Homocysteine modifies the association of coronary stenosis and HIV infection in an inner city African American population

BACKGROUND AND AIMS

People with HIV (PWH) whose disease is controlled on anti-retroviral regimens remain at an increased risk for coronary artery disease (CAD). Traditional cardiovascular risk factors do not fully explain the residual risk in PWH suggesting contributions from nontraditional factors. Homocysteine (Hcy) may be one of these as prior work in adults without HIV demonstrate that Hcy may impair endothelial function by decreasing the availability of nitric oxide, promoting the development of atherosclerosis. In addition, plasma Hcy levels are higher in PWH than in individuals living without HIV. The aim of this study was to investigate whether Hcy levels influence the association between HIV and coronary stenosis in an inner city African American population.

METHODS

African Americans from the Heart Study in Baltimore, with and without HIV, recruited from inner-city Baltimore between June 2004 and February 2015, were included in this analysis. Participants underwent coronary CT angiography to evaluate the presence of coronary stenosis, defined as luminal stenosis >10%. Hcy was measured from stored serum samples.

RESULTS

In this analysis, the median [IQR] age of the 664 participants was 56 [50-66] years; 68.1% were living with HIV and 43.1% were women. Elevated Hcy (>15 µmol/L) was more prevalent in those with coronary stenosis (23.3%, 95% CI: 18.4%-28.2%) than in those without coronary stenosis (13.1%, 95% CI: 9.7%-16.5%) (p = 0.0007), and HIV was associated with coronary stenosis in those participants with an elevated Hcy (Prevalence Ratio: 1.94, 95% CI: 1.04-3.64, p = 0.0038) and not in those with a Hcy ≤15 µmol/L (Prevalence Ratio: 1.02, 95% CI: 0.83-1.25, p = 0.87).

CONCLUSIONS

Our data suggest an association between elevated Hcy levels (>15 µmol/L) and the prevalence of coronary stenosis in PWH from this inner city African American population.

Mechanisms of Coronary Sinus Reducer for Treatment of Myocardial Ischemia: In Silico Study

The coronary sinus reducer (CSR) is an emerging medical device for treating patients with refractory angina, often associated with myocardial ischemia. Patients implanted with CSR have shown positive outcomes, but the underlying mechanisms are unclear. This study sought to understand the mechanisms of CSR by investigating its effects on coronary microcirculation hemodynamics that may help explain the therapy's efficacy. We applied a validated computer model of the coronary microcirculation to investigate how CSR affects hemodynamics under different degrees of coronary artery stenosis. With moderate coronary stenosis, an increase in capillary transit time (CTT) (up to 69% with near-complete coronary sinus (CS) occlusion) is the key change associated with CSR. Because capillaries in the microcirculation can still receive oxygenated blood from the upstream artery with moderate stenosis, the increase in CTT allows more time for the exchange of gases and nutrients, aiding tissue oxygenation. With severe coronary stenosis, however, the redistribution of blood draining from the non-ischemic region to the ischemic region (up to 96% with near-complete CS occlusion) and the reduction in capillary flow heterogeneity are the key changes associated with CSR. Because blood draining from the non-ischemic region is not completely devoid of O2, the redistribution of blood to the capillaries in the ischemic region by CSR is beneficial especially when little or no oxygenated blood reaches these capillaries. This simulation study provides insights into the mechanisms of CSR in improving clinical symptoms. The mechanisms differ with the severity of the upstream stenosis.

Contact with general practice in patients with suspected chronic coronary syndrome before and after CT angiography compared with the general population

BACKGROUND

Most patients undergoing coronary computed tomography angiography (CCTA) to diagnose coronary artery disease (CAD) are referred from general practitioners (GP). The burden in contacts to GP in relation to investigation on suspected CAD is unknown.

METHODS

All patients undergoing CCTA in Western Denmark from 2014-2022 were included. CCTA stenosis was defined as diameter stenosis of ≥ 50%. Patients with and without stenosis were matched, in each group, 1:5 to a reference population based on birth-year, gender and municipality using data from national registries. All GP visits were registered in up to five years preceding and one year after the CTA and stratified by gender and age. Charlson comorbidity index (CCI) were calculated in all groups.

RESULTS

Of the 62 512 patients included, 12 886 had a stenosis while 49 626 did not. Patients in both groups had a substantially higher GP visit frequency compared to reference populations. In the year of coronary CTA median GP contacts in patients with stenosis was 11 [6-17] vs. 6 [2-11] in the reference population (P < 0.001), in patients without stenosis 10 [6-17] vs. 5 [2-11] (P < 0.001). These findings were consistent across age and gender. CCI was higher among both patients with and without stenosis compared to reference groups.

CONCLUSION

In patients undergoing CCTA to diagnose CAD, a substantially increased frequency of contacts to GP was observed in the five-year period prior to examination compared to the reference populations regardless of the CCTA findings. Obtaining the CCTA result did not seem to substantially affect the GP visit frequency.

Pathophysiology and Treatment of Intraseptal-Course Left Coronary Anomaly: Surgery for All?

Intraseptal-course, ectopic coronary anomalies are not well characterized as to anatomy, function, prognosis, and treatment. Recently, a revolutionary but unsupported new theory is claiming that most patients with a Left Anomalous Coronary Artery originating from the Opposite Sinus with anomalous Intra-Septal course (L-ACAOS-IS)-even small children-have significant stenoses and require open-heart surgery to prevent acute myocardial infarction and death. This surprising view has spurred ongoing discussions among adult and pediatric cardiologists and cardiac surgeons, compelling us (the conservative party in the discussion) to offer an in-depth and comprehensive review of this anomaly, based on objective but opposite data. We and other adult cardiologists have followed numerous L-ACAOS-IS patients for many years and have observed none of the claimed catastrophes. Rather, we have consistently found that L-ACAOS-IS generally has a benign clinical prognosis. We present the general principle of coronary artery dysfunction in anatomical congenital anomalies (that only significant luminal coronary stenosis can have clinical repercussions). We then review anatomical and functional details of L-ACAOS-IS related to prognosis and treatment indications, which could explain many of the clinical presentations recently mentioned. Finally, we encourage our more liberal colleagues to recognize that, compared with normal coronary arteries, those with anomalies of origin and course are associated with frequent coronary spasm. In particular, we underscore that some of the ischemic manifestations and other results might actually be caused by pressure wire-induced artifacts (rigid wires tend to cause coronary spasm when advanced into tortuous coronary arteries).

Research on individualized distribution approach of coronary resting blood flow for noninvasive calculation of fractional flow reserve

BACKGROUND AND OBJECTIVES

The distribution of coronary resting blood flow is critical for accurately calculating the computed tomography (CT) angiography-derived fractional flow reserve (FFRCT). However, the diagnostic accuracy of FFRCT calculated by the fixed exponents between two risk factors and coronary resting blood flow, including myocardial mass and diameter of the coronary artery branch, was insufficient compared with invasive fractional flow reserve (FFR). In this study, we proposed the individualized distribution of coronary resting blood flow based on coronary ultrasound blood flow measurement, to improve the diagnostic accuracy of FFRCT calculation.

METHODS

Five risk factors and an unknown coefficient K were integrated to calculate the individualized distribution of coronary resting blood flow. The K value was fit using the least square method based on coronary ultrasound blood flow measurement results of 30 volunteers. We developed a novel approach for calculating the individualized distribution of coronary resting blood flow and applied it to calculate FFRCT (FFRCTI). Then, we tested the performance of the individualized distribution approach by comparing it with the approach proposed by Taylor based on coronary ultrasound blood flow measurement results of 13 volunteers. Finally, we tested the diagnostic accuracy of FFRCT calculated by two approaches in invasive FFR of 121 vessels with coronary stenosis.

RESULTS

We identified five risk factors and 6.83×10-5 for K value, including cardiac output, mean arterial pressure, myocardial mass, coronary artery volume, and diameter of the coronary artery branch, to calculate the individualized distribution of coronary resting blood flow. The mean square error of the individualized distribution approach (0.0088) was significantly less than that of the approach proposed by Taylor (0.0799). The diagnostic accuracy of FFRCTI calculated by the individualized distribution approach (91.74%) was higher than that of the approach proposed by Taylor (FFRCTT) (82.64%).

CONCLUSIONS

The individualized distribution approach of coronary resting blood flow can significantly improve the diagnostic accuracy of FFRCT calculation compared with invasive FFR, and support its wide clinical application for diagnosing myocardial ischemia caused by coronary stenosis.

Sex-specific associations of cardiovascular risk factors and coronary plaque composition for hemodynamically significant coronary artery stenosis: a coronary computed tomography angiography study

BACKGROUND

It has been reported that there are sex differences in plaque composition and hemodynamically significant stenosis. This study aimed to explore the impact of sex on cardiovascular risk factors for specific plaque compositions and hemodynamically significant stenosis.

METHODS

Data regarding demographics and cardiovascular risk factors were collected. Hemodynamically significant stenosis was identified by a computed tomography-derived fractional flow reserve of ≤ 0.8. Associations among cardiovascular risk factors, plaque composition, and hemodynamically significant stenosis were assessed using a multivariate binary logistic regression analysis across sexes. The discriminating capacity of diverse plaque components for hemodynamically significant stenosis was assessed by area under the receiver-operating characteristics curve with 95% confidence intervals.

