (36.6% in MFR < 2 versus 17.9% MFR ≥ 2, p < 0.001). During a median follow-up of 37.0 [31.0-45.8 IQR] months, 251 experienced a MACE and 173 died. Revascularisation was associated with lower adjusted risk of all-cause mortality (hazard ratio [HR], 0.51 [95% CI, 0.30-0.88], p = 0.015) and MACE (HR, 0.54 [0.33-0.87], p = 0.012) in patients with MFR < 2 but not MFR ≥ 2 for all-cause mortality (HR 1.33 [0.52-3.40], p = 0.542) and MACE (HR 1.50 [0.79-2.84], p = 0.211). MFR significantly modified the association between revascularisation and MACE, but not all-cause mortality (interaction p-value 0.021 and 0.094, respectively). CONCLUSIONS Revascularization was associated with improved prognosis among patients with impaired MFR. No association was seen in patients with normal MFR. In patients with regional ischemia, MFR may identify patients with a prognostic benefit from revascularization.
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Affiliation(s)
- M H Toftholm
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark.
| | - S Højstrup
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark.
| | - U Talleruphuus
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Clinical Physiology and Nuclear Medicine, Denmark
| | - L Marner
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Clinical Physiology and Nuclear Medicine, Denmark
| | - L Bjerking
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark
| | - L Jakobsen
- Aarhus University Hospital, Department of Cardiology, Denmark
| | | | - K Bouchelouche
- Aarhus University Hospital, Department of Nuclear Medicine & PET Centre, Denmark
| | - S Galatius
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark
| | - E Prescott
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark
| | - K W Skak-Hansen
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Department of Cardiology, Denmark
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Redfors B, Gaudino MFL. Reply: Initial Medical Therapy for Stable Coronary Artery Disease: Until Death Do Us Part. J Am Coll Cardiol 2024; 83:e219. [PMID: 38811100 DOI: 10.1016/j.jacc.2024.03.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Bjorn Redfors
- Gothenburg University, Gothenburg, Sweden; Sahlgrenska University Hospital, Gothenburg, Sweden; Weill Cornell Medicine, New York, New York, USA
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Falcão-Pires I, Ferreira AF, Trindade F, Bertrand L, Ciccarelli M, Visco V, Dawson D, Hamdani N, Van Laake LW, Lezoualc'h F, Linke WA, Lunde IG, Rainer PP, Abdellatif M, Van der Velden J, Cosentino N, Paldino A, Pompilio G, Zacchigna S, Heymans S, Thum T, Tocchetti CG. Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function. Eur J Heart Fail 2024. [PMID: 38837573 DOI: 10.1002/ejhf.3264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.
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Affiliation(s)
- Inês Falcão-Pires
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Filipa Ferreira
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Fábio Trindade
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Luc Bertrand
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle of Cardiovascular Research, Brussels, Belgium
- WELBIO, Department, WEL Research Institute, Wavre, Belgium
| | - Michele Ciccarelli
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Valeria Visco
- Cardiovascular Research Unit, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Nazha Hamdani
- Department of Cellular and Translational Physiology, Institute of Physiology, Ruhr University Bochum, Bochum, Germany
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- HCEMM-SU Cardiovascular Comorbidities Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht, Maastricht, the Netherlands
| | - Linda W Van Laake
- Division Heart and Lungs, Department of Cardiology and Regenerative Medicine Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank Lezoualc'h
- Institut des Maladies Métaboliques et Cardiovasculaires, Inserm, Université Paul Sabatier, UMR 1297-I2MC, Toulouse, France
| | - Wolfgang A Linke
- Institute of Physiology II, University Hospital Münster, Münster, Germany
| | - Ida G Lunde
- Oslo Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- KG Jebsen Center for Cardiac Biomarkers, Campus Ahus, University of Oslo, Oslo, Norway
| | - Peter P Rainer
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | - Mahmoud Abdellatif
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | | | - Nicola Cosentino
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Cardiovascular Section, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alessia Paldino
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Serena Zacchigna
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Stephane Heymans
- Department of Cardiology, CARIM Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
- Centre of Cardiovascular Research, University of Leuven, Leuven, Belgium
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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Vergallo R, Galiuto L. Weekly journal scan: angina severity reduced by percutaneous coronary intervention in the ORBITA-2 trial. Eur Heart J 2024; 45:1874-1876. [PMID: 38596889 DOI: 10.1093/eurheartj/ehae215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy
| | - Leonarda Galiuto
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Azienda Ospedaliero-Universitaria S. Andrea, Rome, Italy
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Shan TK, Qian LL, Han XD, Deng B, Gu LF, Wang ZM, He Y, Zhu T, Jing P, Wang QM, Wang ZD, Wang RX, Wang SB, Wang LS. Symptom-to-balloon time and risk of ventricular arrhythmias in patients with STEMI undergoing percutaneous coronary intervention: The VERY-STEMI study. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200286. [PMID: 38813099 PMCID: PMC11133922 DOI: 10.1016/j.ijcrp.2024.200286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
Background Ventricular arrhythmias (VAs) mainly occur in the early post-myocardial infarction (MI) period. However, studies examining the association between total myocardial ischemia time interval and the risk of new-onset VAs during a long-term follow-up are scarce. Methods This study (symptom-to-balloon time and VEntricular aRrhYthmias in patients with STEMI, VERY-STEMI study) was a multicenter, observational cohort and real-world study, which included patients with ST-segment elevation MI (STEMI) undergoing percutaneous coronary intervention (PCI). The primary endpoint was cumulative new-onset VAs during follow-up. The secondary endpoints were the major adverse cardiovascular events (MACE) and changes in left ventricular ejection fraction (ΔLVEF, %). Results A total of 517 patients with STEMI were included and 236 primary endpoint events occurred. After multivariable adjustments, compared to patients with S2BT of 24 h-7d, those with S2BT ≤ 24 h and S2BT > 7d had a lower risk of primary endpoint. RCS showed an inverted U-shaped relationship between S2BT and the primary endpoint, with an S2BT of 68.4 h at the inflection point. Patients with S2BT ≤ 24 h were associated with a lower risk of MACE and a 4.44 increase in LVEF, while there was no significant difference in MACE and LVEF change between the S2BT > 7d group and S2BT of 24 h-7d group. Conclusions S2BT of 24 h-7d in STEMI patients was associated with a higher risk of VAs during follow-up. There was an inverted U-shaped relationship between S2BT and VAs, with the highest risk at an S2BT of 68.4 h.
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Affiliation(s)
- Tian-Kai Shan
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ling-Ling Qian
- Department of Cardiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, China
| | - Xu-Dong Han
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Bo Deng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ling-Feng Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ze-Mu Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ye He
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ting Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Peng Jing
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qi-Ming Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zi-Dun Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ru-Xing Wang
- Department of Cardiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, China
| | - Si-Bo Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Lian-Sheng Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
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França Neto OR, Fernandes-Silva MM, Cerci RJ, Cunha-Pereira CA, Masukawa M, Vitola JV. Effects of Ivabradine on Myocardial Perfusion in Chronic Angina: A Prospective, Preliminary, Open-Label, Single-Arm Study. Cardiol Ther 2024; 13:341-357. [PMID: 38514522 PMCID: PMC11093942 DOI: 10.1007/s40119-024-00363-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024] Open
Abstract
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).
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Affiliation(s)
- Olímpio R França Neto
- Quanta Diagnostico Por Imagem, 1000 Almirante Tamandaré Street, Curitiba, PR, 80045-170, Brazil.
| | | | - Rodrigo J Cerci
- Quanta Diagnostico Por Imagem, 1000 Almirante Tamandaré Street, Curitiba, PR, 80045-170, Brazil
| | - Carlos A Cunha-Pereira
- Quanta Diagnostico Por Imagem, 1000 Almirante Tamandaré Street, Curitiba, PR, 80045-170, Brazil
| | - Margaret Masukawa
- Quanta Diagnostico Por Imagem, 1000 Almirante Tamandaré Street, Curitiba, PR, 80045-170, Brazil
| | - João V Vitola
- Quanta Diagnostico Por Imagem, 1000 Almirante Tamandaré Street, Curitiba, PR, 80045-170, Brazil
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Persits I, Layoun H, Kondoleon NP, Spilias N, Badwan O, Sipko J, Yun JJ, Kalra A, Dykun I, Tereshchenko LG, Krishnaswamy A, Reed GW, Kapadia SR, Puri R. Impact of untreated chronic obstructive coronary artery disease on outcomes after transcatheter aortic valve replacement. Eur Heart J 2024; 45:1890-1900. [PMID: 38270189 DOI: 10.1093/eurheartj/ehae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND AND AIMS In transcatheter aortic valve replacement (TAVR) recipients, the optimal management of concomitant chronic obstructive coronary artery disease (CAD) remains unknown. Some advocate for pre-TAVR percutaneous coronary intervention, while others manage it expectantly. The aim of this study was to assess the impact of varying degrees and extent of untreated chronic obstructive CAD on TAVR and longer-term outcomes. METHODS The authors conducted a retrospective cohort study of TAVR recipients from January 2015 to November 2021, separating patients into stable non-obstructive or varying degrees of obstructive CAD. The major outcomes of interest were procedural all-cause mortality and complications, major adverse cardiovascular events, and post-TAVR unplanned coronary revascularization. RESULTS Of the 1911 patients meeting inclusion, 75%, 6%, 10%, and 9% had non-obstructive, intermediate-risk, high-risk, and extreme-risk CAD, respectively. Procedural complication rates overall were low (death 0.4%, shock 0.1%, extracorporeal membrane oxygenation 0.1%), with no difference across groups. At a median follow-up of 21 months, rates of acute coronary syndrome and unplanned coronary revascularization were 0.7% and 0.5%, respectively, in the non-obstructive population, rising in incidence with increasing severity of CAD (P < .001 for acute coronary syndrome/unplanned coronary revascularization). Multivariable analysis did not yield a significantly greater risk of all-cause mortality or major adverse cardiovascular events across groups. One-year acute coronary syndrome and unplanned coronary revascularization rates in time-to-event analyses were significantly greater in the non-obstructive (98%) vs. obstructive (94%) subsets (Plog-rank< .001). CONCLUSIONS Transcatheter aortic valve replacement can be performed safely in patients with untreated chronic obstructive CAD, without portending higher procedural complication rates and with relatively low rates of unplanned coronary revascularization and acute coronary syndrome at 1 year.
