Evaluation of novel indices of walking performance taking oxygen desaturation into account during six-minute walk test in cardiovascular disease patients

In pulmonary disease patients since oxygen desaturation during 6-min walk test (6MWT) affects walk distance (6MWD), some novel indices such as desaturation/distance ratio [DDR, oxygen desaturation area (DAO2)/6MWD] and distance-saturation product [DSP, 6MWD × minimum peripheral oxygen saturation (SpO2)] are evaluated. However, there has been no study examining these indices that consider exercise-induced desaturation (EID) in patients with cardiovascular disease. In 94 cardiovascular disease patients without pulmonary complications, 6MWT and echocardiography were performed at the entry of cardiac rehabilitation. SpO2 was measured during 6MWT using a continuously monitorable pulse oximeter, and DSP and DDR were calculated using minimum SpO2 and DAO2 [sum of (100-SpO2) per second during 6MWT], respectively. EID was defined as SpO2 decrease of ≥ 4% or minimum SpO2 of < 90% during 6MWT. DSP was slightly lower and DDR was markedly higher in patients with EID than in those without. When examining correlations of DSP and DDR with their components, DSP was correlated with 6MWD much closely than minimum SpO2, while DDR was correlated as closely with DAO2 as 6MWD. Furthermore, DAO2, but not minimum SpO2, had a direct correlation with 6MWD. As for associations with cardiac function, DSP was correlated with several cardiac parameters, but DDR was not correlated with any of these parameters. Our findings suggest that oxygen desaturation during 6MWT affects walking distance in cardiovascular disease patients even without pulmonary complications and that DDR is more appropriate than DSP as an index of walking performance that takes EID into consideration, independently of cardiac function.

Impact of diabetes mellitus and triglyceride glucose index on mortality and cardiovascular outcomes in patients with chronic coronary syndrome undergoing coronary computed tomography angiography

Background

There is limited knowledge regarding whether an elevated triglyceride glucose (TyG) index can serve as a prognostic marker for mortality and cardiovascular outcomes, independent of diabetes mellitus (DM) and plaque burden, in patients with chronic coronary syndrome (CCS).

Methods

Patients with CCS (n = 684) were categorized into subgroups based on the presence of DM, and patients without DM were further divided into two groups based on presence or absence of an elevation of TyG index >8.8. Coronary plaque burden was evaluated using coronary computed tomography angiography. Major cardiovascular adverse event (MACE) was defined as a composite event of nonfatal myocardial infarction, unstable angina or unplanned coronary revascularization, stroke, non-cardiovascular mortality and cardiovascular mortality.

Results

Patients without DM exhibited significantly greater plaque and epicardial adipose tissue volumes than those with DM. Multivariable Cox proportional hazards models demonstrated that DM and an elevated TyG index >8.8 were independently associated with the risk of MACE after adjusting for age, sex, and plaque volume. Patients with DM (hazard ratio, 3.74; 95% confidence interval, 1.97-7.08; p < 0.001) and patients without DM with an elevated TyG index (hazard ratio, 1.99; 95% confidence interval, 1.01-3.91; p = 0.045) had an increased risk of MACE.

Conclusion

This study indicates that DM and an elevated TyG index are predictors of MACE, independent of plaque volume, in patients with CCS.

Thoracic Aortic Plaque Burden and Prediction of Cardiovascular Events in Patients Undergoing 320-row Multidetector CT Coronary Angiography

AIM

Wide volume scan (WVS) coronary computed tomography angiography (CCTA) enables aortic arch visualization. This study assessed whether the thoracic aortic plaque burden (TAPB) score can predict major cardiovascular adverse events (MACE) in addition to and independently of other obstructive coronary artery disease (CAD) attributes.

METHODS

This study included patients with suspected CAD who underwent CCTA (n=455). CCTA-WVS was used to assess CAD and the prognostic capacity of TAPB scores. Data analysis included the coronary artery calcification score (CACS), CAD status and extent, and TAPB score, calculated as the sum of plaque thickness and plaque angle at five thoracic aortic segments. The primary endpoint was MACE defined as a composite event comprised of ischemic stroke, acute coronary syndrome, and cardiovascular death.