RESULTS

A total of 1164 patients (489 men and 675 women) were included. For men, hyperlipidemia and cigarette smoking were risk factors for each plaque component (all P < 0.05), and diabetes mellitus also predicted fibrotic components (P < 0.05). For women, risk factors for each plaque component were hypertension and diabetes mellitus (all P < 0.01). Nonetheless, hyperlipidemia (P < 0.05) was a specific risk factor for non-calcified components. Calcified components combined with fibrotic components showed superior discrimination of hemodynamically significant stenosis in men and calcified components alone in women (all P < 0.01). Hypertension (P < 0.01) was a risk factor for hemodynamically significant stenosis in women. In contrast, diabetes, hyperlipidemia, and cigarette smoking were risk factors for hemodynamically significant stenosis in men (all P < 0.05).

CONCLUSIONS

In men, hemodynamically significant stenosis was predicted by a combination of calcified and fibrotic components with multiple risk factors. In women, hemodynamically significant stenosis was predicted by calcified components caused by a single risk factor. It might be a key point to improve prognosis by more precise risk management between men and women, which needs to be proved by further prospective trials.

Association of ambient PM10 and PM2.5 with coronary stenosis measured using selective coronary angiography

BACKGROUND

Long-term ambient particulate matter (PM) exposure exerts detrimental effects on cardiovascular health. Evidence on the relation of chronically exposed ambient PM10 and PM2.5 with coronary stenosis remains lacking. Our aim was to investigate the association of PM10 and PM2.5 with coronary stenosis in patients undergoing coronary angiography.

METHODS

We performed a retrospective cohort study consisting of 7513 individuals who underwent coronary angiography in Fujian Province, China, from January 2019 to December 2021. We calculated a modified Gensini score (GS) to represent the degree of stenosis in coronary arteries by selective coronary angiography. We fitted linear regressions and logistic models to assess the association of PM10 and PM2.5 with coronary stenosis. We employed restricted cubic splines to describe the exposure-response curves. We performed mediation analyses to assess the potential mediators.

RESULTS

Long-term ambient PM10 and PM2.5 (prior three years average) exposure was significantly associated with the GS, with a breakpoint concentration of 47.5 μg/m3 and 25.8 μg/m3 for PM10 and PM2.5, respectively, above which we found a linear positive exposure-response relationship of ambient PM with GS. Each 10 µg /m3 increase in PM10 exposure (β: 4.81, 95 % CI: 0.44-9.19) and PM2.5 exposure [β: 10.50, 95 % CI: 3.14-17.86] were positively related to the GS. The adjusted odds ratio (OR) for each 10 µg/m3 increment in PM10 exposure on severe coronary stenosis was 1.33 (95 % CI: 1.04-1.76). Correspondingly, the adjusted OR for PM2.5 was 1.87 (95 % CI: 1.24-2.99). The mediation analysis indicated that the effect of PM10 on coronary stenosis may be partially mediated through total cholesterol, low-density lipoprotein cholesterol, apolipoprotein B, serum creatinine and blood urea nitrogen, and the effect of PM2.5 may be mediated in part by hemoglobin A1c.

CONCLUSION

Our study provides the first evidence that chronic ambient PM10 and PM2.5 exposure was associated with coronary stenosis assessed by GS in patients with suspected coronary artery disease and reveals its potential mediators.

Coronary computed tomography in emergencies: The importance of the radiologist's experience

INTRODUCTION

Incorporating coronary computed tomography angiography (CTA) in the hospital workup for suspected acute coronary syndrome requires appropriate skills for interpreting this imaging test. Radiologists' skills can affect the interobserver agreement in evaluating these studies.

OBJECTIVE

To determine the interobserver agreement according to radiologists' experience in the interpretation of coronary CTA studies done in patients who present at the emergency department with acute chest pain and low-to-intermediate probability of acute coronary syndrome.

MATERIALS AND METHODS

We studied the interobserver agreement in the urgent evaluation of coronary CTA studies in which CAD-RADS was used to register the findings. We created pairs of observers among a total of 8 assessors (4 attending radiologists and 4 radiology residents). We used the kappa coefficient to estimate the overall concordance and the concordance between subgroups according to their experience.

RESULTS

The agreement was substantial between experienced radiologists and residents (k=0.627; 95%CI: 0.436-0.826) as well as between all the pairs of observers (k=0.661; 95%CI: 0.506-0.823) for all the CAD-RADS together. The degree of agreement within the group of experienced radiologists was greater than that within the group of residents in all the analyses. The agreement was excellent for the overall CAD-RADS (k=0.950; 95% CI: 0.896-1) and for CAD-RADS ≥ 4 (k=1); the agreement was lower for CAD-RADS ≥ 3 (k=0.754; 95% CI: 0.246-1.255). The agreement for the residents for these categories was k=0.623, k=0.596, and k=0.473, respectively.

CONCLUSION

The agreement among attending radiologists regarding the assessment of urgent coronary CTA studies is excellent. The agreement is lower when residents are paired with attending radiologists. These findings should be taken into consideration when implementing coronary CTA in emergency departments and in the organisation of radiological staff for interpreting and reporting this imaging test.

Prognostic value of CT-derived coronary artery disease characteristics varies by ASCVD risk: insights from the PROMISE trial

OBJECTIVES

To compare the prognostic value of individual CT-derived coronary artery disease (CAD) characteristics across categories of clinical cardiovascular risk.

METHODS

The central core laboratory assessed coronary artery calcium (CAC), obstructive CAD (stenosis ≥ 50%), and high-risk plaque (HRP) in stable outpatients with suspected CAD enrolled in the PROMISE trial. Multivariable Cox regression models (endpoint: unstable angina, nonfatal myocardial infarction, or all-cause mortality; median follow-up: 2 years) were used to compare hazard ratios (HR) of the CT measures between low-borderline (< 7.5%) and moderate-high (≥ 7.5%) atherosclerotic cardiovascular disease (ASCVD) risk based on the pooled cohort equation.

RESULTS

Among 4356 included patients (aged 61 ± 8 years, 52% women), 67% had ASCVD risk ≥ 7.5%. Stratified by ASCVD risk, CAD ≥ 50% had nearly threefold greater HR in individuals with ASCVD < 7.5% (aHR, 6.85; 95% CI, 2.33-20.15; p < 0.001) vs. ASCVD ≥ 7.5% (aHR: 2.66, 95% CI: 1.67-4.25, p < 0.001; interaction p = 0.041). CAC predicted events solely in ASCVD ≥ 7.5% patients (aHR: 1.92, 95% CI: 1.01-3.63, p = 0.045; interaction p = 0.571), while HRP predicted events only in ASCVD < 7.5% (aHR: 3.11, 95% CI: 1.09-8.85, p = 0.034; interaction p = 0.034).

CONCLUSIONS

Prognostic values of CT-derived CAD characteristics differ by ASCVD risk categories. While CAD ≥ 50% has the highest prognostic value regardless of ASCVD risk, CAC is prognostic in high and HRP in low ASCVD risk. These findings suggest that CAD ≥ 50% and HRP detection rather than CAC scoring may better risk-stratify symptomatic low-risk patients and thus potentially improve downstream care.

KEY POINTS

• Prognostic value of individual CT-derived CAD characteristics differs by categories of cardiovascular risk. • Presence of obstructive coronary artery stenosis ≥ 50% has the highest prognostic value regardless of cardiovascular risk. • Coronary artery calcium is independently prognostic in high and high-risk plaque features in low cardiovascular risk.

Relationship Between Red Cell Distribution Width and Oxidative Stress Indexes in Patients with Coronary Artery Disease

Background

Red blood cell distribution (RDW), an index of the size variability of erythrocytes, is significantly associated with coronary stenosis and can strongly predict the mortality risk in coronary artery disease (CAD). The biological mechanisms involved are not fully understood but may include oxidative stress. We sought to investigate the relationship between RDW and markers of oxidative stress in patients with CAD.

Methods

Participants were 112 consecutive patients referred to department of cardiac surgery for evaluation of chest pain. 32 patients had stable CAD, 40 patients had unstable CAD and 40 subjects were diagnosed as non-CAD. The levels of lipid peroxidation (TBARS) were measured in plasma and membrane samples by a fluorometric method. The plasma levels of glutathione (GSH) and total antioxidant capacity (TAC) were determined using spectrophotometric methods.

Results

Lipid peroxidation levels were significantly higher in the erythrocyte membrane of stable CAD patients than non-CAD patients. The levels of TAC were significantly lower in both stable and unstable groups when compared to that of the control group (P< 0.019 and P< 0.001, respectively), but did not differ between stable and unstable CAD. In addition, there was no significant difference in the serum GSH levels among the study groups. Membrane TBARS was directly associated with RDW in three groups of study.

Conclusions

We found an independent association between RDW levels and membrane lipid peroxidation in patients with CAD. This finding suggests that oxidative stress may be a potential underlying biological mechanism for increased RDW in CAD patients.