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Affiliation(s)
- Ian Persits
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Sipko
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - James J Yun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | - Iryna Dykun
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Larisa G Tereshchenko
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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11
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Yamamoto A, Nagao M, Kawakubo M, Nakao R, Matsuo Y, Sakai A, Kaneko K, Fukushima K, Momose M, Sakai S, Yamaguchi J. Risk Stratification Using Right Ventricular Longitudinal Strain Ratio Derived from 13N-Ammonia PET in Patients with Ischemic Heart Disease. Radiol Cardiothorac Imaging 2024; 6:e230298. [PMID: 38814185 DOI: 10.1148/ryct.230298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Purpose To investigate whether right ventricular (RV) myocardial strain ratio (RVMSR) assessed using nitrogen 13 ammonia (13N-NH3) PET can predict cardiovascular events in patients with ischemic heart disease (IHD). Materials and Methods This retrospective study included 480 consecutive patients (mean age, 66 years ± 12 [SD]; 334 males and 146 females) with IHD who underwent 13N-NH3 PET. RVMSR was defined as the ratio of RV strain during stress to that at rest. The primary end point was major adverse cardiac events (MACEs), defined as cardiac death or heart failure hospitalization. The ability of RVMSR to predict MACE was assessed using receiver operating characteristic (ROC) curve and Kaplan-Meier analyses. Cox proportional hazards regression analysis was used to calculate hazard ratios (HRs) with 95% CIs. Results ROC curve analysis identified a sensitivity and specificity of 84% and 82%, respectively, for predicting MACE from RVMSR. Patients with reduced RVMSR (<110.2) displayed a significantly higher rate of MACE than those with a preserved RVMSR (34 of 240 vs four of 240; P < .001). Cox proportional hazards regression analysis of imaging parameters, including myocardial flow reserve, indicated that RVMSR was an independent predictor of MACE (HR, 0.94 [95% CI: 0.92, 0.97]; P < .001). Conclusion RVMSR was an independent predictor of MACE and has potential to aid in the risk stratification of patients with IHD. Keywords: Right Ventricular Myocardial Strain Ratio, Myocardial Flow Reserve, Ischemic Heart Disease, 13N-Ammonia Positron Emission Tomography Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Atsushi Yamamoto
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Michinobu Nagao
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Masateru Kawakubo
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Risako Nakao
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Yuka Matsuo
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Akiko Sakai
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Koichiro Kaneko
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Kenji Fukushima
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Mitsuru Momose
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Shuji Sakai
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
| | - Junichi Yamaguchi
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K., M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan (K.F.)
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Yoshida K, Tanabe Y, Hosokawa T, Morikawa T, Fukuyama N, Kobayashi Y, Kouchi T, Kawaguchi N, Matsuda M, Kido T, Kido T. Coronary computed tomography angiography for clinical practice. Jpn J Radiol 2024; 42:555-580. [PMID: 38453814 PMCID: PMC11139719 DOI: 10.1007/s11604-024-01543-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
Coronary artery disease (CAD) is a common condition caused by the accumulation of atherosclerotic plaques. It can be classified into stable CAD or acute coronary syndrome. Coronary computed tomography angiography (CCTA) has a high negative predictive value and is used as the first examination for diagnosing stable CAD, particularly in patients at intermediate-to-high risk. CCTA is also adopted for diagnosing acute coronary syndrome, particularly in patients at low-to-intermediate risk. Myocardial ischemia does not always co-exist with coronary artery stenosis, and the positive predictive value of CCTA for myocardial ischemia is limited. However, CCTA has overcome this limitation with recent technological advancements such as CT perfusion and CT-fractional flow reserve. In addition, CCTA can be used to assess coronary artery plaques. Thus, the indications for CCTA have expanded, leading to an increased demand for radiologists. The CAD reporting and data system (CAD-RADS) 2.0 was recently proposed for standardizing CCTA reporting. This RADS evaluates and categorizes patients based on coronary artery stenosis and the overall amount of coronary artery plaque and links this to patient management. In this review, we aimed to review the major trials and guidelines for CCTA to understand its clinical role. Furthermore, we aimed to introduce the CAD-RADS 2.0 including the assessment of coronary artery stenosis, plaque, and other key findings, and highlight the steps for CCTA reporting. Finally, we aimed to present recent research trends including the perivascular fat attenuation index, artificial intelligence, and the advancements in CT technology.
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Affiliation(s)
- Kazuki Yoshida
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yuki Tanabe
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Takaaki Hosokawa
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoro Morikawa
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naoki Fukuyama
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yusuke Kobayashi
- Department of Radiology, Matsuyama Red Cross Hospital, Bunkyocho, Matsuyama, Ehime, Japan
| | - Takanori Kouchi
- Department of Radiology, Juzen General Hospital, Kitashinmachi, Niihama, Ehime, Japan
| | - Naoto Kawaguchi
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Megumi Matsuda
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoyuki Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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Liu Z, Liu W, Han M, Wang M, Li Y, Yao Y, Duan Y. A comprehensive review of natural product-derived compounds acting on P2X7R: The promising therapeutic drugs in disorders. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 128:155334. [PMID: 38554573 DOI: 10.1016/j.phymed.2023.155334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/30/2023] [Indexed: 04/01/2024]
Abstract
BACKGROUND The P2X7 receptor (P2X7R) is known to play a significant role in regulating various pathological processes associated with immune regulation, neuroprotection, and inflammatory responses. It has emerged as a potential target for the treatment of diseases. In addition to chemically synthesized small molecule compounds, natural products have gained attention as an important source for discovering compounds that act on the P2X7R. PURPOSE To explore the research progress made in the field of natural product-derived compounds that act on the P2X7R. METHODS The methods employed in this review involved conducting a thorough search of databases, include PubMed, Web of Science and WIKTROP, to identify studies on natural product-derived compounds that interact with P2X7R. The selected studies were then analyzed to categorize the compounds based on their action on the receptor and to evaluate their therapeutic applications, chemical properties, and pharmacological actions. RESULTS The natural product-derived compounds acting on P2X7R can be classified into three categories: P2X7R antagonists, compounds inhibiting P2X7R expression, and compounds regulating the signaling pathway associated with P2X7R. Moreover, highlight the therapeutic applications, chemical properties and pharmacological actions of these compounds, and indicate areas that require further in-depth study. Finally, discuss the challenges of the natural products-derived compounds exploration, although utilizing compounds from natural products for new drug research offers unique advantages, problems related to solubility, content, and extraction processes still exist. CONCLUSION The detailed information in this review will facilitate further development of P2X7R antagonists and potential therapeutic strategies for P2X7R-associated disorders.
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Affiliation(s)
- Zhenling Liu
- Children's Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou 450018, China
| | - Wenjin Liu
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450001, China
| | - Mengyao Han
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450001, China
| | - Mingzhu Wang
- Children's Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou 450018, China
| | - Yinchao Li
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450001, China.
| | - Yongfang Yao
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450001, China; Pingyuan Laboratory (Zhengzhou University), Zhengzhou 450001, China; Key Laboratory of Advanced Drug Preparation Technologies, Ministry of Education, Zhengzhou University, Zhengzhou 450001, China.
| | - Yongtao Duan
- Children's Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou 450018, China; Henan International Joint Laboratory of Prevention and Treatment of Pediatric Diseases, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou 450018, China; Henan Neurodevelopment Engineering Research Center for Children, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou 450018, China.
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14
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Frisvold D, Dogan M, Dogan T, Abdullahi K, Koep T, Philibert R. The Use of Precision Epigenetic Methods for the Diagnosis and Care of Stable Coronary Heart Disease Reduces Healthcare Costs. Adv Ther 2024; 41:2367-2380. [PMID: 38662186 PMCID: PMC11133094 DOI: 10.1007/s12325-024-02860-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The cost of secondary prevention of coronary heart disease (CHD) is continuing to increase, with a substantial portion of this acceleration being driven by the expense of confirmatory diagnostic testing. Conceivably, newly developed precision epigenetic technologies could drive down these costs. However, at the current time, their impact on overall expense for CHD care is poorly understood. We hypothesized that the use of a newly developed, highly sensitive, and specific epigenetic test, PrecisionCHD, could decrease the costs of secondary prevention. METHODS To test this hypothesis, we constructed a budget impact analysis using a cost calculation model that examined the effects of substituting PrecisionCHD for conventional CHD diagnostic tests on the expenses of the initial evaluation and first year of care of stable CHD using a 1-year time horizon with no discounting. RESULTS The model projected that for a commercial insurer with one million members, full adoption of PrecisionCHD as the primary method of initial CHD assessment would save approximately $113.6 million dollars in the initial year. CONCLUSION These analyses support the use of precision epigenetic methods as part of the initial diagnosis and care of stable CHD and can meaningfully reduce cost. Real-world pilots to test the reliability of these analyses are indicated.
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Affiliation(s)
- David Frisvold
- Department of Economics, University of Iowa, Iowa City, IA, 52242, USA
| | | | - Timur Dogan
- Cardio Diagnostics Inc, Chicago, IL, 60654, USA
| | | | - Tyler Koep
- Cardio Diagnostics Inc, Chicago, IL, 60654, USA
| | - Robert Philibert
- Cardio Diagnostics Inc, Chicago, IL, 60654, USA.
- Department of Psychiatry, University of Iowa, Iowa City, IA, 52242, USA.
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15
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Kuno T, Kiyohara Y, Kohsaka S. Intravascular Imaging-Guided Percutaneous Coronary Intervention With Adequate Stent Optimization. JACC Cardiovasc Interv 2024; 17:1244-1245. [PMID: 38811105 DOI: 10.1016/j.jcin.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/05/2024] [Accepted: 04/19/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA.
| | - Yuko Kiyohara
- Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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16
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Nurmohamed NS, van Rosendael AR, Danad I, Ngo-Metzger Q, Taub PR, Ray KK, Figtree G, Bonaca MP, Hsia J, Rodriguez F, Sandhu AT, Nieman K, Earls JP, Hoffmann U, Bax JJ, Min JK, Maron DJ, Bhatt DL. Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography. Eur Heart J 2024; 45:1783-1800. [PMID: 38606889 PMCID: PMC11129796 DOI: 10.1093/eurheartj/ehae190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.