RESULTS

During a mean follow-up period of 2.8±0.9 years, 40 of 455 (8.8%) patients experienced MACE. In the Cox proportional hazards model adjusted for clinical risks (Suita cardiovascular disease risk score), we identified TAPB score (T3) as a predictor of MACE independent of CACS ＞400 (hazards ratio [HR], 2.91; 95% confidence interval [CI], 1.26-6.72; p=0.012) or obstructive CAD (HR, 2.83; 95% CI, 1.30-6.18; p=0.009). The area under the curve for predicting MACE improved from 0.75 to 0.795 (p value=0.008) when TAPB score was added to CACS ＞400 and obstructive CAD.

CONCLUSIONS

We found that comprehensive non-invasive evaluation of TAPB and CAD has prognostic value in MACE risk stratification for suspected CAD patients undergoing CCTA.

The E/e' ratio on echocardiography as an independent predictor of the improvement of left ventricular contraction in patients with heart failure with reduced ejection fraction

OBJECTIVE

Clinical feature of heart failure with improved ejection fraction (HFimpEF) remains to be fully elucidated. The present study investigated the association of clinical and echocardiographic parameters with the subsequent improvement of left ventricular ejection fraction (LVEF) in heart failure with reduced ejection fraction (HFrEF).

METHODS

From outpatients with a history of hospitalized for heart failure, 128 subjects diagnosed as HFrEF (LVEF <40%) on heart failure hospitalization were enrolled and longitudinally surveyed. During follow-up periods more than 1 year, 58 and 42 patients were identified as HFimpEF (improved LVEF to ≥40% and its increase of ≥10 points) and persistent HFrEF, respectively.

RESULTS

There was no difference in age or sex between the two groups with HFimpEF and persistent HFrEF. The rate of ischemic heart disease was lower and that of tachyarrhythmia was higher in the HFimpEF group than in the persistent HFrEF group. At baseline (i.e., on heart failure hospitalization), LVEF did not differ between the two groups, but left ventricular systolic and diastolic diameters were already smaller and the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/e') was lower in the HFimpEF group. A multiple logistic regression analysis revealed that lower baseline E/e' was a significant determinant of HFimpEF, independently of confounding factors such as ischemic heart disease, tachyarrhythmia, and baseline left ventricular dimension.

CONCLUSION

Our findings indicate that the lower ratio of E/e' in the acute phase of heart failure onset is an independent predictor of the subsequent improvement of LVEF in HFrEF patients.

Aortic arch plaque morphology in patients with coronary artery disease undergoing coronary computed tomography angiography with wide-volume scan

BACKGROUND

Wide-volume scanning with 320-row multidetector computed tomography coronary angiography (CTCA-WVS) enables the assessment of the aortic arch plaque (AAP) morphology and coronary arteries without requiring additional contrast volume. This study aimed to investigate the prevalence of AAPs and their association with coronary artery disease (CAD) and major adverse cardiovascular events (MACEs) in patients who underwent CTCA-WVS.

METHODS

This study included 204 patients without known CAD (mean age, 65 years; 53% men) who underwent CTCA-WVS. We evaluated the presence of aortic plaques in the ascending aorta, aortic arch, and thoracic descending aorta using CTCA-WVS. Large aortic plaques were defined as plaques of at least 4 mm in thickness. A complex aortic plaque was defined as a plaque with ulceration or protrusion. MACEs were defined as composite events of cardiovascular (CV) death, nonfatal myocardial infarction, and ischemic stroke.

RESULTS

AAPs and large/complex AAPs were identified in 51% ( n = 105) and 18% ( n = 36) of the study patients, respectively. The prevalence of AAPs with large/complex morphology increased with CAD severity (2.1% in no CAD, 12% in nonobstructive CAD, and 39% in obstructive CAD). The univariate Cox hazard model demonstrated that the predictors associated with MACEs were diabetes, obstructive CAD, and large/complex AAPs. Independent factors associated with large/complex AAPs were male sex [odds ratio (OR), 2.90; P = 0.025], stroke history (OR, 3.48; P = 0.026), obstructive CAD (OR, 3.35; P = 0.011), and thoracic aortic calcification (OR, 1.77; P = 0.005).