Drug-coated balloon combined with drug-eluting stent for the treatment of coronary bifurcation lesions: insights from the HYPER study

True coronary bifurcation lesions (CBL) represent a challenging scenario for percutaneous coronary interventions (PCI), and are associated with a higher risk of target lesion failure (TLF), particularly when two stents are implanted. A hybrid strategy combining a drug-eluting stent (DES) in the main branch, and a drug-coated balloon in the side branch may improve outcomes by reducing the total stent length while maintaining an effective anti-prolipherative action. In this sub-study of the HYPER trial, 50 patients with true CBL were treated with a hybrid strategy: procedural success was 96%, one case of peri-procedural myocardial infarction and one case of TLF (in a DES-treated segment) at 1 year were reported. This study suggests that such a hybrid strategy may be a safe and effective option for true CBL PCI, and warrants additional investigations to compare outcomes with standard of care strategies.

HbA1c is a predictive factor of severe coronary stenosis and major adverse cardiovascular events in patients with both type 2 diabetes and coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is not only a macrovascular complication of type 2 diabetes mellitus (T2DM). Cardiovascular disease (CVD) is one of the leading causes of mortality among individuals with T2DM. Reducing the risk of adverse cardiovascular events (MACE) is crucial for the management of patients with CHD. This study aimed to investigate the effect of glycemic control on CHD severity and 3-point MACE (3p-MACE) risk in patients with T2DM and CHD.

METHODS

681 patients with both T2DM and CHD throughout October 2017 and October 2021 who were hospitalized in the second affiliated hospital of Nanchang university were included. A total of 300 patients were eventually enrolled in this retrospective cohort research. The severity of CHD in these patients was assessed, and the primary outcome during follow-up was recorded, with the primary result being the 3-point major adverse cardiovascular event (3p-MACE). The correlation between baseline glycated hemoglobin A1c (b-HbA1c) and the severity of CHD was evaluated by logistic regression analysis. The effect of b-HbA1c and follow-up HbA1c (f-HbA1c) levels on the risk of 3p-MACE were investigated by cox regression analysis.

RESULTS

b-HbA1c was positively correlated with the severity of CHD (r = 0.207, p = 0.001), and patients with b-HbA1c > 9% were more likely to have severe CHD. The HRs for b-HbA1c and f-HbA1c on the risk of 3p-MACE were 1.24 (95% CI 0.94-1.64, p = 0.123) and 1.32 (95% CI 1.02-1.72, p = 0.036), respectively. Patients with f-HbA1c   ≥8.6% had a higher risk of 3p-MACE than f-HbA1c < 8.6% (HR = 1.79, 95% CI 1.16-2.79, p = 0.009).

CONCLUSION

In patients with both T2DM and CHD, b-HbA1c was an independent predictive factor of severe CHD. f-HbA1c was an independent predictive factor of 3p-MACE. Having the f-HbA1c below 8.6% significantly reduced the risk of 3p-MACE.

Radiomics features of pericoronary adipose tissue improve CT-FFR performance in predicting hemodynamically significant coronary artery stenosis

OBJECTIVES

To evaluate the value of radiomics-based model of pericoronary adipose tissue (PCAT) combined with CT fractional flow reserve (CT-FFR) in predicting hemodynamically significant coronary stenosis.

METHODS

Patients with suspected or known coronary artery disease, who had coronary computed tomography angiography (CCTA), invasive coronary angiography (ICA), and FFR within 1 month, were retrospectively included. Radiomics features of lesion-based PCAT were extracted. The lesion-specific CT-FFR values, CCTA-derived diameter stenosis, lesion length, and PCAT attenuation were also measured. FFR values were used as the reference standard to assess the diagnostic performance of radiomics model, CT-FFR, and combined model for detection of flow-limiting stenosis.

RESULTS

A total of 146 patients with 180 lesions were included in the study. All lesions were divided into training and validation cohorts at a ratio of 2:1. CT-FFR model exhibited the highest area under the curve (AUC) (0.803 for training, 0.791 for validation) in predicting hemodynamically significant stenosis, followed by radiomics model (0.776 for training, 0.744 for validation). However, no statistically significant difference was found between the AUCs of the above two models (p > 0.05). When CT-FFR was combined with radiomics model, the AUC reached 0.900 for training cohort and 0.875 for validation cohort, which were significantly higher than that of CT-FFR and radiomics model alone (both p < 0.05).

CONCLUSION

The diagnostic performance of PCAT radiomics model was comparable to that of CT-FFR for identification of ischemic coronary stenosis. Adding PCAT radiomics model to CT-FFR showed incremental value in discriminating flow-limiting from non-flow-limiting lesions.

KEY POINTS

• Radiomics analysis of lesion-based PCAT is potentially an alternative method to identify hemodynamic significance of coronary artery stenosis. • Adding radiomics model of PCAT to CT-FFR improved diagnostic performance for the detection of flow-limiting coronary stenosis. • Radiomics features + CT-FFR is a promising noninvasive method for comprehensive evaluation of hemodynamic significance of coronary artery stenosis.

Association between socioeconomic position and coronary artery calcium score in patients with symptoms suggestive of obstructive coronary artery disease

AIM

Low socioeconomic-position (SEP) is associated with increased prevalence of cardiovascular disease. Whether this is caused by earlier development of atherosclerotic calcifications is not well understood. This study aimed to investigate the association between SEP and coronary artery calcium score (CACS) in a population presenting with symptoms suggestive of obstructive coronary artery disease.

METHODS

We included 50,561 patients (mean age 57 ​± ​11, 53% women) from a national registry undergoing coronary computed tomography angiography (CTA) from 2008 to 2019. CACS was used as outcome in categories; 1-399 and ​≥ ​400 in regression analyses. SEP was obtained from central registries and defined as mean personal income and length of education.

RESULTS

The number of risk factors were negatively associated with income and education among both men and women. The adjusted OR of having a CACS≥400 was 1.67(1.50-1.86) among women with <10 years of education compared to >13 years. For men the corresponding OR was 1.03(0.91-1.16). For women with low income the adjusted OR of CACS ≥400 was 2.29(1.96-2.69) using high income as a reference. For men the corresponding OR was 1.13(0.99-1.29).

CONCLUSION

In patients referred for coronary CTA we found an increased level of risk factors among men and women with short education and low income. Among women with longer education and a higher income we demonstrated a lower CACS compared to other women and men. Socioeconomic differences seem to affect the development of CACS beyond what can be explained by traditional risk factors. Part of the observed result may be due to referral bias.

CLINICALTRIALS

GOV IDENTIFIER

None.

Declined plasma microfibrillar-associated protein 4 levels in acute coronary syndrome

BACKGROUND

Microfibrillar-associated protein (MFAP4), initially identified as an extracellular matrix protein, has been demonstrated in multiple human disorders, but it is yet to be discovered following acute coronary syndrome (ACS) in clinical practice. Therefore, this study aimed to investigate the relationship between circulating MFAP4 levels and coronary stenosis in ACS.

METHODS

We performed the study in 148 ACS subjects, including 75 ST-segment elevation myocardial infarction (STEMI), 27 non-ST-segment elevation myocardial infarction (non-STEMI) and 46 unstable angina (UA). Clinical variables were collected and Gensini and Syntax stenosis scoring systems were applied to assess the severity of coronary stenosis. Kaplan-Meier and logistic regression analysis were used to analyze the relationship between MFAP4 and the severity of coronary stenosis or ACS outcomes. Spearman analysis was used to describe the correlation between MFAP4 and clinical parameters.

RESULTS

Circulating MFAP4 levels were significantly decreased in the STEMI group (0.008 ng/ml) compared with the non-STEMI group (0.014 ng/ml) and UA group (0.019 ng/ml) (p < 0.001). After adjusting for confounding factors, we found that MFAP4 was an independent risk factor for STEMI (odds ratio = 0.395, 95% CI 0.174-0.895, p = 0.026). MFAP4 level was negatively correlated with Gensini score and Syntax score (r = - 0.311 and - 0.211, p < 0.001 and 0.01, respectively). Based on the MFAP4 level of 0.117 ng/ml, ACS patients were divided into two groups: the low-MFAP4 group (< 0.117 ng/ml, n = 60) and the high-MFAP4 group (≥ 0.117 ng/ml, n = 88). After the median follow-up of 165 days, Kaplan-Meier survival analysis revealed that the MACE-free rate was significantly lower in ACS patients with lower MFAP4 levels (p = 0.009).

CONCLUSIONS

MFAP4 has a potential as a biomarker for the degree of coronary stenosis in ACS. Confirmation of observations in larger cohorts and longer follow-up periods is warranted.

Coronary angiography using spectral detector dual-energy CT: is it the time to assess myocardial first-pass perfusion?

Coronary computed tomography angiography (CCTA) represents a common approach to the diagnostic workup of patients with suspected coronary artery disease. Technological development has recently allowed the integration of conventional CCTA information with spectral data. Spectral CCTA used in clinical routine may allow for improving CCTA diagnostic performance by measuring myocardial iodine distribution as a marker of first-pass perfusion, thus providing additional functional information about coronary artery disease.