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Affiliation(s)
- Nick S Nurmohamed
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Division of Cardiology, The George Washington University School of Medicine, Washington, DC, United States
| | | | - Ibrahim Danad
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Quyen Ngo-Metzger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Pam R Taub
- Section of Cardiology, Department of Medicine, University of California, San Diego, CA, United States
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Australia, St Leonards, Australia
| | - Marc P Bonaca
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Judith Hsia
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Fatima Rodriguez
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Koen Nieman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - James P Earls
- Cleerly, Inc., Denver, CO, United States
- Department of Radiology, The George Washington University School of Medicine, Washington, DC, United States
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1030, New York, NY 10029, United States
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17
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Ando H, Collet C, Amano T. Can Coronary Flow Reserve After Stenting Be a Useful Predictor of Target Vessel Failure? Circ J 2024; 88:860-862. [PMID: 37981323 DOI: 10.1253/circj.cj-23-0773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
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18
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Chen H, Huang Y, Wan G, Zou X. Circulating metabolites and coronary heart disease: a bidirectional Mendelian randomization. Front Cardiovasc Med 2024; 11:1371805. [PMID: 38836062 PMCID: PMC11148779 DOI: 10.3389/fcvm.2024.1371805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Background Numerous studies have established a link between coronary heart disease and metabolic disorders. Yet, causal evidence connecting metabolites and Coronary Heart Disease (CHD) remains scarce. To address this, we performed a bidirectional Mendelian Randomization (MR) analysis investigating the causal relationship between blood metabolites and CHD. Methods Data were extracted from published genome-wide association studies (GWASs) on metabolite levels, focusing on 1,400 metabolite summary data as exposure measures. Primary analyses utilized the GWAS catalog database GCST90199698 (60,801 cases and 123,504 controls) and the FinnGen cohort (43,518 cases and 333,759 controls). The primary method used for causality analysis was random inverse variance weighting (IVW). Supplementary analyses included MR-Egger, weighted mode, and weighted median methods. Sensitivity analyses were conducted to evaluate heterogeneity and pleiotropy. Reverse MR analysis was employed to evaluate the direct impact of metabolites on coronary heart disease. Additionally, replication and meta-analysis were performed. We further conducted the Steiger test and colocalization analysis to reflect the causality deeply. Results This study identified eight metabolites associated with lipids, amino acids and metabolite ratios that may influence CHD risk. Findings include: 1-oleoyl-2-arachidonoyl-GPE (18:1/20:4) levels: OR = 1.08; 95% CI 1.04-1.12; P = 8.21E-06; 1-palmitoyl-2-arachidonoyl-GPE (16:0/20:4) levels: OR = 1.07; 95% CI 1.04-1.11; P = 9.01E-05; Linoleoyl-arachidonoyl-glycerol (18:2/20:4): OR = 1.08; 95% CI 1.04-1.22; P = 0.0001; Glycocholenate sulfate: OR = 0.93; 95% CI 0.90-0.97; P = 0.0002; 1-stearoyl-2-arachidonoyl-GPE (OR = 1.07; 95% CI 1.03-1.11; P = 0.0002); N-acetylasparagine (OR = 1.04; 95% CI 1.02-1.07; P = 0.0030); Octadecenedioate (C18:1-DC) (OR = 0.93; 95% CI 0.90-0.97; P = 0.0004); Phosphate to linoleoyl-arachidonoyl-glycerol (18:2-20:4) (1) ratio (OR = 0.92; 95% CI 0.88-0.97; P = 0.0005). Conclusion The integration of genomics and metabolomics offers novel insights into the pathogenesis of CHD and holds significant importance for the screening and prevention of CHD.
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Affiliation(s)
- Huanyu Chen
- The Second Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuxuan Huang
- The Second Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guangjing Wan
- The Second Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xu Zou
- Department of Cardiology, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
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19
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van Veelen A, Coerkamp CF, Somsen YBO, Råmunddal T, Ioanes D, Laanmets P, van der Schaaf RJ, Eriksen E, Bax M, Suttorp MJ, Strauss BH, Barbato E, Marques KM, Meuwissen M, Bertrand O, van der Ent M, Knaapen P, Tijssen JGP, Claessen BEPM, Hoebers LPC, Elias J, Henriques JPS. Ten-Year Outcome of Recanalization or Medical Therapy for Concomitant Chronic Total Occlusion After Myocardial Infarction. J Am Heart Assoc 2024; 13:e033556. [PMID: 38726918 DOI: 10.1161/jaha.123.033556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The EXPLORE (Evaluating Xience and Left Ventricular Function in PCI on Occlusions After STEMI) trial was the first and only randomized trial investigating chronic total occlusion (CTO) percutaneous coronary intervention (PCI) early after primary PCI for ST-segment-elevation myocardial infarction, compared with medical therapy for the CTO. We performed a 10-year follow-up of EXPLORE to investigate long-term safety and clinical impact of CTO PCI after ST-segment-elevation myocardial infarction, compared with no-CTO PCI. METHODS AND RESULTS In EXPLORE, 302 patients post-ST-segment-elevation myocardial infarction with concurrent CTO were randomized to CTO PCI within ≈1 week or no-CTO PCI. We performed an extended clinical follow-up for the primary end point of major adverse cardiac events, consisting of cardiovascular death, coronary artery bypass grafting, or myocardial infarction. Secondary end points included all-cause death, angina, and dyspnea. Median follow-up was 10 years (interquartile range, 8-11 years). The primary end point occurred in 25% of patients with CTO PCI and in 24% of patients with no-CTO PCI (hazard ratio [HR], 1.11 [95% CI, 0.70-1.76]). Cardiovascular mortality was higher in the CTO PCI group (HR, 2.09 [95% CI, 1.10-2.50]), but all-cause death was similar (HR, 1.53 [95% CI, 0.93-2.50]). Dyspnea relief was more frequent after CTO PCI (83% versus 65%, P=0.005), with no significant difference in angina. CONCLUSIONS This 10-year follow-up of patients post-ST-segment-elevation myocardial infarction randomized to CTO PCI or no-CTO PCI demonstrated no clinical benefit of CTO PCI in major adverse cardiac events or overall mortality. However, CTO PCI was associated with a higher cardiovascular mortality compared with no-CTO PCI. Our long-term data support a careful weighing of effective symptom relief against an elevated cardiovascular mortality risk in CTO PCI decisions. REGISTRATION URL: https://www.trialregister.nl; Unique identifier: NTR1108.
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Affiliation(s)
- Anna van Veelen
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Casper F Coerkamp
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Yvemarie B O Somsen
- Department of Cardiology, Heart Center, Amsterdam UMC, Location VUMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Truls Råmunddal
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Dan Ioanes
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Peep Laanmets
- Department of Cardiology North-Estonia Medical Center Tallinn Estonia
| | | | - Erlend Eriksen
- Department of Cardiology Haukeland University Hospital Bergen Norway
| | - Matthijs Bax
- Department of Cardiology Haga Teaching Hospital The Hague the Netherlands
| | | | - Bradley H Strauss
- Department of Cardiology Sunnybrook Health Sciences Centre Toronto Canada
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine Sapienza University of Rome Rome Italy
| | - Koen M Marques
- Department of Cardiology, Heart Center, Amsterdam UMC, Location VUMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | | | - Olivier Bertrand
- Department of Cardiology Quebec Heart-Lung Institute Quebec Canada
| | | | - Paul Knaapen
- Department of Cardiology, Heart Center, Amsterdam UMC, Location VUMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - Loes P C Hoebers
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
- Department of Cardiology Maastricht UMC+ Maastricht the Netherlands
| | - Joëlle Elias
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
| | - José P S Henriques
- Department of Cardiology, Heart Center, Amsterdam UMC, Location AMC Amsterdam Cardiovascular Sciences Amsterdam the Netherlands
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20
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Manolis AA, Manolis TA, Manolis AS. Managing chronic coronary syndrome: how do we achieve optimal patient outcomes? Expert Rev Cardiovasc Ther 2024:1-21. [PMID: 38757743 DOI: 10.1080/14779072.2024.2357344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 05/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Chronic coronary syndrome (CCS) remains the leading cause of death worldwide with high admission/re-admission rates. Medical databases were searched on CCS & its management. AREAS COVERED This review discusses phenotypes per stress-echocardiography, noninvasive/invasive testing (coronary computed-tomography angiography-CCTA; coronary artery calcium - CAC score; echocardiography assessing wall-motion, LV function, valvular disease; biomarkers), multidisciplinary management (risk factors/anti-inflammatory/anti-ischemic/antithrombotic therapies and revascularization), newer treatments (colchicine/ivabradine/ranolazine/melatonin), cardiac rehabilitation/exercise improving physical activity and quality-of-life, use of the implantable-defibrillator, and treatment with extracorporeal shockwave-revascularization for refractory symptoms. EXPERT OPINION CCS is age-dependent, leading cause of death worldwide with high hospitalization rates. Stress-echocardiography defines phenotypes and guides prophylaxis and management. CAC is a surrogate for atherosclerosis burden, best for patients of intermediate/borderline risk. Higher CAC-scores indicate more severe coronary abnormalities. CCTA is preferred for noninvasive detection of CAC and atherosclerosis burden, determining stenosis' functional significance, and guiding management. Combining CAC score with CCTA improves diagnostic yield and assists prognosis. Echocardiography assesses LV wall-motion and function and valvular disease. Biomarkers guide diagnosis/prognosis. CCS management is multidisciplinary: risk-factor management, anti-inflammatory/anti-ischemic/antithrombotic therapies, and revascularization. Newer therapies comprise colchicine, ivabradine, ranolazine, melatonin, glucagon-like peptide-1-receptor antagonists. Cardiac rehabilitation/exercise improves physical activity and quality-of-life. An ICD protects from sudden death. Extracorporeal shockwave-revascularization treats refractory symptoms.