CONCLUSION

CTCA-WVS provides a comprehensive assessment of coronary atherosclerosis and thoracic aortic plaques in patients with CAD, which may improve the stratification of patients at risk for CV events.

Determinants of Non-calcified Low-Attenuation Coronary Plaque Burden in Patients Without Known Coronary Artery Disease: A Coronary CT Angiography Study

Background

Although epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD), it is unclear whether EAT volume (EAV) can be used to diagnose high-risk coronary plaque burden associated with coronary events. This study aimed to investigate (1) the prognostic impact of low-attenuation non-calcified coronary plaque (LAP) burden on patient level analysis, and (2) the association of EAV with LAP volume in patients without known CAD undergoing coronary computed tomography angiography (CCTA).

Materials and Methods

This retrospective study consisted of 376 patients (male, 57%; mean age, 65.2 ± 13 years) without known CAD undergoing CCTA. Percent LAP volume (%LAP, <30 HU) was calculated as the LAP volume divided by the vessel volume. EAT was defined as adipose tissue with a CT attenuation value ranging from −250 to −30 HU within the pericardial sac. The primary endpoint was a composite event of death, non-fatal myocardial infarction, and unstable angina and worsening symptoms requiring unplanned coronary revascularization >3 months after CCTA. The determinants of %LAP (Q4) were analyzed using a multivariable logistic regression model.

Results

During the follow-up period (mean, 2.2 ± 0.9 years), the primary endpoint was observed in 17 patients (4.5%). The independent predictors of the primary endpoint were %LAP (Q4) (hazard ratio [HR], 3.05; 95% confidence interval [CI], 1.09–8.54; p = 0.033] in the Cox proportional hazard model adjusted by CAD-RADS category. Cox proportional hazard ratio analysis demonstrated that %LAP (Q4) was a predictor of the primary endpoint, independnet of CAD severity, Suita score, EAV, or CACS. The independent determinants of %LAP (Q4) were CACS ≥218.3 (p < 0.0001) and EAV ≥125.3 ml (p < 0.0001). The addition of EAV to CACS significantly improved the area under the curve (AUC) to identify %LAP (Q4) than CACS alone (AUC, EAV + CACS vs. CACS alone: 0.728 vs. 0.637; p = 0.013).

Conclusions

CCTA-based assessment of EAV, CACS, and LAP could help improve personalized cardiac risk management by administering patient-suited therapy.

Reverse Takotsubo Cardiomyopathy as a Cause of Acute Chest Pain in a Young Woman Following COVID-19 Vaccination

Supplemental Digital Content is available in the text.

Epicardial adipose tissue volume is associated with low-attenuation plaque volume in subjects with or without increased visceral fat: a 3-vessel coronary artery analysis with CT angiography

Background

Low-attenuation plaque (LAP) with a CT value of less than or equal 30 HU on coronary CT angiography (CCTA) is a marker of high-risk plaque features that leads to future acute coronary syndromes. Perivascular and epicardial adipose tissue (EAT) have been shown to be associated with progression of high-risk coronary plaques through metabolic and inflammatory mechanisms. However, association of EAT with LAP volume in three coronary arteries in subjects with or without visceral obesity remain unclear.

Aims

This study aimed to investigate the association of EAT volume (EAV) and coronary 3-vessel LAP volume in subjects with or without visceral obesity who underwent CCTA.

Methods

Patients who underwent CCTA without known coronary artery disease were included in the study (525 patients). Study subjects were classified as having non-obstructive or obstructive coronary artery disease according to the degree of coronary artery stenosis on CCTA. The plaque volume and EAV of the main vessel of the left anterior descending artery, left circumflex artery, and right coronary artery were measured with VINCENT software. Coronary plaque composition was classified as calcified plaque (CP, &gt;150HU), noncalcified plaque (NCP, 30–150HU), and Lap (&lt;30HU). The %LAP volume of the three coronary arteries was classified into quartiles. Multiple logistic regression analysis was used to analyze the factors associated with the %LAP volume.