Optimization of FFR prediction algorithm for gray zone by hemodynamic features with synthetic model and biometric data

BACKGROUND

Recent attempts on adopting artificial intelligence algorithm on coronary diagnosis had limitations on data quantity and quality. While most of previous studies only used vessel image as input data, flow features and biometric features should be also considered. Moreover, the accuracy should be optimized within gray zone as the purpose is to decide stent insertion with estimated fractional flow reserve.

OBJECTIVES

The main purpose of this study is to develop an artificial intelligence-based coronary vascular diagnosis system focused on performance in the gray zone, from CT image extraction to FFR estimation. Three main issues should be considered for an algorithm to be used for pre-screening: algorithm optimization in the gray zone, minimization of labor during image processing, and consideration of flow and biometric features. This paper introduces a full FFR pre-screening system from automatic image extraction to an algorithm for estimating the FFR value.

METHOD

The main techniques used in this study are an automatic image extraction algorithm, lattice Boltzmann method based computational fluid dynamics analysis of a synthetic model and patient data, and an AI algorithm optimization. For feature extraction, this study focused on an automatic process to reduce manual labor. The algorithm consisted of two steps: the first algorithm calculates flow features from geometrical features, and the second algorithm estimates the FFR value from flow features and patient biometric features. Algorithm selection, outlier elimination, and k-fold selection were included to optimize the algorithm.

CONCLUSION

Eight types of algorithms including two neural network models and six machine learning models were optimized and tested. The random forest model shows the highest performance before optimization, whereas the multilayer perceptron regressor shows the highest gray zone accuracy after optimization.

The association of dental pulp stones to cardiovascular and renal diseases: A systematic review and meta-analysis

BACKGROUND

Pulp stone (PS) is a dystrophic calcification in the tooth's pulp chamber and was suggested in the literature to be associated with other calcifications in the body. This study aimed to investigate the association of PS to cardiovascular diseases (CVD) and renal stones (RS).

METHODS

Three databases were searched until June 2021 in addition to manual searching of Google Scholar and grey literature. Original studies were only included and critically appraised using an adapted version of the Newcastle-Ottawa scale. The odds ratio (OR) effect measure was calculated using the Mantel-Haenszel statistical test (95% confidence interval [CI]) to investigate the association of PS with CVD and or RS (p-value ˂ 0.05).

RESULTS

The database search identified 4933 studies, and 19 studies were finally included. The risk of bias was low in thirteen studies, moderate in four studies, and high in two studies. The meta-analysis of the moderate-and-low risk of bias studies revealed a significant association between PS and CVD (OR 3.35, 95% CI 1.91-5.89, P < 0.001, I² = 65%), but no association was found between PS and RS. The results also revealed an association between PS and CVD in patients older than 40 (OR 8.78, 95% CI 3.64-21.17, P < 0.001, I² = 0%).

CONCLUSIONS

The current study results showed an association between PS and CVD, but no association was found between PS and RS. PS in patients younger than 40 years, compared to older patients (> 40 years), was associated with CVD.

A 14.5-Year-Old Boy with Coronary Obstruction after Kawasaki Disease: A Case Report

Kawasaki disease (KD) is a febrile vasculitis and is considered a leading cause of acquired coronary artery disease in children. A clinically critical complication is the coronary artery aneurysm, which may progress and lead to coronary stenosis or even obstruction. Herein, we describe a 14.5-year-old boy with a history of KD at 6 months old, who developed multiple aneurysms along all the coronary branches. During the follow-up at the age of 14 years, the left coronary artery aneurysms regressed, while the aneurysm of the right coronary artery persisted and was complicated by obstruction at its proximal part, according to computed tomography angiography. However, the patient at the last follow-up was asymptomatic and well. The serious nature of KD coronary complications warrants follow-up visits. Since echocardiography alone may fail to reveal stenosis or obstruction, other adjunct follow-up imaging modalities such as conventional, computed tomography, and magnetic resonance angiography should be performed in patients with coronary aneurysms.

Artificial intelligence stenosis diagnosis in coronary CTA: effect on the performance and consistency of readers with less cardiovascular experience

Background

To investigate the influence of artificial intelligence (AI) based on deep learning on the diagnostic performance and consistency of inexperienced cardiovascular radiologists.

Methods

We enrolled 196 patents who had undergone both coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) within 6 months. Four readers with less cardiovascular experience (Reader 1–Reader 4) and two cardiovascular radiologists (level II, Reader 5 and Reader 6) evaluated all images for ≥ 50% coronary artery stenosis, with ICA as the gold standard. Reader 3 and Reader 4 interpreted with AI system assistance, and the other four readers interpreted without the AI system. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (area under the receiver operating characteristic curve (AUC)) of the six readers were calculated at the patient and vessel levels. Additionally, we evaluated the interobserver consistency between Reader 1 and Reader 2, Reader 3 and Reader 4, and Reader 5 and Reader 6.

Results

The AI system had 94% and 78% sensitivity at the patient and vessel levels, respectively, which were higher than that of Reader 5 and Reader 6. AI-assisted Reader 3 and Reader 4 had higher sensitivity (range + 7.2–+ 16.6% and + 5.9–+ 16.1%, respectively) and NPVs (range + 3.7–+ 13.4% and + 2.7–+ 4.2%, respectively) than Reader 1 and Reader 2 without AI. Good interobserver consistency was found between Reader 3 and Reader 4 in interpreting ≥ 50% stenosis (Kappa value = 0.75 and 0.80 at the patient and vessel levels, respectively). Only Reader 1 and Reader 2 showed poor interobserver consistency (Kappa value = 0.25 and 0.37). Reader 5 and Reader 6 showed moderate agreement (Kappa value = 0.55 and 0.61).

Conclusions

Our study showed that using AI could effectively increase the sensitivity of inexperienced readers and significantly improve the consistency of coronary stenosis diagnosis via CCTA.

Trial registration Clinical trial registration number: ChiCTR1900021867. Name of registry: Diagnostic performance of artificial intelligence-assisted coronary computed tomography angiography for the assessment of coronary atherosclerotic stenosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00756-y.

Assessment of Lewis negative phenotype as a risk factor for multivessel disease in patients with acute coronary syndrome

INTRODUCTION

Acute coronary syndrome is a manifestation of coronary artery disease caused by decreased blood flow to the heart musculature resulting in ischaemia and infarction of the heart. The Lewis (Le) blood group system comprise mainly Lewis a & b antigens which are secreted in plasma and are expressed on red cells, platelets and endothelium. This study assesses the risk of multivessel disease in acute coronary patients with lewis negative (a- b-) phenotype.

MATERIALS AND METHODS

The study included 183 patients diagnosed with acute coronary syndrome and who underwent coronary angiography to detect stenosis of the coronary vessels. The severity of the disease was classified based upon the number of vessels stenosed and their blood sample was phenotyped for Lewis antigens. The patients' risk factors, GRACE score and management were included for the study and multivariate logistic regression was carried out for analysis.

RESULTS

The prevalence of Lewis (a- b-) was 27.4% and there was a significant association with multivessel disease (P<0.05). However, there was no association of lewis (a- b-) with any of the risk factors causing coronary disease. The adjusted odds ratio of triple vessel disease in lewis (a- b-) was 2.6, female gender was 0.6 and patients with diabetes mellitus was 3.1, respectively. The GRACE score showed a significant association with ABO blood group (P<0.05) but not with lewis (a- b-).

DISCUSSION

Lewis negative patients are more likely to develop triple vessel disease compared to other lewis blood groups. This warrants further studies to investigate the link between lewis system and atherothrombosis.

Prognostic value of comprehensive intracoronary physiology assessment early after heart transplantation

AIMS

We evaluated the long-term prognostic value of invasively assessing coronary physiology after heart transplantation in a large multicentre registry.

METHODS AND RESULTS

Comprehensive intracoronary physiology assessment measuring fractional flow reserve (FFR), the index of microcirculatory resistance (IMR), and coronary flow reserve (CFR) was performed in 254 patients at baseline (a median of 7.2 weeks) and in 240 patients at 1 year after transplantation (199 patients had both baseline and 1-year measurement). Patients were classified into those with normal physiology, reduced FFR (FFR ≤ 0.80), and microvascular dysfunction (either IMR ≥ 25 or CFR ≤ 2.0 with FFR > 0.80). The primary outcome was the composite of death or re-transplantation at 10 years. At baseline, 5.5% had reduced FFR; 36.6% had microvascular dysfunction. Baseline reduced FFR [adjusted hazard ratio (aHR) 2.33, 95% confidence interval (CI) 0.88-6.15; P = 0.088] and microvascular dysfunction (aHR 0.88, 95% CI 0.44-1.79; P = 0.73) were not predictors of death and re-transplantation at 10 years. At 1 year, 5.0% had reduced FFR; 23.8% had microvascular dysfunction. One-year reduced FFR (aHR 2.98, 95% CI 1.13-7.87; P = 0.028) and microvascular dysfunction (aHR 2.33, 95% CI 1.19-4.59; P = 0.015) were associated with significantly increased risk of death or re-transplantation at 10 years. Invasive measures of coronary physiology improved the prognostic performance of clinical variables (χ2 improvement: 7.41, P = 0.006). However, intravascular ultrasound-derived changes in maximal intimal thickness were not predictive of outcomes.