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Affiliation(s)
| | - Theodora A Manolis
- Department of Psychiatry, Aiginiteio University Hospital, Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Ippokrateio University Hospital, Athens, Greece
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21
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Jorda A, Hengstenberg C, Lang IM, Kautzky-Willer A, Harreiter J, Zeitlinger M, Jilma B, Gelbenegger G. Association of prediabetes with clinical outcomes in patients with chronic coronary syndrome: a post hoc analysis of the ISCHEMIA and ISCHEMIA-CKD trials. Cardiovasc Diabetol 2024; 23:176. [PMID: 38769562 PMCID: PMC11106853 DOI: 10.1186/s12933-024-02232-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND There is conflicting evidence whether prediabetes is associated with adverse clinical outcomes in patients with chronic coronary syndrome. We aimed to assess the effect of prediabetes in patients with chronic coronary syndrome on clinical outcomes. METHODS This is a secondary analysis of data from the ISCHEMIA and ISCHEMIA-CKD trials, including patients with chronic coronary syndrome determined by coronary computed tomography angiography or exercise-stress testing. Participants were assigned to the normoglycemia group (HbA1c < 5.7% [< 39 mmol/mol]), prediabetes group (HbA1c 5.7-6.4% [40-47 mmol/mol]), or diabetes group (HbA1c ≥ 6.5% [≥ 48 mmol/mol]). The primary end point of this study was all-cause mortality. Secondary endpoints included major adverse cardiovascular events and composites thereof. RESULTS Overall, the primary endpoint all-cause mortality occurred in 330 (8.4%) of 3910 patients over a median follow-up time of 3.1 years (IQR 2.1-4.1). The primary endpoint all-cause mortality occurred in 37 (5.2%) of 716 patients in the normoglycemia group, in 63 (6.9%) of 911 in the prediabetes group, and in 230 (10.1%) of 2283 in the diabetes group. In the covariate-adjusted Cox model analysis, the estimated adjusted HR (aHR) in the prediabetes group as compared with the normoglycemia group was 1.45 (95%CI, 0.95-2.20). The aHR in the diabetes group as compared with the normoglycemia group was 1.84 (95%CI, 1.29-2.65). Prediabetes, compared with normoglycemia, was associated with an increased risk of stroke (aHR, 3.44, 95%CI, 1.15-10.25). Subgroup analyses suggested an increased risk of all-cause death associated with prediabetes in males and patients under 65 years. CONCLUSIONS In patients with chronic coronary syndrome, diabetes but not prediabetes was associated with significantly increased risk of all-cause death within a median follow-up period of 3.1 years. Trial Registration NCT01471522, BioLINCC ID 13936.
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Affiliation(s)
- Anselm Jorda
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jürgen Harreiter
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Medicine, Landesklinikum Scheibbs, Scheibbs, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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22
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Zheng YL, Cai PY, Li J, Huang DH, Wang WD, Li MM, Du JR, Wang YG, Cai YL, Zhang RC, Wu CC, Lin S, Lin HL. A novel radiomics-based technique for identifying vulnerable coronary plaques: a follow-up study. Coron Artery Dis 2024:00019501-990000000-00232. [PMID: 38767051 DOI: 10.1097/mca.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Previous reports have suggested that coronary computed tomography angiography (CCTA)-based radiomics analysis is a potentially helpful tool for assessing vulnerable plaques. We aimed to investigate whether coronary radiomic analysis of CCTA images could identify vulnerable plaques in patients with stable angina pectoris. METHODS This retrospective study included patients initially diagnosed with stable angina pectoris. Patients were randomly divided into either the training or test dataset at an 8 : 2 ratio. Radiomics features were extracted from CCTA images. Radiomics models for predicting vulnerable plaques were developed using the support vector machine (SVM) algorithm. The model performance was assessed using the area under the curve (AUC); the accuracy, sensitivity, and specificity were calculated to compare the diagnostic performance using the two cohorts. RESULTS A total of 158 patients were included in the analysis. The SVM radiomics model performed well in predicting vulnerable plaques, with AUC values of 0.977 and 0.875 for the training and test cohorts, respectively. With optimal cutoff values, the radiomics model showed accuracies of 0.91 and 0.882 in the training and test cohorts, respectively. CONCLUSION Although further larger population studies are necessary, this novel CCTA radiomics model may identify vulnerable plaques in patients with stable angina pectoris.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Shu Lin
- Centre of Neurological and Metabolic Research, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China and
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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23
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Klüner LV, Chan K, Antoniades C. Using artificial intelligence to study atherosclerosis from computed tomography imaging: A state-of-the-art review of the current literature. Atherosclerosis 2024:117580. [PMID: 38852022 DOI: 10.1016/j.atherosclerosis.2024.117580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/10/2024]
Abstract
With the enormous progress in the field of cardiovascular imaging in recent years, computed tomography (CT) has become readily available to phenotype atherosclerotic coronary artery disease. New analytical methods using artificial intelligence (AI) enable the analysis of complex phenotypic information of atherosclerotic plaques. In particular, deep learning-based approaches using convolutional neural networks (CNNs) facilitate tasks such as lesion detection, segmentation, and classification. New radiotranscriptomic techniques even capture underlying bio-histochemical processes through higher-order structural analysis of voxels on CT images. In the near future, the international large-scale Oxford Risk Factors And Non-invasive Imaging (ORFAN) study will provide a powerful platform for testing and validating prognostic AI-based models. The goal is the transition of these new approaches from research settings into a clinical workflow. In this review, we present an overview of existing AI-based techniques with focus on imaging biomarkers to determine the degree of coronary inflammation, coronary plaques, and the associated risk. Further, current limitations using AI-based approaches as well as the priorities to address these challenges will be discussed. This will pave the way for an AI-enabled risk assessment tool to detect vulnerable atherosclerotic plaques and to guide treatment strategies for patients.
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Affiliation(s)
- Laura Valentina Klüner
- Acute Multidisciplinary Imaging and Interventional Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, United Kingdom
| | - Kenneth Chan
- Acute Multidisciplinary Imaging and Interventional Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, United Kingdom
| | - Charalambos Antoniades
- Acute Multidisciplinary Imaging and Interventional Centre, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford NIHR Biomedical Research Centre, University of Oxford, United Kingdom.
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24
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Ghobrial M, Haley H, Gosling R, Taylor DJ, Richardson J, Morgan K, Barmby D, Iqbal J, Krishnamurthy A, Singh R, Conway D, Hall I, Adam Z, Wheeldon N, Grech ED, Storey RF, Rothman A, Payne G, Tahir MN, Smith S, Cooke J, Hunter S, Cartwright N, Sadeque S, Briffa NP, Al-Mohammad A, O'Toole L, Rogers D, Lawford PV, Hose DR, Gunn J, Morris PD. Modelled impact of virtual fractional flow reserve in patients undergoing coronary angiography (VIRTU-4). Heart 2024:heartjnl-2024-324039. [PMID: 38754969 DOI: 10.1136/heartjnl-2024-324039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/28/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The practical application of 'virtual' (computed) fractional flow reserve (vFFR) based on invasive coronary angiogram (ICA) images is unknown. The objective of this cohort study was to investigate the potential of vFFR to guide the management of unselected patients undergoing ICA. The hypothesis was that it changes management in >10% of cases. METHODS vFFR was computed using the Sheffield VIRTUheart system, at five hospitals in the North of England, on 'all-comers' undergoing ICA for non-ST-elevation myocardial infarction acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). The cardiologists' management plan (optimal medical therapy, percutaneous coronary intervention (PCI), coronary artery bypass surgery or 'more information required') and confidence level were recorded after ICA, and again after vFFR disclosure. RESULTS 517 patients were screened; 320 were recruited: 208 with ACS and 112 with CCS. The median vFFR was 0.82 (0.70-0.91). vFFR disclosure did not change the mean number of significantly stenosed vessels per patient (1.16 (±0.96) visually and 1.18 (±0.92) with vFFR (p=0.79)). A change in intended management following vFFR disclosure occurred in 22% of all patients; in the ACS cohort, there was a 62% increase in the number planned for medical management, and in the CCS cohort, there was a 31% increase in the number planned for PCI. In all patients, vFFR disclosure increased physician confidence from 8 of 10 (7.33-9) to 9 of 10 (8-10) (p<0.001). CONCLUSION The addition of vFFR to ICA changed intended management strategy in 22% of patients, provided a detailed and specific 'all-in-one' anatomical and physiological assessment of coronary artery disease, and was accompanied by augmentation of the operator's confidence in the treatment strategy.
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Affiliation(s)
- Mina Ghobrial
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hazel Haley
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Gosling
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel James Taylor
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
| | - James Richardson
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kenneth Morgan
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David Barmby
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Javaid Iqbal
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Arvindra Krishnamurthy
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rajender Singh
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dwayne Conway
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Hall
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zulfiquar Adam
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nigel Wheeldon
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ever D Grech
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert F Storey
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alexander Rothman
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gillian Payne
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Simon Smith
- The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Justin Cooke
- Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - Steven Hunter
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Cartwright
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Syed Sadeque
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Norman Paul Briffa
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdallah Al-Mohammad
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Laurence O'Toole
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dominic Rogers
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Patricia V Lawford
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
| | - David R Hose
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
| | - Julian Gunn
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul D Morris
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute of In Silico medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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25
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Gaudino M, Alexander JH, Sandner S, Harik L, Kim J, Stone GW, Rahouma M, O'Gara P, Bhatt DL, Redfors B. Outcomes by sex in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial. EUROINTERVENTION 2024; 20:551-560. [PMID: 38444364 PMCID: PMC11067519 DOI: 10.4244/eij-d-24-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND In the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial, among participants with stable coronary artery disease, the risk of cardiac events was similar between an invasive (INV) strategy of angiography and coronary revascularisation and a conservative (CON) strategy of initial medical therapy alone. Outcomes according to participant sex were not reported. AIMS We aimed to analyse the outcomes of ISCHEMIA by participant sex. METHODS We evaluated 1) the association between participant sex and the likelihood of undergoing revascularisation for participants randomised to the INV arm; 2) the risk of the ISCHEMIA primary composite outcome (cardiovascular death, any myocardial infarction [MI] or rehospitalisation for unstable angina, heart failure or resuscitated cardiac arrest) by participant sex; and 3) the contribution of the individual primary outcome components to the composite outcome by participant sex. RESULTS Of 5,179 randomised participants, 1,168 (22.6%) were women. Female sex was independently associated with a lower likelihood of revascularisation when assigned to the INV arm (adjusted odds ratio 0.75, 95% confidence interval [CI]: 0.57-0.99; p=0.04). The INV versus CON effect on the primary composite outcome was similar between sexes (women: hazard ratio [HR] 0.96, 95% CI: 0.70-1.33; men: HR 0.90, 95% CI: 0.76-1.07; pinteraction=0.71). The contribution of the individual components to the composite outcome was similar between sexes except for procedural MI, which was significantly lower in women (9/151 [5.9%]) than men (67/519 [12.9%]; p=0.01). CONCLUSIONS In ISCHEMIA, women assigned to the INV arm were less likely to undergo revascularisation than men. The effect of an INV versus CON strategy was consistent by sex, but women had a significantly lower contribution of procedural MI to the primary outcome.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John H Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Jessica Kim
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Patrick O'Gara
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Nogueira-Garcia B, Vilela M, Oliveira C, Caldeira D, Martins AM, Nobre Menezes M. A Narrative Review of Revascularization in Chronic Coronary Syndrome/Disease: Concepts and Misconceptions. J Pers Med 2024; 14:506. [PMID: 38793088 PMCID: PMC11122013 DOI: 10.3390/jpm14050506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/04/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Ischemic heart disease represents a significant global burden of morbidity and mortality. While revascularization strategies are well defined in acute settings, there are uncertainties regarding chronic coronary artery disease treatment. Recent trials have raised doubts about the necessity of revascularization for "stable", chronic coronary syndromes or disease, leading to a shift towards a more conservative approach. However, the issue remains far from settled. In this narrative review, we offer a summary of the most pertinent evidence regarding revascularization for chronic coronary disease, while reflecting on less-often-discussed details of major clinical trials. The cumulative evidence available indicates that there can be a prognostic benefit from revascularization in chronic coronary syndrome patients, provided there is significant ischemia, as demonstrated by either imaging or coronary physiology. Trials that have effectively met this criterion consistently demonstrate a reduction in rates of spontaneous myocardial infarction, which holds both prognostic and clinical significance. The prognostic benefit of revascularization in patients with heart failure with reduced ejection fraction remains especially problematic, with a single contemporary trial favouring surgical revascularization. The very recent publication of a trial focused on revascularizing non-flow-limiting "vulnerable" plaques adds further complexity to the field. The ongoing debates surrounding revascularization in chronic coronary syndromes emphasize the importance of personalized strategies. Revascularization, added to the foundational pillar of medical therapy, should be considered, taking into account symptoms, patient preferences, coronary anatomy and physiology, ischemia tests and intra-coronary imaging.