Results

Compared with subjects without increase visceral fat, subjects with increased visceral fat had a significantly higher BMI, a greater total plaque volume, a greater total %LAP volume, a greater EAV, and a lower mean CT value of EAT. A significant correlation was observed between EAV and %LAP volume (R=0.24, p&lt;0.001). EAV (odds ratio; 1.83, 95% confidence interval 1.071–3.141, p-value 0.027) and type 2 diabetes mellitus (odds ratio 1.76, 95%confidence interval 1.042–3.000, p-value 0.034) appeared to be independent predictors of %LAP volume (Q4), when adjusted by age, gender, BMI&gt;25 kg/m2, visceral fat &gt;100cm2, LogCRP, coronary artery calcium score&gt;300, and obstructive coronary artery disease requiring revascularization.

Conclusion

This study suggests that LAP volume, which reflects the high-risk plaques in the three coronary arteries, is associated with EAV in subjects with or without increased visceral fat. Further research is needed whether pharmacological therapeutic intervention enables the prevention of coronary plaque progression and destabilization through the reduction of EAV in patients.

Funding Acknowledgement

Type of funding sources: None.

Clinical significance of aortic arch plaques simultaneously assessed with coronary atherosclerosis on cardiovascular outcomes in patients undergoing coronary CT angiography

Aims

Computed tomography (CT) coronary angiography is a useful diagnostic imaging modality in assessing presence, severity, and extent of coronary artery disease (CAD). Aortic arch plaques have been shown to be an underlying cause of embolic stroke and also related to increased risk of cardiovascular events. Yet, conventional CTCA imaging protocol does not include aortic arch for the reduction of radiation exposure. This study aimed to investigate prevalence of aortic arch plaques simultaneously assessed by CTCA and their clinical significance in combination with the presence of obstructive CAD for prediction of CVD events in patients with suspected CAD.

Methods

This study consisted of 310 (mean age, 66 years old, 42% female) patients with suspected CAD undergoing CTCA between 2017 and 2019. All CTCA examination was performed with 320-row detector scanner using ECG-triggered prospective gating method. Aortic arch images were simultaneously acquired during CTCA scanning without an increase of contrast media. Using Agatston method, coronary artery calcium score (CACS) was categorized into either of the groups having CACS of 0, 0–99, 100–299, or more than 300. The presence of CAD was reported as non-obstructive or obstructive CAD. High-risk featured aortic plaque was defined as large plaques &gt;4 mm in thickness showing ulceration or protrusion. A composite event of cardiovascular disease, including all-cause mortality, non-fatal myocardial infarction, unplanned hospitalization requiring revascularization or stroke was defined as the primary endpoint.

Results

Patients having CACS of 0, 0–99, 100–299, and &gt;300 were found in 41%, 24%, 15%, 20%%, respectively, where obstructive CAD was diagnosed in 11%. Aortic HRPs in ascending aorta, aortic arch, and thoracic descending aorta were observed in 1.6%, 6.9%, and 15%, respectively. During a mean follow-up period of 2.2 years, the primary endpoint was observed in 27 patients (8.7%). Cox regression hazard model demonstrated an independent association of aortic arch high-risk plaques (HR; 3.2, 95% CI; 1.20–8.64, p=0.02) and obstructive CAD (HR; 3.3, 95% CI; 1.45–7.92, P=0.005) when adjusted by age, CACS, and chronic kidney disease. Kaplan-Meier curve analysis showed a worse outcome of patients with aortic HRP and obstructive CAD compared to those without aortic plaques and obstructive CAD (p&lt;0.001).

Conclusion

This study demonstrated an independent association of aortic arch high-risk featured plaques with CVD events. Further study is warranted whether pharmacological interventional therapies can reduce future CVD risks in patients with CAD and aortic arch plaques.

Funding Acknowledgement

Type of funding sources: None.

Ankle-brachial index, arterial stiffness, and biomarkers in the prediction of mortality and outcomes in patients with end-stage kidney disease

BACKGROUND

Although ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are significant predictors of major adverse cardiovascular event (MACE), their prognostic value in association with biomarkers has not been fully evaluated in patients with end-stage kidney disease (ESKD).