CONCLUSION

Abnormal coronary physiology 1 year after heart transplantation was common and was a significant predictor of death or re-transplantation at 10 years.

High-Sensitivity C-Reactive Protein to HDL-C Ratio

Inflammation and lipid signaling are involved in the pathogenesis and progression of coronary artery disease (CAD). We proposed that high-sensitivity C-reactive proteins, as a marker of the pro-inflammatory state, and high-density lipoprotein cholesterol (HDL-C), as an anti-atherosclerosis component, should be integrated into a single novel biomarker. Our work was conducted to discuss and compare the predictive ability of the high-sensitivity C-reactive protein to high-density lipoprotein cholesterol ratio (CHR) with other existing indices, for example, neutrophil high-density lipoprotein ratio (NHR) and neutrophil lymphocyte ratio (NLR), in the severity of CAD patients.Based on the results of coronary angiography, patients were divided into the CAD⁺ group, CAD^- group, and control group. The relationship between various serum markers and the severity of coronary artery disease was examined via Spearman's correlation analysis. Logistic regression analysis was conducted to identify the influencing factors of the coronary artery disease severity.This study included 420 patients. The Gensini score was positively correlated with CHR. Multiple regression analysis revealed that the CHR was significantly associated with CAD. CHR is an independent predictor of CAD. The receiver operating characteristic (ROC) analysis provided a cut-off value of 1.17 for CHR to predict CAD, with a specificity of 86.7%, Yoden index of 0.264, and area under the ROC curve of 0.662 (95% confidence intervals 0.606-0.719, P < 0.001). At the same time, the area under the ROC curve of the NHR was 0.652, and that of the NLR was 0.579. The results of the DeLong test indicated that the area under the ROC curve of the CHR was larger than that of the NLR (P = 0.0306). This suggests that the CHR as a predictor of CAD has better diagnostic performance than the NLR.CHR was not only closely related to the presence and severity of CAD but also an independent predictor of severe CAD.

Accuracy of ultra-high-resolution computed tomography with a 0.3-mm detector for quantitative assessment of coronary artery stenosis grading in comparison with conventional computed tomography: A phantom study

BACKGROUND

The development of ultra-high-resolution CT (U-HRCT) is expected to improve the accuracy of coronary stenosis evaluation. This study aimed to evaluate the accuracy of the stenosis severities of coronary artery phantoms estimated using U-HRCT by comparing them to those estimated with conventional CT.

METHODS

Coronary artery phantoms with non-calcified and calcified lesions were scanned with conventional CT (64-row ​× ​0.625 ​mm) and U-HRCT (32-row ​× ​0.3125 ​mm). The coronary artery phantoms had lumen diameters of 2.0, 3.0, and 4.0 ​mm with non-calcified lesions representing 0%, 25%, 50%, and 75% stenosis and 3.0 and 4.0 ​mm with calcified lesions representing 0%, 25%, 50%, and 75% stenosis. The lumen diameters at the stenotic and non-stenotic regions were measured, and the stenosis severities were compared with the true values.

RESULTS

For non-calcified lesions, conventional CT significantly underestimated the stenosis severity in the phantom showing 75% stenosis with lumen diameters of 2.0 and 3.0 ​mm (p ​< ​0.05), while the estimated stenosis severities were not significantly different from the true values at all settings with U-HRCT. For the calcified lesions, conventional CT overestimated the stenosis severities at all settings (p ​< ​0.05), while U-HRCT yielded estimations closer to the true values, although still with some overestimation (p ​< ​0.05).

CONCLUSION

By using U-HRCT, the estimated stenosis severities of the coronary artery with non-calcified lesion become almost equal to the true value, while those with calcified lesion are still overestimated although they become closer to the true value.

Relationship of serum vitamin D deficiency with coronary artery disease severity using multislice CT coronary angiography

AIM

To assess the relationship between vitamin D deficiency and severity of coronary artery disease using multislice CT coronary angiography.

METHODS

100 patients diagnosed with coronary artery disease during multislice CT coronary angiography were subjected to full evaluation of coronary artery disease severity followed by measurement of serum vitamin D level.

RESULTS

The mean value of serum vitamin D level was 13.35±7.49ng/ml. 76% of the patients had vitamin D deficiency (<20ng/ml). 41% of the patients had single vessel disease, 28% had two vessel diseases, and 31% had multi-vessel disease. Patients with vitamin D deficiency had higher degree of coronary stenosis, higher coronary Ca score (p<0.001) and higher number of affected vessels compared with normal vitamin D level subgroup (p<0.001). Vitamin D level showed a significant negative correlations with age (r=-0.290, p=0.003), coronary Ca score (r=-0.630, p<0.001) and severity of coronary lesions. Multivariate linear regression analysis showed that dyslipidemia and vitamin D level were independent predictors of percent severity of coronary stenosis.

CONCLUSION

In addition to traditional cardiovascular risk factors, vitamin D deficiency looks to be independent predictor of coronary artery disease severity including percent stenosis, number of the affected vessels as well as degree of coronary calcification.

Effect of plaque compositions on fractional flow reserve in a fluid-structure interaction analysis

Coronary artery disease involves the reduction of blood flow to the myocardium due to atherosclerotic plaques. The findings of myocardial ischemia may indicate severe coronary stenosis, but many studies have demonstrated a mismatch between lumen stenosis and fractional flow reserve (FFR). Recently, some clinical studies have found that the composition of atherosclerotic plaques may be a potential missing link between stenosis and ischemia. To investigate the relationship between myocardial ischemia and plaque composition, we have developed and adopted a new fluid-structure interaction (FSI) patient-specific coronary plaque model, based on computed tomography angiography data, to assess the impact on FFR as a biomechanical indicator of ischemia. A total of 180 analyses have been performed in 3D-FSI coronary artery disease models based on plaque compositions, plaque location, and stenosis degree. Hemodynamic analysis of simulation results and comparisons with other methods has been conducted to validate our models. Our results have successfully verified that the different compositions of plaques have resulted in differences in the calculated FFR. The mean FFR values with lipid plaques are [Formula: see text] as compared to the mean FFR values in lesions with fibrous plaques [Formula: see text] and calcified plaques [Formula: see text]. Besides, FFR differences between the three different plaque compositions have been shown to increase as the diameter stenosis increased. Plaque composition affects vascular stiffness and vascular dilation ability, and thereby affects the stenosis degree, resulting in abnormal FFR leading to myocardial ischemia. This interrelationship can help to diagnose the cause of high-risk coronary artery disease, leading to myocardial ischemia.

Assessment of the routine reporting of very low-dose exercise-first myocardial perfusion SPECT from a large-scale real-world cohort and correlation with the subsequent reporting of coronary stenosis at angiography

PURPOSE

Our study assesses the routine reporting of exercise ischemia using very low-dose exercise-first myocardial perfusion SPECT in a large number of patients and under real-life conditions, by evaluating correlations with the subsequent routine reporting of coronary stenosis by angiography and with factors that predict ischemia.

METHODS

Data from 13,126 routine exercise MPI reports, from 11,952 patients (31% women), using very low doses of sestamibi and a high-sensitivity cardiac CZT camera, were extracted to assess the reporting of significant MPI-ischemia (> 1 left ventricular segment), to determine the MPI normalcy rate in a group with < 5% pretest probability of coronary artery disease (CAD) (n = 378), and to assess the ability of MPI to predict a > 50% coronary stenosis in patients with available coronary angiography reports in the 3 months after the MPI (n = 713).

RESULTS

The median effective patient dose was 2.51 [IQR: 1.00-4.71] mSv. The normalcy rate was 98%, and the MPI-ischemia rate was independently predicted by a known CAD, the male gender, obesity, and a < 50% LV ejection fraction, ranging from 29.5% with all these risk factors represented to 1.5% when there were no risk factors. A > 50% coronary stenosis was significantly predicted by MPI-ischemia, less significantly for mild (odds ratio [95% confidence interval]: 1.61 [1.26-1.96]) than for moderate-to-severe MPI-ischemia (4.05 [3.53-4.57]) and was also impacted by having a known CAD (2.17 [1.83-2.51]), by a submaximal exercise test (1.48 [1.15-1.81]) and being ≥ 65 years of age (1.43 [1.11-1.76]).

CONCLUSION

Ischemia detected using a very low-dose exercise-first MPI protocol in a large-scale clinical cohort and under real-life routine conditions is a highly significant predictor for the subsequent reporting of coronary stenosis, although this prediction is enhanced by other variables. This weakly irradiating approach is amenable to being repeated at shorter time intervals, in target patient groups with a high probability of MPI-ischemia.

Prognostic value of CAD-RADS classification by coronary CTA in patients with suspected CAD

BACKGROUND

The study sought to compare Coronary Artery Disease Reporting and Data System (CAD-RADS) classification with traditional coronary artery disease (CAD) classifications and Duke Prognostic CAD Index for predicting the risk of all-cause mortality in patients with suspected CAD.

METHODS

9625 consecutive suspected CAD patients were assessed by coronary CTA for CAD-RADS classification, traditional CAD classifications and Duke Prognostic CAD Index. Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality. Discriminatory ability of classifications was assessed using time dependent receiver-operating characteristic (ROC) curves and The Hosmer-Lemeshow goodness-of-fit test was employed to evaluate calibration.