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Affiliation(s)
- Beatriz Nogueira-Garcia
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
| | - Marta Vilela
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Catarina Oliveira
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Daniel Caldeira
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
- Faculdade de Medicina, Centro de Estudos de Medicina Baseada na Evidência (CEMBE), 1649-028 Lisbon, Portugal
| | - Ana Margarida Martins
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Miguel Nobre Menezes
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
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Doan VD, Zheng C, Onwuzurike J, Chen A, Wu YL, Lee MS. Prognostic Value of Stress Myocardial Perfusion Imaging Across the Spectrum of Cardiovascular Risk. Can J Cardiol 2024:S0828-282X(24)00355-6. [PMID: 38734205 DOI: 10.1016/j.cjca.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/27/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is widely used to identify ischemia. There is limited research to evaluate if there is a risk threshold below which SPECT-MPI may not add significant prognostic value. METHODS Between January 1, 2012, and December 31, 2018, individuals who underwent SPECT-MPI were stratified into four risk groups. The primary outcome was acute myocardial infarction (MI) or death. Multivariable Cox proportional hazards regression analysis was used to calculated HRs with 95% CIs. RESULTS Among 48,845 patients (52.3% male, median age 67 years), 8.5% were low risk, 4.8% borderline risk, 18.1% intermediate risk, and 68.6% high risk based on the American College of Cardiology pooled cohort equation. Ischemia was more commonly detected in the high-risk cohort (19.4% in high-risk vs. 6.5% in low-risk). SPECT-MPI testing was associated with a significantly increased use of preventive medications such as statin therapy, regardless of stress test results. At a median follow-up of 4.2 years, there was no significant association between ischemia and death or MI in the low-risk cohort (adjusted HR 1.91, 95% CI 0.94-3.92) or the borderline-risk cohort (adjusted HR 1.58, 95% CI 0.79-3.15). Ischemia was associated with a higher risk of death or MI in the intermediate-risk (adjusted HR 1.57, 95% CI 1.24-1.99) and high-risk groups (adjusted HR 1.54, 95% CI 1.44-1.64). CONCLUSION SPECT-MPI was less useful for risk stratification among low-risk patients due to their low event rates regardless of test result.
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Affiliation(s)
- Vinh D Doan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - James Onwuzurike
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Aiyu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Yi-Lin Wu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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28
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Yu MM, Wang ML, Wang JJ, Lin BL, Zhao X, Tao XW, Chen YY, Li PY, Zhang JK, Ge JB, Jin H, Zeng MS. Association of Lipoprotein(a) Levels With Myocardial Infarction in Patients With Low-Attenuation Plaque. J Am Coll Cardiol 2024; 83:1743-1755. [PMID: 38692827 DOI: 10.1016/j.jacc.2024.03.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/20/2024] [Accepted: 03/01/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Lipoprotein(a) (Lp[a]) is associated with an increased risk of myocardial infarction (MI). However, the mechanism underlying this association has yet to be fully elucidated. OBJECTIVES This multicenter study aimed to investigate whether association between Lp(a) and MI risk is reinforced by the presence of low-attenuation plaque (LAP) identified by coronary computed tomography angiography (CCTA). METHODS In a derivation cohort, a total of 5,607 patients with stable chest pain suspected of coronary artery disease who underwent CCTA and Lp(a) measurement were prospectively enrolled. In validation cohort, 1,122 patients were retrospectively collected during the same period. High Lp(a) was defined as Lp(a) ≥50 mg/dL. The primary endpoint was a composite of time to fatal or nonfatal MI. Associations were estimated using multivariable Cox proportional hazard models. RESULTS During a median follow-up of 8.2 years (Q1-Q3: 7.2-9.3 years), the elevated Lp(a) levels were associated with MI risk (adjusted HR [aHR]: 1.91; 95% CI: 1.46-2.49; P < 0.001). There was a significant interaction between Lp(a) and LAP (Pinteraction <0.001) in relation to MI risk. When stratified by the presence or absence of LAP, Lp(a) was associated with MI in patients with LAP (aHR: 3.03; 95% CI: 1.92-4.76; P < 0.001). Mediation analysis revealed that LAP mediated 73.3% (P < 0.001) for the relationship between Lp(a) and MI. The principal findings remained unchanged in the validation cohort. CONCLUSIONS Elevated Lp(a) augmented the risk of MI during 8 years of follow-up, especially in patients with LAP identified by CCTA. The presence of LAP could reinforce the relationship between Lp(a) and future MI occurrence.
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Affiliation(s)
- Meng-Meng Yu
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Ming-Liang Wang
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin-Jin Wang
- Department of Radiology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Bo-Li Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xin Zhao
- Department of Cardiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | | | - Yin-Yin Chen
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, Shanghai, China
| | - Peng-Yang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jing-Kun Zhang
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Jun-Bo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Hang Jin
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, Shanghai, China; Department of Radiology, Zhongshan Hospital (Minhang Meilong Branch), Fudan University and Shanghai Geriatric Medical Center, Shanghai, China.
| | - Meng-Su Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, Shanghai, China.
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29
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Nambo R, Karashima S, Mizoguchi R, Konishi S, Hashimoto A, Aono D, Kometani M, Furukawa K, Yoneda T, Imamura K, Nambo H. Prediction and causal inference of cardiovascular and cerebrovascular diseases based on lifestyle questionnaires. Sci Rep 2024; 14:10492. [PMID: 38714730 PMCID: PMC11076536 DOI: 10.1038/s41598-024-61047-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/30/2024] [Indexed: 05/10/2024] Open
Abstract
Cardiovascular and cerebrovascular diseases (CCVD) are prominent mortality causes in Japan, necessitating effective preventative measures, early diagnosis, and treatment to mitigate their impact. A diagnostic model was developed to identify patients with ischemic heart disease (IHD), stroke, or both, using specific health examination data. Lifestyle habits affecting CCVD development were analyzed using five causal inference methods. This study included 473,734 patients aged ≥ 40 years who underwent specific health examinations in Kanazawa, Japan between 2009 and 2018 to collect data on basic physical information, lifestyle habits, and laboratory parameters such as diabetes, lipid metabolism, renal function, and liver function. Four machine learning algorithms were used: Random Forest, Logistic regression, Light Gradient Boosting Machine, and eXtreme-Gradient-Boosting (XGBoost). The XGBoost model exhibited superior area under the curve (AUC), with mean values of 0.770 (± 0.003), 0.758 (± 0.003), and 0.845 (± 0.005) for stroke, IHD, and CCVD, respectively. The results of the five causal inference analyses were summarized, and lifestyle behavior changes were observed after the onset of CCVD. A causal relationship from 'reduced mastication' to 'weight gain' was found for all causal species theory methods. This prediction algorithm can screen for asymptomatic myocardial ischemia and stroke. By selecting high-risk patients suspected of having CCVD, resources can be used more efficiently for secondary testing.
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Affiliation(s)
- Riku Nambo
- School of Electrical Information Communication Engineering, College of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Shigehiro Karashima
- Institute of Liberal Arts and Science, Kanazawa University, Kanazawa, Japan.
| | - Ren Mizoguchi
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Seigo Konishi
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Atsushi Hashimoto
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Daisuke Aono
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kometani
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Kenji Furukawa
- Health Care Center, Japan Advanced Institute of Science and Technology, Nomi, Japan
| | - Takashi Yoneda
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Japan
| | - Kousuke Imamura
- Faculty of Electrical, Information and Communication Engineering, Institute of Science and Engineering, Kanazawa University, Kanazawa, Japan
| | - Hidetaka Nambo
- Institute of Transdisciplinary Sciences, Kanazawa University, Kanazawa, Japan.
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30
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López-Palop R, Carrillo P, Lozano Í. Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome. Curr Heart Fail Rep 2024:10.1007/s11897-024-00663-z. [PMID: 38703306 DOI: 10.1007/s11897-024-00663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
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.
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Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain.