HYPOTHESIS

We hypothesized that ABI/baPWV would provide better prognostic value independent of biomarkers in ESKD patients.

METHODS

This study included 104 ESKD patients treated with maintenance hemodialysis who underwent ABI and baPWV examinations and laboratory tests, including brain-natriuretic peptide, high-sensitive cardiac troponin T (hs-cTnT), and high-sensitive C-reactive protein (hs-CRP). MACE was defined as a composite event of all-cause death, acute coronary syndrome, and stroke.

RESULTS

During a mean follow-up of 3.6 ± 1.7 years, a total of 51 MACE were observed. The independent factors associated with MACE were age >75 years (adjusted hazard ratio [HR], 2.15; P < .05), abnormal ABI (adjusted HR, 2.01; P < .05), left ventricular ejection fraction (LVEF) <50% (adjusted HR, 3.33; P < .001), the upper tertile of hs-cTnT (adjusted HR, 2.77; P < .05), and hs-CRP (HR, 1.96; P < .05). However, baPWV did not remain as an independent predictor of MACE in the entire cohort and also in patients without abnormal ABI. The combination of predictors improves the predictive value of MACE, providing increased HR with 4.00 for abnormal ABI + hs-CRP, 4.42 for abnormal ABI + hs-cTnT, and 7.04 for abnormal ABI + LVEF <50% (all P < .001).

CONCLUSION

Abnormal ABI is a robust predictor of MACE independent of biomarkers and their combination provides better risk stratification compared with a single predictor in ESKD patients.

Associations of sensitive cardiac troponin-I with left ventricular morphology, function and prognosis in end-stage renal disease patients with preserved ejection fraction

Sensitive cardiac troponin I (cTnI) predicts all-cause and cardiovascular mortality in various clinical settings. However, its clinical significance in hemodialysis (HD) patients with preserved left ventricular ejection fraction (LVEF) has not been fully elucidated. This study investigated the association of cTnI with LV morphology and function, and its long-term outcome in HD patients with preserved LVEF. This prospective study consists of 96 HD patients with preserved LVEF (69 ± 8 years and 63% male) who underwent two-dimensional echocardiographic examination and biomarker tests including cTnI, brain natriuretic peptide, and high-sensitive C-reactive protein. The primary endpoint was all-cause death and secondary endpoint was cardiovascular death. Factors independently associated with cTnI were systolic blood pressure (β = - 0.239, p = 0.011), heart rate (β = 0.216, p = 0.021), LV mass index (β = 0.231, p = 0.020), and E to e' ratio (β = 0.237, p = 0.016). During a mean follow-up of 3.6 years, primary and secondary endpoints were observed in 23 (24%) and 18 (19%) patients, respectively. In the multivariate Cox proportional hazard analysis, the upper cTnI tertile has significantly increased risk of all-cause mortality [hazard ratio (HR), 2.69; 95% confidence interval (CI), 1.139-6.386; p = 0.024] and that of cardiovascular death (HR, 4.56; 95% CI 2.021-16.968; p = 0.006) independent of echocardiographic measures and other serum biomarkers. In HD patients with preserved LVEF, serum cTnI levels were significantly associated with diastolic function and risk of mortality independent of echocardiographic variables and other biomarkers.

Adding thiazide to a renin-angiotensin blocker improves left ventricular relaxation and improves heart failure in patients with hypertension

Hypertension is associated with an increased risk of diastolic dysfunction. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) have failed to show improvement in clinical outcomes for patients with diastolic dysfunction. In this study, we investigated the effect of changing an ACEi or ARB to a combination of losartan and hydrochlorothiazide (HCTZ) on left ventricular (LV) preload and relaxation in patients with hypertension and diastolic dysfunction. We enrolled 371 hypertensive patients with diastolic dysfunction who had not achieved their treatment goals with an ACEi or ARB. We switched the ACEi or ARB to losartan/HCTZ and followed the patients for 24 weeks. The primary end points were changes in septal mitral annular velocity during diastole (e′) and in the ratio of mitral inflow velocity to e′ velocity (E/e′ ratio) from baseline to the end of follow-up. Mean systolic and diastolic blood pressures (BP) decreased by 22 and 11 mm Hg, respectively, after changing from an ACEi or ARB to losartan/HCTZ. The e′ velocity increased, and the E/e′ ratio and brain natriuretic peptide level decreased significantly. High-sensitivity C-reactive protein also decreased significantly (0.50 vs. 0.29 mg dl⁻¹, P<0.0001). There were only slight or no changes in glucose levels, homeostasis model assessment insulin resistance (HOMA-R), uric acid and electrolytes after the drug change. Changing from an ACEi or ARB to losartan/HCTZ is associated with a reduction in BP, improvement in LV relaxation, improvement in heart failure state and attenuation of systemic inflammation with few adverse effects in patients with hypertension and diastolic dysfunction.