RESULTS

A total of 540 patients died from all causes with a median follow-up of 4.3 ± 2.1 years. Kaplan-Meier survival curves showed the cumulative events increased significantly associated with CAD-RADS, three traditional CAD classifications and Duke Prognostic CAD Index. In multivariate Cox regressions, the risk for the all-cause death increased from HR 0.861 (95% CI 0.420-1.764) for CAD-RADS 1 to HR 2.761 (95% CI 1.961-3.887) for CAD-RADS 4B&5, using CAD-RADS 0 as the reference group. The relative HRs for all-cause death increased proportionally with the grades of the three traditional CAD classifications and Duke Prognostic CAD Index. The area under the time dependent ROC curve for prediction of all-cause death was 0.7917, 0.7805, 0.7991for CAD-RADS in 1 year, 3 year, 5 year, respectively, which was non-inferior to the traditional CAD classifications and Duke Prognostic CAD Index.

CONCLUSIONS

The CAD-RADS classification provided important prognostic information for patients with suspected CAD with noninvasive evaluation, which was non-inferior than Duke Prognostic CAD Index and traditional stenosis-based grading schemes in prognostic value of all-cause mortality. Traditional and simplest CAD classification should be preferable, given the more number of groups and complexity of CAD-RADS and Duke prognostic index, without using more time consuming classification.

A 1D-3D Hybrid Model of Patient-Specific Coronary Hemodynamics

PURPOSE

Coronary flow is affected by evolving events such as atherosclerotic plaque formation, rupture, and thrombosis, resulting in myocardial ischemia and infarction. Highly resolved 3D hemodynamic data at the stenosis is essential to model shear-sensitive thrombotic events in coronary artery disease.

METHODS

We developed a hybrid 1D-3D simulation framework to compute patient-specific coronary hemodynamics efficiently. A 1D model of the coronary flow is coupled to an image-based 3D model of the region of interest. This framework affords the advantages of reduced-order modeling, decreasing the global computational cost, without sacrificing the accuracy of the quantities of interest.

RESULTS

We validated our 1D-3D model against full 3D coronary simulations in healthy and diseased conditions. Our results showed good agreement between the 3D and the 1D-3D models while reducing the computational cost by 40-fold compared to the 3D simulation. The 1D-3D model predicted left/right coronary flow distribution within 3% and provided an accurate estimation of fractional flow reserve and wall shear stress distribution at the stenosis comparable to the 3D simulation.

CONCLUSION

Savings in computational cost may be significant in situations with changing geometry, such as growing thrombosis. Also, this approach would allow quantifying the time-dependent effect of thrombotic growth and occlusion on the global coronary circulation.

Do plaque-related factors affect the diagnostic performance of an artificial intelligence coronary-assisted diagnosis system? Comparison with invasive coronary angiography

OBJECTIVE

The aim of this study was to investigate the effects of plaque-related factors on the diagnostic performance of an artificial intelligence coronary-assisted diagnosis system (AI-CADS).

METHODS

Patients who underwent coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) were retrospectively included in this study. The degree of stenosis in each vessel was collected from CCTA and ICA, and the information on plaque-related factors (plaque length, plaque type, and coronary artery calcium score (CAC)) of the vessels with plaques was collected from CCTA.

RESULTS

In total, 1224 vessels in 306 patients (166 men; 65.7 ± 10.1 years) were analyzed. Of these, 391 vessels in 249 patients showed significant stenosis using ICA as the gold standard. Using per-vessel as the unit, the area under the curves of coronary stenosis ≥ 50% for AI-CADS, doctor, and AI-CADS + doctor was 0.764, 0.837, and 0.853, respectively. The accuracies in interpreting the degree of coronary stenosis were 56.0%, 68.1%, and 71.2%, respectively. Seven hundred fifty vessels showed plaques on CCTA; plaque type did not affect the interpretation results by AI-CADS (chi-square test: p = 0.0093; multiple logistic regression: p = 0.4937). However, the interpretation results for plaque length (chi-square test: p < 0.0001; multiple logistic regression: p = 0.0061) and CACs (chi-square test: p < 0.0001; multiple logistic regression: p = 0.0001) were significantly different.

CONCLUSION

AI-CADS has an ability to distinguish ≥ 50% coronary stenosis, but additional manual interpretation based on AI-CADS is necessary. The plaque length and CACs will affect the diagnostic performance of AI-CADS.

KEY POINTS

• AI-CADS can help radiologists quickly assess CCTA and improve diagnostic confidence. • Additional manual interpretation on the basis of AI-CADS is necessary. • The plaque length and CACs will affect the diagnostic performance of AI-CADS.

CT-derived fractional flow reserve (FFRct) for functional coronary artery evaluation in the follow-up of patients after heart transplantation

OBJECTIVES

Invasively measured fractional flow reserve (FFR) is associated with outcome in heart transplant (HTx) patients. Coronary computed tomography angiography (CCTA)-derived FFR (FFRct) provides additional functional information from anatomical CT images. We describe the first use of FFRct in HTx patients.

METHODS

HTx patients underwent CCTA with FFRct to screen for cardiac allograft vasculopathy. FFRct was measured distal to each coronary stenosis > 30% and FFRct ≤ 0.8 indicated hemodynamically significant stenosis. FFRct was also measured at the most distal location of each vessel. Overall distal FFRct was calculated as the mean of the distal values in the left, right, and circumflex coronary artery in each patient.

RESULTS

Seventy-three patients (age 56 (42-65) years, 63% males) at 11 (8-16) years after HTx were included. Eighteen (25%) patients had a focal hemodynamically significant stenosis (stenosis > 30% with FFRct ≤ 0.8). In the 55 patients without a hemodynamically significant focal FFRct stenosis (FFRct > 0.80), the distal left anterior descending artery FFRct was < 0.90 in 74% of the patients and 10 (18%) patients had ≥ 1 coronary artery with a distal FFRct ≤ 0.8, including 1 with a distal FFRct ≤ 0.8 in all coronaries. Overall distal FFRct in patients without focal stenosis was 0.88 (0.86-0.91), 0.87 (0.86-0.90), and 0.88 (0.86-0.91) (median with 25th-75th percentile) at 5-9, 10-14, or ≥ 15 years post-transplantation, respectively (p = 0.93).

CONCLUSIONS

FFRct performed on CCTA scans of HTx patients demonstrated that 25% of patients had a focal coronary stenosis with FFRct ≤ 0.8. Even without a focal stenosis, FFRct values are often abnormal in HTx patients.

KEY POINTS

• This is the first report describing the use of FFRct in in heart transplant patients. • FFRct identifies patients after heart transplantation with hemodynamically significant coronary stenosis. • Even without a focal stenosis, FFRct values are often abnormal in heart transplant patients.

Prognostic value of myocardial perfusion imaging after first-line coronary computed tomography angiography: A multi-center cohort study

PURPOSE

Further diagnostic testing may be required after a coronary computed tomography angiography (CTA) showing suspected coronary stenosis. Whether myocardial perfusion imaging (MPI) provides further prognostic information post-CTA remains debated. We evaluated the prognosis for patients completing CTA stratified for post-CTA diagnostic work-up using real-world data.

METHODS

We identified all patients in our uptake area with angina symptoms undergoing first-time CTA over a 10-year period. Follow-up time was a median of 3.7 years [1.9-5.8]. The primary endpoint was a composite of myocardial infarction or death. The secondary endpoint was late revascularization.

RESULTS

During the study period 53,351 patients underwent CTA. Of these, 24% were referred for further down-stream testing, 3,547 (7%) to MPI and 9,135 (17%) to invasive coronary angiography (ICA). The primary and secondary endpoints occurred in 2,026 (3.8%) and 954 (1.8%) patients. Patient-characteristic-adjusted hazard ratios for the primary and secondary endpoint using patients with a normal CTA as reference were 1.37 (1.21-1.55) and 2.50 (1.93-3.23) for patient treated medically, 1.68 (1.39-2.03) and 6.13 (4.58-8.21) for patients referred to MPI and 1.94 (1.69-2.23) and 9.18 (7.16-11.78) for patients referred for ICA, respectively. Adjusted analysis with stratification for disease severity at CTA showed similar hazard ratios for patients treated medically after CTA and patients referred for MPI and treated medically after the MPI.

CONCLUSION

In patients completing coronary CTA, second-line MPI testing seems to identify patients at low risk of future events. MPI seems to have the potential to act as gatekeeper for ICA after coronary CTA.

Estimation of coronary stenosis severity based on flow distribution ratios

We suggest improving minimally-invasive stenosis severity estimation, using a combination of existing geometry-based methods with Transluminal Attenuation Gradient measurements. Instead of local flow values, the method uses flow distribution ratios along the entire tree. The tree geometry is used to derive a lumped model and predict the 'theoretical' ratios in each bifurcation, while attenuation measurements are used for extracting 'actual' ratios. The discrepancies between the measured and the theoretical values are utilized to assess a functional degree of stenosis. Our experimental and numerical analyses show that the quantitative value of discrepancy is proportional to stenosis severity, regardless of boundary conditions.