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain
| | - Íñigo Lozano
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
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31
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Park SJ, Ahn JM, Kang DY, Yun SC, Ahn YK, Kim WJ, Nam CW, Jeong JO, Chae IH, Shiomi H, Kao HL, Hahn JY, Her SH, Lee BK, Ahn TH, Chang KY, Chae JK, Smyth D, Mintz GS, Stone GW, Park DW. Preventive percutaneous coronary intervention versus optimal medical therapy alone for the treatment of vulnerable atherosclerotic coronary plaques (PREVENT): a multicentre, open-label, randomised controlled trial. Lancet 2024; 403:1753-1765. [PMID: 38604213 DOI: 10.1016/s0140-6736(24)00413-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/25/2024] [Accepted: 02/27/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Acute coronary syndrome and sudden cardiac death are often caused by rupture and thrombosis of lipid-rich atherosclerotic coronary plaques (known as vulnerable plaques), many of which are non-flow-limiting. The safety and effectiveness of focal preventive therapy with percutaneous coronary intervention of vulnerable plaques in reducing adverse cardiac events are unknown. We aimed to assess whether preventive percutaneous coronary intervention of non-flow-limiting vulnerable plaques improves clinical outcomes compared with optimal medical therapy alone. METHODS PREVENT was a multicentre, open-label, randomised controlled trial done at 15 research hospitals in four countries (South Korea, Japan, Taiwan, and New Zealand). Patients aged 18 years or older with non-flow-limiting (fractional flow reserve >0·80) vulnerable coronary plaques identified by intracoronary imaging were randomly assigned (1:1) to either percutaneous coronary intervention plus optimal medical therapy or optimal medical therapy alone, in block sizes of 4 or 6, stratified by diabetes status and the performance of percutaneous coronary intervention in a non-study target vessel. Follow-up continued annually in all enrolled patients until the last enrolled patient reached 2 years after randomisation. The primary outcome was a composite of death from cardiac causes, target-vessel myocardial infarction, ischaemia-driven target-vessel revascularisation, or hospitalisation for unstable or progressive angina, assessed in the intention-to-treat population at 2 years. Time-to-first-event estimates were calculated with the Kaplan-Meier method and were compared with the log-rank test. This report is the principal analysis from the trial and includes all long-term analysed data. The trial is registered at ClinicalTrials.gov, NCT02316886, and is complete. FINDINGS Between Sept 23, 2015, and Sept 29, 2021, 5627 patients were screened for eligibility, 1606 of whom were enrolled and randomly assigned to percutaneous coronary intervention (n=803) or optimal medical therapy alone (n=803). 1177 (73%) patients were men and 429 (27%) were women. 2-year follow-up for the primary outcome assessment was completed in 1556 (97%) patients (percutaneous coronary intervention group n=780; optimal medical therapy group n=776). At 2 years, the primary outcome occurred in three (0·4%) patients in the percutaneous coronary intervention group and in 27 (3·4%) patients in the medical therapy group (absolute difference -3·0 percentage points [95% CI -4·4 to -1·8]; p=0·0003). The effect of preventive percutaneous coronary intervention was directionally consistent for each component of the primary composite outcome. Serious clinical or adverse events did not differ between the percutaneous coronary intervention group and the medical therapy group: at 2 years, four (0·5%) versus ten (1·3%) patients died (absolute difference -0·8 percentage points [95% CI -1·7 to 0·2]) and nine (1·1%) versus 13 (1·7%) patients had myocardial infarction (absolute difference -0·5 percentage points [-1·7 to 0·6]). INTERPRETATION In patients with non-flow-limiting vulnerable coronary plaques, preventive percutaneous coronary intervention reduced major adverse cardiac events arising from high-risk vulnerable plaques, compared with optimal medical therapy alone. Given that PREVENT is the first large trial to show the potential effect of the focal treatment for vulnerable plaques, these findings support consideration to expand indications for percutaneous coronary intervention to include non-flow-limiting, high-risk vulnerable plaques. FUNDING The CardioVascular Research Foundation, Abbott, Yuhan Corp, CAH-Cordis, Philips, and Infraredx, a Nipro company.
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Affiliation(s)
- Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Cheol Yun
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Keun Ahn
- Division of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
| | - Won-Jang Kim
- Division of Cardiology, CHA University School of Medicine, CHA Ilsan Medical Center, Goyang, South Korea
| | - Chang-Wook Nam
- Division of Cardiology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Chungnam National University Hospital, Daejeon, South Korea
| | - In-Ho Chae
- Division of Cardiology, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Hiroki Shiomi
- Division of Cardiology, Kyoto University Hospital, Kyoto, Japan
| | - Hsien-Li Kao
- Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Ho Her
- Department of Cardiology, Saint Vincent's Hospital, Suwon, South Korea
| | - Bong-Ki Lee
- Division of Cardiology, Kangwon National University Hospital, Chuncheon, South Korea
| | - Tae Hoon Ahn
- Cardiovascular Center, Na-Eun Hospital, Incheon, South Korea
| | - Ki-Yuk Chang
- Division of Cardiology, Seoul Saint Mary's Hospital, Catholic University of Korea, Seoul, South Korea
| | - Jei Keon Chae
- Division of Cardiology, Jeonbuk National University Hospital, Jeonju, South Korea
| | - David Smyth
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Gary S Mintz
- Cardiovascular Research Foundation, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
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Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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Michallek F, Nakamura S, Kurita T, Ota H, Nishimiya K, Ogawa R, Shizuka T, Nakashima H, Wang YN, Ito T, Sakuma H, Dewey M, Kitagawa K. Differentiating Macrovascular and Microvascular Ischemia Using Fractal Analysis of Dynamic Myocardial Perfusion Stress-CT. Invest Radiol 2024; 59:413-423. [PMID: 37812495 DOI: 10.1097/rli.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Fractal analysis of dynamic myocardial stress computed tomography perfusion imaging (4D-CTP) has shown potential to noninvasively differentiate obstructive coronary artery disease (CAD) and coronary microvascular disease (CMD). This study validates fractal analysis of 4D-CTP in a multicenter setting and assesses its diagnostic accuracy in subgroups with ischemia and nonobstructed coronary arteries (INOCA) and with mild to moderate stenosis. MATERIALS AND METHODS From the AMPLIFiED multicenter trial, patients with suspected or known chronic myocardial ischemia and an indication for invasive coronary angiography were included. Patients underwent dual-source CT angiography, 4D-CTP, and CT delayed-enhancement imaging. Coronary artery disease, CMD, and normal perfusion were defined by a combined reference standard comprising invasive coronary angiography with fractional flow reserve, and absolute or relative CT-derived myocardial blood flow. Nonobstructed coronary arteries were defined as ≤25% stenosis and mild to moderate stenosis as 26%-80%. RESULTS In 127 patients (27% female), fractal analysis accurately differentiated CAD (n = 61, 23% female), CMD (n = 23, 30% female), and normal perfusion (n = 34, 35% female) with a multiclass area under the receiver operating characteristic curve (AUC) of 0.92 and high agreement (multiclass κ = 0.89). In patients with ischemia (n = 84), fractal analysis detected CAD (n = 61) over CMD (n = 23) with sensitivity of 95%, specificity of 74%, accuracy of 89%, and AUC of 0.83. In patients with nonobstructed coronary arteries (n = 33), INOCA (n = 15) was detected with sensitivity of 100%, specificity of 78%, accuracy of 88%, and AUC of 0.94. In patients with mild to moderate stenosis (n = 27), fractal analysis detected CAD (n = 19) over CMD with sensitivity of 84%, specificity of 100%, accuracy of 89%, and AUC of 0.95. CONCLUSIONS In this multicenter study, fractal analysis of 4D-CTP accurately differentiated CAD and CMD including subgroups with INOCA and with mild to moderate stenosis.
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Affiliation(s)
- Florian Michallek
- From the Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (F.M., M.D.); Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Japan (F.M., K.K.); Department of Radiology, Mie University Graduate School of Medicine, Tsu, Japan (S.N., H.S.); Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (T.K.); Department of Advanced MRI Collaborative Research, Tohoku University Graduate School of Medicine, Sendai, Japan (H.O.); Department of Cardiology, Tohoku University Graduate School of Medicine, Sendai, Japan (K.N.); Saiseikai Matsuyama Hospital, Matsuyama, Japan (R.O.); Takasaki General Medical Center, Takasaki, Japan (T.S.); National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan (H.N.); Peking Union Medical College Hospital, Beijing, China (Y.-N.W.); Kobe University Graduate School of Medicine, Kobe, Japan (T.I.); German Center for Cardiovascular Research, Berlin, Germany (M.D.); and Deutsches Herzzentrum der Charité (M.D.), Berlin, Germany
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Oikonomou EK, Aminorroaya A, Dhingra LS, Partridge C, Velazquez EJ, Desai NR, Krumholz HM, Miller EJ, Khera R. Real-world evaluation of an algorithmic machine-learning-guided testing approach in stable chest pain: a multinational, multicohort study. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:303-313. [PMID: 38774380 PMCID: PMC11104476 DOI: 10.1093/ehjdh/ztae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/20/2024] [Indexed: 05/24/2024]
Abstract
Aims An algorithmic strategy for anatomical vs. functional testing in suspected coronary artery disease (CAD) (Anatomical vs. Stress teSting decIsion Support Tool; ASSIST) is associated with better outcomes than random selection. However, in the real world, this decision is rarely random. We explored the agreement between a provider-driven vs. simulated algorithmic approach to cardiac testing and its association with outcomes across multinational cohorts. Methods and results In two cohorts of functional vs. anatomical testing in a US hospital health system [Yale; 2013-2023; n = 130 196 (97.0%) vs. n = 4020 (3.0%), respectively], and the UK Biobank [n = 3320 (85.1%) vs. n = 581 (14.9%), respectively], we examined outcomes stratified by agreement between the real-world and ASSIST-recommended strategies. Younger age, female sex, Black race, and diabetes history were independently associated with lower odds of ASSIST-aligned testing. Over a median of 4.9 (interquartile range [IQR]: 2.4-7.1) and 5.4 (IQR: 2.6-8.8) years, referral to the ASSIST-recommended strategy was associated with a lower risk of acute myocardial infarction or death (hazard ratioadjusted: 0.81, 95% confidence interval [CI] 0.77-0.85, P < 0.001 and 0.74 [95% CI 0.60-0.90], P = 0.003, respectively), an effect that remained significant across years, test types, and risk profiles. In post hoc analyses of anatomical-first testing in the Prospective Multicentre Imaging Study for Evaluation of Chest Pain (PROMISE) trial, alignment with ASSIST was independently associated with a 17% and 30% higher risk of detecting CAD in any vessel or the left main artery/proximal left anterior descending coronary artery, respectively. Conclusion In cohorts where historical practices largely favour functional testing, alignment with an algorithmic approach to cardiac testing defined by ASSIST was associated with a lower risk of adverse outcomes. This highlights the potential utility of a data-driven approach in the diagnostic management of CAD.