Quadricuspid aortic valve: report of three cases

Quadricuspid aortic valve (QAV) is a very rare congenital malformation. We have encountered three patients with QAV, of whom one patient may be the eldest reported patient with this particular anatomical abnormality. In another of our patients, there was aortic regurgitation, aortic stenosis, and healed infective endocarditis, with adhesion of the tips of the cusps. In all three patients, the cusps were all of equal size. Until now, there has been very little documented evidence about the anatomical variations in QAV or its relationship with infective endocarditis. From the available literature, we conclude that the anatomical variations in patients with QAV are similar to those in patients with quadricuspid pulmonary valve, and infective endocarditis may not be an uncommon complication.

In situ detection of platelet-derived growth factor-A and -B chain mRNA in human coronary arteries after percutaneous transluminal coronary angioplasty

Experimental studies have shown that platelet-derived growth factor (PDGF) plays a role in wound-healing processes after angioplasty. In humans, after percutaneous transluminal coronary angioplasty (PTCA), this has not yet been documented. Six coronary arteries of five patients who died after PTCA were studied. The angioplasty sites were sliced serially, and the slices were studied using immunocytochemistry and in situ hybridization. Monoclonal antibodies were directed against muscle actin, vimentin, macrophages, and endothelium. In situ hybridization was performed using a synthetic oligonucleotide probe complementary to the PDGF-A and -B chain mRNAs. The identification of cells was based on a comparison with immune-stained sections. Positive autoradiographic signals for PDGF-A and -B chain mRNAs were found at the site of the PTCA injury and related to areas that contained macrophages, spindle cells, smooth muscle cells, and endothelial cells of neovascularization. In humans, both PDGF-A and -B chain mRNAs are expressed at sites of PTCA injury. The expression relates to the reparative response, and it appears that the cells involved are macrophages, spindle cells, smooth muscle cells, and endothelial cells of neovascularization. This is the first study to document the expression of PDGF-A and -B mRNAs at sites of repair in human coronary arteries after PTCA. It suggests strongly that PDGF is involved in the repair process after PTCA.

In vivo effect of TGF- beta 1. Enhanced intimal thickening by administration of TGF- beta 1 in rabbit arteries injured with a balloon catheter

The in vivo effect of transforming growth factor-beta 1 (TGF-beta 1) was studied in a model system in which arterial intimal thickening was induced by injury of rabbit arteries with a balloon catheter (BCI). Intimal area and its ratio to medial area in carotid arteries after BCI were significantly higher in rabbits treated with 10 micrograms/kg TGF-beta 1 and 10 mg/kg aspirin i.v. QD (TGF-beta 1 group) than in those treated with 10 mg/kg aspirin i.v. QD only (control group). Intimal cell numbers in the TGF-beta 1 and control groups were not significantly different from each other, but matrix volume in the intimal layer was significantly higher in the TGF-beta 1 group. By immunohistochemical and Northern blot analyses, the fibronectin content in carotid intimal and medial layers was greater in the TGF-beta 1 group compared with that in the control group. Thus, in intimal thickenings induced by BCI. TGF-beta 1 mainly enhanced the formation of matrix containing fibronectin. Moreover, the mRNAs of TGF-beta 1 and type II receptors were detected in carotid arteries 7 and 14 days after, but not before, BCI. Thus, TGF-beta 1 influences the process of intimal thickening induced by BCI through a receptor-mediated mechanism in vivo. The significance of this fact is discussed in relation to the development of atherosclerosis.