Incremental improvement of diagnostic performance of coronary CT angiography for the assessment of coronary stenosis in the presence of calcium using a dual-layer spectral detector CT: validation by invasive coronary angiography

To investigate value of spectral reconstructions for the quantification of coronary stenosis in the presence of calcified or partially calcified plaques using a dual-layer spectral detector CT (SDCT). Seventy-two consecutive patients were retrospectively enrolled. Conventional 120 kVp images, eight virtual monoenergetic images (VMI) (70 to 140 keV), the effective atomic number (Z effective) and iodine no water images were reconstructed. Invasive coronary angiography was used as the reference standard. Parallel and serial testing were used to assess the incremental diagnostic value of Z effective and iodine no water images to the best VMI series. 122 coronary lesions of 72 patients (49 men and 23 women; 63.7 ± 10.2 years) were enrolled in analysis. Reconstruction at 100 keV yielded optimal diagnostic performance, the sensitivity, specificity, PPV, NPV and diagnostic accuracy to identify stenosis ≥ 50% or ≥ 70% were 84%, 70%, 80%, 76%, 79% and 78%, 98%, 93%, 91%, 92%, respectively. A serial combination (100 keV VMI followed by Z effective images) resulted in an improved specificity (from 70 to 80%) with a moderate loss of sensitivity (81% from 84%) in identifying ≥ 50% stenosis (P = 0.021). For patients with high Agatston score, this combination could further reduce false positive cases and improve diagnostic accuracy. 100 keV VMI provide optimal diagnostic performance for the detection of coronary stenosis in the presence of calcified or partially calcified plaques using a dual-layer SDCT, with further improvements obtained with the combined use of Z effective images.

Diagnostic performance of corrected FFRCT metrics to predict hemodynamically significant coronary artery stenosis

OBJECTIVES

To determine the diagnostic performance of the fractional flow reserve (FFR) derived from coronary computed tomography angiography (CCTA) (FFR_CT) difference across the lesion (ΔFFR_{CT lesion}) or the vessel (ΔFFR_{CT vessel}) and the gradient of FFR_CT for the identification of hemodynamically significant coronary stenosis.

METHODS

From June 2016 to December 2018, 73 patients suspected of having coronary artery disease who underwent CCTA followed invasive coronary angiography (ICA) within 1 month were retrospectively included. ΔFFR_{CT lesion}, ΔFFR_{CT vessel}, and FFR_CT gradient were calculated. Performance characteristics of different corrected FFR_CT metrics in detecting ischemic stenosis were analyzed. Impacts of coronary calcification and lesion length on the corrected FFR_CT metrics were also analyzed.

RESULTS

The diagnostic sensitivities, specificities, and accuracies of 94.4%, 88.7%, and 91.0% with ΔFFR_{CT lesion}, 57.1%, 72.3%, and 65.2% with ΔFFR_{CT vessel}, and 50.0%, 85.1%, and 68.5% with FFR_CT gradient, respectively, were detected. There was higher specificity, accuracy, and area under the curve (AUC) for ΔFFR_{CT lesion} compared with CCTA (p < 0.05 for all). The specificity and AUC of FFR_CT gradient and ΔFFR_{CT vessel} were significantly higher than CCTA (p < 0.05 for all). Coronary calcification showed no impact on corrected FFR_CT metrics. ΔFFR_{CT lesion} for lesion length ratio (LLR) < 1/10 was significantly lower than that for LLR 1/10 to 3/10 and LLR > 3/10.

CONCLUSIONS

ΔFFR_{CT lesion} was significantly correlated with the hemodynamically significant coronary artery stenosis. ΔFFR_{CT lesion} had the potential to be immediately used in real-world practice to discriminate ischemic coronary artery stenosis.

KEY POINTS

• The difference of FFR_CT across the lesion or the vessel and the gradient of FFR_CT was related to the hemodynamically significant coronary artery stenosis. • The difference of FFR_CT across the lesion showed the best diagnostic performance in detecting the hemodynamically significant coronary artery stenosis. • Coronary calcification showed no impact on corrected FFR_CT metrics, while lesion length related to the difference of FFR_CT across the lesion.

Validation of the European Society of Cardiology pre-test probability model for obstructive coronary artery disease

AIMS

Estimation of pre-test probability (PTP) of disease in patients with suspected coronary artery disease (CAD) is a common challenge. Due to decreasing prevalence of obstructive CAD in patients referred for diagnostic testing, the European Society of Cardiology suggested a new PTP (2019-ESC-PTP) model. The aim of this study was to validate that model.

METHODS AND RESULTS

Symptomatic patients referred for coronary computed tomography angiography (CTA) due to suspected CAD in a geographical uptake area of 3.3 million inhabitants were included. The reference standard was a combined endpoint of CTA and invasive coronary angiography (ICA) with obstructive CAD defined at ICA as a ≥50% diameter stenosis or fractional flow reserve ≤0.80 when performed. The 2019-ESC-PTP, 2013-ESC-PTP, and CAD Consortium basic PTP scores were calculated based on age, sex, and symptoms. Of the 42 328 identified patients, coronary stenosis was detected in 8.8% using the combined endpoint. The 2019-ESC-PTP and CAD Consortium basic scores classified substantially more patients into the low PTP groups (PTP < 15%) than did the 2013-ESC-PTP (64% and 65% vs. 16%, P < 0.001). Using the combined endpoint as reference, calibration of the 2019-ESC-PTP model was superior to the 2013-ESC-PTP and CAD Consortium basic score.

CONCLUSION

The new 2019-ESC-PTP model is well calibrated and superior to the previously recommended models in predicting obstructive stenosis detected by a combined endpoint of CTA and ICA.

Expanding the coronary tree reconstruction to smaller arteries improves the accuracy of FFRCT

OBJECTIVES

We attempted to improve the accuracy of coronary CT angiography (CCTA)-derived fractional flow reserve (FFR) (FFR_CT) by expanding the coronary tree in the computational fluid dynamics (CFD) domain. An observational study was performed to evaluate the effects of extending the coronary tree analysis for FFR_CT from a minimal diameter of 1.2 to 0.8 mm.

METHODS

Patients who underwent CCTA and interventional FFR were enrolled retrospectively. Seventy-six patients qualified based on the inclusion criteria. The three-dimensional (3D) coronary artery tree was reconstructed to generate a finite element mesh for each subject with different lower limits of luminal diameter (1.2 mm and 0.8 mm). Outlet boundary conditions were defined according to Murray's law. The Newton-Krylov-Schwarz (NKS) method was applied to solve the governing equations of CFD to derive FFR_CT.

RESULTS

At the individual patient level, extending the minimal diameter of the coronary tree from 1.2 to 0.8 mm improved the sensitivity of FFR_CT by 16.7% (p = 0.022). This led to the conversion of four false-negative cases into true-positive cases. The AUC value of the ROC curve increased from 0.74 to 0.83. Moreover, the NKS method can solve the computational problem of extending the coronary tree to an 0.8-mm luminal diameter in 10.5 min with 2160 processor cores.

CONCLUSIONS

Extending the reconstructed coronary tree to a smaller luminal diameter can considerably improve the sensitivity of FFR_CT. The NKS method can achieve favorable computational times for future clinical applications.

KEY POINTS

• Extending the reconstructed coronary tree to a smaller luminal diameter can considerably improve the sensitivity of FFR_CT. • The NKS method applied in our study can effectively reduce the computational time of this process for future clinical applications.

The change in high-sensitivity troponin-T as a risk factor for significant coronary stenosis in patients with acute coronary syndrome

BACKGROUND/AIMS

High-sensitivity cardiac troponin (hs-TnT) assays detect very low levels of cardiac troponin. This study examined the interval change between initial and subsequent hs-TnT levels and evaluated its ability to predict significant coronary stenosis.

METHODS

The study analyzed 163 patients who presented with acute coronary syndrome (ACS) and underwent coronary angiography (CAG) between April 2014 and May 2018. The 0 and 3-hour hs-TnT were checked. The patients were subdivided into positive (n = 32) and negative (n = 131) interval change groups. The presence of significant coronary artery stenosis on CAG in the two groups was compared.

RESULTS

The positive interval change group was older and had higher 0 and 3-hour hs-TnT and blood glucose levels than the negative interval change group. Significant coronary stenosis was more common in the positive interval change group than in the negative interval change group (68.8% vs. 23.7%, p = 0.001). However, vasospasm was more common in the negative interval change group (6.3% vs. 31.3%, p = 0.003). The positive interval change group had higher rates of bifurcation lesions and received more percutaneous coronary intervention. In multivariate analysis, age, interval change of serial hs-TnT and diabetes mellitus were independent predictors of significant coronary artery stenosis.

CONCLUSION

This study identified a relationship between the serial change in cardiac biomarkers and the presence of significant coronary stenosis in patients with ACS. Serial hs-TnT change was associated with real angiographic stenosis in patients with ACS.