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Affiliation(s)
- Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Arya Aminorroaya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Lovedeep S Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Caitlin Partridge
- Yale Center for Clinical Investigation, 2 Church Street South, New Haven, 06519 CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, 100 College Street, New Haven, 06511 CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, 06510 CT, USA
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Assante R, Zampella E, D'Antonio A, Mannarino T, Gaudieri V, Nappi C, Arumugam P, Panico M, Buongiorno P, Petretta M, Cuocolo A, Acampa W. Impact on cardiovascular outcome of coronary revascularization-induced changes in ischemic perfusion defect and myocardial flow reserve. Eur J Nucl Med Mol Imaging 2024; 51:1612-1621. [PMID: 38191816 PMCID: PMC11043198 DOI: 10.1007/s00259-023-06588-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE We evaluated the impact on cardiovascular outcome of coronary revascularization-induced changes in ischemic total perfusion defect (ITPD) and myocardial flow reserve (MFR) as assessed by 82Rb positron emission tomography (PET)/computed tomography (CT) imaging. METHODS The study included 102 patients referred to 82Rb PET/CT myocardial perfusion imaging before and after coronary revascularization. All patients were followed for the occurrence of cardiovascular events (cardiac death, nonfatal myocardial infarction, repeated revascularization, and heart failure) after the second imaging study. RESULTS During a median follow-up of 20 months, 21 events occurred. The clinical characteristics were comparable between patients with and without events. In the overall study population, after revascularization, there was a significant reduction (P < 0.001) of ITPD, while hyperemic myocardial blood flow (MBF) (P < 0.01) and MFR (P < 0.05) significantly improved. Event rate was higher in patients with ITPD (P < 0.005) or MFR (P < 0.001) worsening compared to those with unchanged or improved ITPD or MFR. At Cox univariable analysis, ITPD and MFR worsening resulted in predictors of events (both P < 0.05). Patients with worsening of both ITPD and MFR had the worst event-free survival (log-rank 32.9, P for trend < 0.001). CONCLUSIONS In patients with stable CAD, worsening of ITPD and MFR after revascularization procedures is associated with higher risk of cardiovascular events. Follow-up MPI with 82Rb PET/CT may improve risk stratification in patients submitted to coronary revascularization.
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Affiliation(s)
- Roberta Assante
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Adriana D'Antonio
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, UK
| | | | - Pietro Buongiorno
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
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Montelaro BM, Ibrahim R, Thames M, Mehta PK. Optimal Medical Therapy for Stable Ischemic Heart Disease: Focus on Anti-anginal Therapy. Med Clin North Am 2024; 108:455-468. [PMID: 38548457 DOI: 10.1016/j.mcna.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Chronic coronary disease (CCD) is a major cause of morbidity and mortality worldwide. The most common symptom of CCD is exertional angina pectoris, a discomfort in the chest that commonly occurs during activities of daily life. Patients are dismayed by recurring episodes of angina and seek medical help in preventing or minimizing episodes. Angina occurs when the coronary arteries are unable to supply sufficient blood flow to the cardiac muscle to meet the metabolic needs of the left ventricular myocardium. While lifestyle changes and aggressive risk factor modification play a critical role in the management of CCD, management of angina usually requires pharmacologic therapy. Medications such as beta-blockers, calcium channel blockers, nitrates, ranolazine, and others ultimately work to improve the mismatch between myocardial blood flow and metabolic demand. This manuscript briefly describes the pathophysiologic basis for symptoms of angina, and how currently available anti-anginal therapies contribute to preventing or minimize the occurrence of angina.
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Affiliation(s)
- Brett M Montelaro
- Division of Cardiology, Department of Medicine, J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Rand Ibrahim
- Division of Cardiology, Department of Medicine, J. Willis Hurst Internal Medicine Residency Training Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Marc Thames
- Division of Cardiology, Department of Medicine, Emory University Division of Cardiology, Atlanta, GA, USA
| | - Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory University Division of Cardiology, Atlanta, GA, USA; Women's Translational Cardiovascular Research, Emory Women's Heart Center, Emory Clinical Cardiovascular Research Institute, 1750 Haygood Drive, 2nd Floor, Office #243, Atlanta, GA 30322, USA.
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Khorsandi M, Blumenthal RS, Blaha MJ, Kohli P. The ABCs of the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. Clin Cardiol 2024; 47:e24284. [PMID: 38766996 PMCID: PMC11103637 DOI: 10.1002/clc.24284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/27/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The 2023 Multisociety Guideline for the Management of Chronic Coronary Disease (CCD) updates recommendations for CCD, formerly known as "stable ischemic heart disease." This condition encompasses a spectrum of coronary vascular pathologies from subclinical to clinical ischemic heart disease. HYPOTHESIS The new "ABC" mnemonic offers clinicians a streamlined framework for applying Class One Recommendations (COR1) and integrating recent updates into CCD management. METHODS A critical analysis of the 2023 CCD guidelines was conducted, with this review highlighting key elements. RESULTS The review outlines crucial changes, including novel recommendations supported by current clinical evidence. The focus is on these developments, clarifying their importance for day-to-day clinical practice. CONCLUSIONS The review encourages a synergistic approach between primary healthcare providers and cardiologists to develop comprehensive strategies for lifestyle modification and medication therapy in CCD care. Furthermore, it suggests that utilizing comprehensive risk assessment tools can refine medical decision-making, ultimately enhancing patient care and clinical outcomes.
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Affiliation(s)
- Michael Khorsandi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Payal Kohli
- Cardiology Division, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Cheng AM, Doll JA. When to Consider Coronary Revascularization for Stable Coronary Artery Disease. Med Clin North Am 2024; 108:517-538. [PMID: 38548461 DOI: 10.1016/j.mcna.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Revascularization is an effective adjunct to medical therapy for some patients with chronic coronary disease. Despite numerous randomized trials, there remains significant uncertainty regarding if and how to revascularize many patients. Coronary artery bypass grafting is a class I indication for patients with significant left main stenosis or multivessel disease with ejection fraction ≤ 35%. For other patients, clinicians must carefully consider the potential benefits of symptom improvement and reduction of future myocardial infarction or CV death against the risk and cost of revascularization. Although guidelines provide a framework for these decisions, each individual patient will have distinct coronary anatomy, clinical factors, and preferences.
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Affiliation(s)
- Andrew M Cheng
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Section of Cardiology, VA Puget Sound Health Care System, 1660 South Columbian Way S111-CARDIO, Seattle, WA 98108, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Section of Cardiology, VA Puget Sound Health Care System, 1660 South Columbian Way S111-CARDIO, Seattle, WA 98108, USA.
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40
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Fanaroff AC, Hirshfeld JW. Chronic Coronary Disease. Med Clin North Am 2024; 108:xvii-xx. [PMID: 38548468 DOI: 10.1016/j.mcna.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine, Perelman Center for Advanced Medicine, 11-103 South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - John W Hirshfeld
- Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine, Perelman Center for Advanced Medicine, 11-109 South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Tang WL, Rodriguez F. Racial and Ethnic Disparities in the Management of Chronic Coronary Disease. Med Clin North Am 2024; 108:595-607. [PMID: 38548466 PMCID: PMC10979033 DOI: 10.1016/j.mcna.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
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.
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Affiliation(s)
- Wilson Lay Tang
- Department of Medicine, Stanford University, 300 Pasteur Drive, L154, Stanford, CA 94305-5133, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Center for Academic Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Bär S, Nabeta T, Maaniitty T, Saraste A, Bax JJ, Earls JP, Min JK, Knuuti J. Prognostic value of a novel artificial intelligence-based coronary computed tomography angiography-derived ischaemia algorithm for patients with suspected coronary artery disease. Eur Heart J Cardiovasc Imaging 2024; 25:657-667. [PMID: 38084894 PMCID: PMC11057943 DOI: 10.1093/ehjci/jead339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 05/01/2024] Open
Abstract
AIMS Coronary computed tomography angiography (CTA) imaging is used to diagnose patients with suspected coronary artery disease (CAD). A novel artificial intelligence-guided quantitative computed tomography ischaemia algorithm (AI-QCTischaemia) aims to identify myocardial ischaemia directly from CTA images and may be helpful to improve risk stratification. The aims were to investigate (i) the prognostic value of AI-QCTischaemia amongst symptomatic patients with suspected CAD entering diagnostic imaging with coronary CTA and (ii) the prognostic value of AI-QCTischaemia separately amongst patients with no/non-obstructive CAD (≤50% visual diameter stenosis) and obstructive CAD (>50% visual diameter stenosis). METHODS AND RESULTS For this cohort study, AI-QCTischaemia was calculated by blinded analysts amongst patients with suspected CAD undergoing coronary CTA. The primary endpoint was the composite of death, myocardial infarction (MI), or unstable angina pectoris (uAP) (median follow-up 6.9 years). A total of 1880/2271 (83%) patients had conclusive AI-QCTischaemia result. Patients with an abnormal AI-QCTischaemia result (n = 509/1880) vs. patients with a normal AI-QCTischaemia result (n = 1371/1880) had significantly higher crude and adjusted rates of the primary endpoint [adjusted hazard ratio (HRadj) 1.96, 95% confidence interval (CI) 1.46-2.63, P < 0.001; covariates: age/sex/hypertension/diabetes/smoking/typical angina]. An abnormal AI-QCTischaemia result was associated with significantly higher crude and adjusted rates of the primary endpoint amongst patients with no/non-obstructive CAD (n = 1373/1847) (HRadj 1.81, 95% CI 1.09-3.00, P = 0.022), but not amongst those with obstructive CAD (n = 474/1847) (HRadj 1.26, 95% CI 0.75-2.12, P = 0.386) (P-interaction = 0.032). CONCLUSION Amongst patients with suspected CAD, an abnormal AI-QCTischaemia result was associated with a two-fold increased adjusted rate of long-term death, MI, or uAP. AI-QCTischaemia may be useful to improve risk stratification, especially amongst patients with no/non-obstructive CAD on coronary CTA.
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Affiliation(s)
- Sarah Bär
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
- Department of Cardiology, Bern University Hospital Inselspital, Bern, Switzerland
| | - Takeru Nabeta
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teemu Maaniitty
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
- Department of Clinical Physiology, Nuclear Medicine, and PET, Turku University Hospital, Hämeentie 11, 20540 Turku, Finland
| | - Antti Saraste
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
- Department of Clinical Physiology, Nuclear Medicine, and PET, Turku University Hospital, Hämeentie 11, 20540 Turku, Finland
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Duncan A, Shiely F. Analysis of core outcome set reporting in coronary intervention trials. Open Heart 2024; 11:e002581. [PMID: 38688715 PMCID: PMC11086530 DOI: 10.1136/openhrt-2023-002581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/15/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND This paper will focus on outcome reporting within percutaneous coronary intervention (PCI) trials. A core outcome set (COS) is a standardised set of outcomes that are recommended to be reported in every clinical trial. Using a COS can help to ensure that all relevant outcomes are consistently reported across clinical trials. In 2018, the European Society of Cardiology outlined the only COS published for PCI trials. METHODS We searched the literature for all randomised controlled trials published between 2014 and 2022. PCI trials included were late-phase trials and must investigate coronary intervention. The primary outcome was the proportion of trials that reported all of the COS-defined outcomes within their publication as either a primary, secondary or safety endpoint. The secondary outcomes included; the number of primary outcomes reported per study, the proportion of studies which use patient and public involvement (PPI) during trial design, outcome variability and outcome consistency. RESULTS 9580 trials were screened and 115 studies met inclusion/exclusion criteria. Our study demonstrated that 55% (34/62) of PCI trials used a COS when it was available, compared with 40% (21/53) before the availability of a PCI COS set, p=0.121. Fewer primary outcomes were reported after the implementation of the COS, 2 compared with 2.3, p=0.014. There was no difference in the use of PPI between either group. There was a higher level of variability in outcomes reported before the availability of the COS, while the consistency of outcome reporting remained similar. CONCLUSION The use of a COS in PCI trials is low. This study provides evidence that there still is a lack of awareness of the COS among those who design clinical trials. We also presented the inconsistency and heterogenicity in reporting clinical trial outcomes. Finally, there was a clear lack of PPI utilisation in PCI trials.
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Affiliation(s)
- Aaron Duncan
- University College Cork, Cork, Ireland
- Beaumont Hospital, Dublin, Ireland
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Scarpa Matuck BR, Akino N, Bakhshi H, Cox C, Ebrahimihoor E, Ishida M, Lemos PA, Lima JAC, Matheson MB, Orii M, Ostovaneh A, Ostovaneh MR, Schuijf JD, Szarf G, Trost JC, Yoshioka K, Arbab-Zadeh A. Ultra-high-resolution CT vs. invasive angiography for detecting hemodynamically significant coronary artery disease: Rationale and methods of the CORE-PRECISION multicenter study. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00107-2. [PMID: 38702271 DOI: 10.1016/j.jcct.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Direct coronary arterial evaluation via computed tomography (CT) angiography is the most accurate noninvasive test for the diagnosis of coronary artery disease (CAD). However, diagnostic accuracy is limited in the setting of severe coronary calcification or stents. Ultra-high-resolution CT (UHR-CT) may overcome this limitation, but no rigorous study has tested this hypothesis. METHODS The CORE-PRECISION is an international, multicenter, prospective diagnostic accuracy study testing the non-inferiority of UHR-CT compared to invasive coronary angiography (ICA) for identifying patients with hemodynamically significant CAD. The study will enroll 150 patients with history of CAD, defined as prior documentation of lumen obstruction, stenting, or a calcium score ≥400, who will undergo UHR-CT before clinically prompted ICA. Assessment of hemodynamically significant CAD by UHR-CT and ICA will follow clinical standards. The reference standard will be the quantitative flow ratio (QFR) with <0.8 defined as abnormal. All data will be analyzed in independent core laboratories. RESULTS The primary outcome will be the comparative diagnostic accuracy of UHR-CT vs. ICA for detecting hemodynamically significant CAD on a patient level. Secondary analyses will focus on vessel level diagnostic accuracy, quantitative stenosis analysis, automated contour detection, in-depth plaque analysis, and others. CONCLUSION CORE-PRECISION aims to investigate if UHR-CT is non-inferior to ICA for detecting hemodynamically significant CAD in high-risk patients, including those with severe coronary calcification or stents. We anticipate this study to provide valuable insights into the utility of UHR-CT in this challenging population and for its potential to establish a new standard for CAD assessment.
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Affiliation(s)
- Bruna R Scarpa Matuck
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Naruomi Akino
- Canon Medical Systems Corporation, Otawara, Tochigi, Japan
| | - Hooman Bakhshi
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Cox
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Elnaz Ebrahimihoor
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba, Japan
| | - Pedro A Lemos
- Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joao A C Lima
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew B Matheson
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Makoto Orii
- Department of Radiology, Iwate Medical University, Yahaba, Japan
| | - Aysa Ostovaneh
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohammad R Ostovaneh
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Gilberto Szarf
- Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jeffrey C Trost
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Armin Arbab-Zadeh
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Hawkins RB. Commentary: What matters more: Method of revascularization or completeness? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00312-X. [PMID: 38636924 DOI: 10.1016/j.jtcvs.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Noblé HJ, Mühlbauer N, Ehling J, Bansmann PM. The value of AI-based analysis of fractional flow reserve of volume computed tomographically detected coronary artery stenosis with regard to their hemodynamic relevance. ROFO-FORTSCHR RONTG 2024. [PMID: 38631371 DOI: 10.1055/a-2271-0887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The aim of our work was to demonstrate the importance of artificial intelligence-based analysis of fractional flow reserves of computed tomographically detected coronary artery stenosis with regard to their hemodynamic relevance in patients with unclear chest pain and suspected stable coronary heart disease with a low to medium pre-test probability.The collective of our retrospective analysis includes 63 patients in whom coronary artery stenosis was detected by volume computed tomographic examination in "one beat, whole heart" mode in the period from March to October 2022. In these patients, the fractional flow reserve was also determined by computed tomography, which was modulated by the use of artificial intelligence.The calculated values of the fractional flow reserve and the degrees of stenosis determined by computed tomography showed a moderate and significant negative correlation for all three coronary vascular territories (LAD/CX/RCA) (correlation coefficient rho = 0.54/0.54/0.6; p < 0.01 respectively). In just over a third (37.6 %) of all stenoses classified as high-grade by computed tomography, the assessment of hemodynamic relevance by calculating the fractional flow reserve deviated from the severity of the stenosis diagnosed by computed tomography, while the results in the peripheral areas "no stenosis/vascular occlusion" were 100 % consistent in each case.The present results of this work illustrate that the calculation of the fractional flow reserve based on artificial intelligence as a supplement to volume computed tomography of the heart can make a decisive contribution to further therapy planning by increasing the specificity of the purely morphological method by the physiological aspect. · Calculation of fractional flow reserve is a useful addition to computed tomography of the heart.. · It provides possibility to dispense with unnecessary further diagnostics by increasing specificity.. · The combination of both procedures leads to therapy optimization for patients.. · Noblé H, Mühlbauer N, Ehling J et al. The value of AI-based analysis of fractional flow reserve of volume computed tomographically detected coronary artery stenosis with regard to their hemodynamic relevance. Fortschr Röntgenstr 2024; DOI: 10.1055/a-2271-0887.
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Affiliation(s)
- Hans-Jürgen Noblé
- Department of Radiology, German Air Force Center of Aerospace Medicine, Cologne, Germany
| | - Nadine Mühlbauer
- Department of Radiology, German Air Force Center of Aerospace Medicine, Cologne, Germany
| | - Josef Ehling
- Department of Radiology, German Air Force Center of Aerospace Medicine, Cologne, Germany
| | - Paul Martin Bansmann
- Institute for Diagnostic and Interventional Radiology, Hospital Porz am Rhein, Cologne, Germany
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Borovac JA. Unlocking the Gates of ISCHEMIA: Moving Toward Personalized Angina Management for Chronic Coronary Syndrome. J Am Coll Cardiol 2024; 83:1367-1369. [PMID: 38599712 DOI: 10.1016/j.jacc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Josip Andelo Borovac
- Division of Interventional Cardiology, University Hospital of Split, Split, Croatia; Department of Pathophysiology, University Hospital of Split, Split, Croatia; University Department of Health Studies, University of Split, Split, Croatia.
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Arnold SV, Jones PG, Maron DJ, Cohen DJ, Mark DB, Reynolds HR, Bangalore S, Chen J, Newman JD, Harrington RA, Stone GW, Hochman JS, Spertus JA. Variation in Health Status With Invasive vs Conservative Management of Chronic Coronary Disease. J Am Coll Cardiol 2024; 83:1353-1366. [PMID: 38599711 DOI: 10.1016/j.jacc.2024.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND The ISCHEMIA trial found that patients with chronic coronary disease randomized to invasive strategy had better health status than those randomized to conservative strategy. It is unclear how best to translate these population-level results to individual patients. OBJECTIVES The authors sought to identify patient characteristics associated with health status from invasive and conservative strategies, and develop a prediction algorithm for shared decision-making. METHODS One-year disease-specific health status was assessed in ISCHEMIA with the Seattle Angina Questionnaire (SAQ) Summary Score (SAQ SS) and Angina Frequency, Physical Limitations (PL), and Quality of Life (QL) domains (range 0-100, higher = less angina/better health status). RESULTS Among 4,617 patients from 320 sites in 37 countries, mean SAQ SS was 74.1 ± 18.9 at baseline and 85.7 ± 15.6 at 1 year. Lower baseline SAQ SS and younger age were associated with better 1-year health status with invasive strategy (P interaction = 0.009 and P interaction = 0.004, respectively). For the individual domains, there were significant treatment interactions for baseline SAQ score (Angina Frequency, PL), age (PL, QL), anterior ischemia (PL), and number of baseline antianginal medications (QL), with more benefit of invasive in patients with worse baseline health status, younger age, anterior ischemia, and on more antianginal medications. Parsimonious prediction models were developed for 1-year SAQ domains with invasive or conservative strategies to support shared decision-making. CONCLUSIONS In the management of chronic coronary disease, individual patient characteristics are associated with 1-year health status, with younger age and poorer angina-related health status showing greater benefit from invasive management. This prediction algorithm can support the translation of the ISCHEMIA trial results to individual patients. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Suzanne V Arnold
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
| | - Philip G Jones
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - David J Maron
- Stanford University Department of Medicine, Stanford, California, USA
| | - David J Cohen
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Daniel B Mark
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - Jiyan Chen
- Guangdong General Hospital, Guangzhou, China
| | - Jonathan D Newman
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | | | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith S Hochman
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - John A Spertus
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
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da Silveira Maia A, Dos Santos MA. 2023 ACC/AHA Chronic Coronary Disease Guideline - An opportunity to reestablish coronary artery bypass recommendations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00172-6. [PMID: 38631937 DOI: 10.1016/j.carrev.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/19/2024]
Abstract
Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.
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Latkovskis G, Krievins D, Zellans E, Kumsars I, Krievina A, Angena A, Jegere S, Erglis A, Lacis A, Zarins C. Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024:15266028241245909. [PMID: 38616613 DOI: 10.1177/15266028241245909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
PURPOSE To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). MATERIALS AND METHODS Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. RESULTS In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). CONCLUSIONS Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). CLINICAL IMPACT Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.
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Affiliation(s)
- Gustavs Latkovskis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Edgars Zellans
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | | | | | - Sanda Jegere
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Riga Stradins University, Riga, Latvia
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