Relationship of epicardial fat volume with coronary plaque characteristics, coronary artery calcification score, coronary stenosis, and CT-FFR for lesion-specific ischemia in patients with known or suspected coronary artery disease

BACKGROUND

We explored the association of epicardial fat volume (EFV) with coronary plaque characteristics, coronary artery calcification (CAC) score, coronary stenosis, lesion-specific ischemia in patients with known or suspected coronary artery disease (CAD).

METHODS

88 controls and 221 patients were analyzed in the study. High-risk plaque was defined as existing≥2 features, including positive remodeling, low attenuation, napkin-ring sign and spotty calcification. EFV, CAC score was measured. The severity of coronary stenosis was quantified using Gensini score. CT-FFR was performed in three major coronary arteries, with a threshold of ≤0.8 considered the presence of ischemia. Univariate and multivariate regression was used to evaluate the association of EFV with CAD, palque characteristics, CAC score, Gensini score, and lesion-specific ischemia derived from CT-FFR.

RESULTS

Median EFV was 104.97 cm³ (85.47-136.09) in controls and 129.28cm³ (101.19-159.44) in patients (P < 0.001). Logistic regression analysis revealed a significant association of EFV with CAD even after adjusting for confounding factors (P < 0.05). At linear regression analysis, EFV was significantly correlated with high-risk plaque and lesion-specific ischemia, but not with non-calcified plaque, mixed plaque, calcified plaque, CAC score and Gensini score (P ≥ 0.05).

CONCLUSION

We found that EFV was associated with CAD, suggesting that it may be a promising marker of CAD. EFV was also correlated with high-risk plaque and lesion-specific ischemia, indicating that EAT was likely to be involved in myocardial ischemia and had the potential to definite patients' risk profile.

Advanced heart sound analysis as a new prognostic marker in stable coronary artery disease

Aims

Recent technological advances enable diagnosing of obstructive coronary artery disease (CAD) from heart sound analysis with a high negative predictive value. However, the prognostic impact of this approach remains unknown. To investigate the prognostic value of heart sound analysis as two scores, the Acoustic-score and the CAD-score, in patients with suspected CAD which is treated according to standard of care.

Methods and results

Consecutive patients with angina symptoms referred for coronary computed tomography angiography (CTA) were enrolled. The Acoustic-score was developed from eight acoustic CAD-related features. This score was combined with risk factors to generate the CAD-score. A cut-off score >20 was pre-specified for both scores to indicate disease. If coronary CTA raised suspicion of obstructive CAD, patients were referred to invasive angiography and revascularized when indicated. Of 1675 enrolled patients, 1464 (87.4%) were included in this substudy. The combined primary endpoint was all-cause mortality and myocardial infarction (n = 26). Follow-up was 3.1 (2.7-3.4) years. Of patients with primary endpoints, the Acoustic-score was >20 in 25 (96%); the CAD-score was >20 in 22 (85%). In an unadjusted Cox analysis of the primary endpoints, the hazard ratio for scores >20 under current standard clinical care was 12.6 (1.7-93.2) for the Acoustic-score and 5.4 (1.9-15.7) for the CAD-score. The CAD-score contained prognostic information even after adjusting for lipid-lowering therapy initiation, stenosis at CTA, and early revascularization.

Conclusion

Heart sound analysis seems to carry prognostic information and may improve initial risk stratification of patients with suspected CAD.

Clinicaltrialsorg ID

NCT02264717.

Relationship between neutrophils to HDL-C ratio and severity of coronary stenosis

Background

Lipid and inflammatory molecules play a key role in the development of inflammation. Neutrophil counts are used as markers of inflammation duration, and HDL-C is used as an anti-atherosclerosis component. However, few studies have been found to integrate these two indicators to explore coronary stenosis. We suggested that neutrophil count as a marker of inflammation persistence and HDL-C as an anti-atherosclerotic component should be integrated into a single biomarker NHR to explore its correlation with CAD degree and predict the severity of coronary stenosis among CAD patients.

Methods

We examined 404 eligible patients who underwent coronary angiography. Based on the results of coronary angiography, patients in CAD⁺ group (n = 155) were defined as those having angiographic coronary stenosis of at least 50% lumen reduction in at least one major coronary artery (including left anterior descending artery, left circumflex artery, left main coronary artery, right coronary artery). Patients with luminal stenosis but no more than 50% were defined as CAD⁻ group (n = 49), and patients without luminal stenosis (n = 200) were regarded as control group. The relationship between various serum markers and the severity of coronary stenosis was examined by Spearman correlation analysis. Logistic regression analysis was performed to identify the influencing factors of the severity of coronary artery disease.

Results

The modified Gensini score was positively correlated with neutrophil HDL-C ratio and negatively correlated with albumin and HDL-C. Multiple regression analysis showed that neutrophil HDL-C ratio were significantly associated with CAD. Neutrophil HDL-C ratio is an independent predictor of CAD. The ROC analysis provided a cut-off value of 1.51 for neutrophil HDL-C ratio to predict CAD with 94.8% sensitivity and 0.024 Yoden index, and area under the ROC curve of 0.617 (95% CI 0.560–0.675, P < 0.001).

Conclusion

Neutrophil HDL-C ratio is not only closely related to coronary artery stenosis, but also an independent predictor of severe coronary stenosis.

Reliability of coronary computed tomography angiography in acute coronary syndrome in an emergency setting

Background

Cardiovascular computed tomography (cardiovascular CT) is currently used as a fast non-invasive method for the visualization of coronary plaques and walls and the assessment of lumen stenosis severity. Previous studies demonstrated the high negative predictive value of CT for the exclusion of coronary lumen stenoses. In this study we hypothesize that coronary CT angiography (CTA) represents a reliable method as diagnostic procedure in acute coronary syndrome (ACS) even in emergency settings.

Methods

36 patients (51 lesions) with ACS who underwent cardiovascular CT, intravascular ultrasound (IVUS) and invasive coronary angiography (ICA) within 48 h were included. The percentage of coronary stenoses were measured and compared by three methods. Influence of available predictors that can potentially affect the measurement results was assessed.

Results

Cardiac CTA provided comparable results to IVUS (mean difference -0.45%, PPV: 98%, NPV: 75%). ICA tends to estimate lower stenoses degrees than cardiac CTA and IVUS (mean difference 13.19% and 13.64%, respectively). The final diagnosis and positive remodeling did not lead to any significant influence on measurements.

Conclusions

The cardiovascular CT results show that even in emergency settings it is possible to identify morphological changes as sequels of coronary artery sclerosis with comparable results to the reference method IVUS. Deviations of IVUS and cardiovascular CT from ICA are comparable and can to a large extent be explained by differences in the measurement technique.

Morphological Characteristics of Eroded Plaques with Noncritical Coronary Stenosis: An Optical Coherence Tomography Study

Aims: Recent studies suggested plaque erosion with noncritical stenosis could be treated distinctly from that with critical stenosis, but their morphological features remained largely unknown. The present study aimed to investigate morphological features of eroded plaques with different lumen stenosis using optical coherence tomography (OCT).

Methods: A total of 348 ST-segment elevated myocardial infarction patients with culprit OCT-defined plaque erosion (OCT-erosion) were analyzed. Based on the severity of lumen area stenosis, all patients with OCT-erosions were divided into the following three groups: Group A (area stenosis ＜50%, n =50); Group B (50% ≤ area stenosis ＜75%, n =146); Group C (area stenosis ≥ 75%, n =152).

Results: Compared with patients in Groups A and B, patients in Group C were older ( p =0.008) and had higher prevalence of hypertension ( p =0.029). Angiographic analysis showed that 72.0% of the eroded plaques in Group A were located in the left anterior descending artery, followed by 67.8% in Group B, and 53.9% in Group C ( p =0.039). OCT analysis showed that Group A had the highest prevalence of fibrous plaques ( p ＜0.001) and nearby bifurcation ( p =0.036), but the lowest prevalence of lipid-rich plaques ( p ＜0.001), macrophage accumulation ( p ＜0.001), microvessels ( p =0.009), cholesterol crystals ( p ＜0.001), and calcification ( p =0.023). Multivariable regression analysis showed fibrous plaque (odds ratio [OR]: 3.014, 95% confidence interval [CI]: 1.932–4.702, p ＜0.001) and nearby bifurcation (OR: 1.750, 95% CI: 1.109–2.761, p =0.016) were independently associated with OCT-erosion with an area stenosis of ＜75%.

Conclusions: More than half of OCT-erosions presented with ＜75% area stenosis, having distinct morphological features from those of OCT-erosions with critical stenosis. Fibrous plaque and nearby bifurcation were independently associated with noncritically stenotic OCT-erosion, suggesting that eroded plaques might need individualized treatment.

The predictive value of HEART score for acute coronary syndrome and significant coronary artery stenosis

Objective

Rapid determination of acute coronary syndrome (ACS) in the emergency department (ED) is very important for patients presenting with ischemic symptoms. The aim of this study was to determine the predictive value of HEART score for ACS and significant coronary artery stenosis (SCS).

Methods

We retrospectively analyzed data of patients who visited the ED with chest discomfort and were admitted to the cardiology department. Enrolled patients were classified into ACS and non-ACS groups according to their discharge diagnosis. Patients who underwent imaging were further divided into SCS and non-SCS groups according to study results. We compared age, sex, vital signs, risk factors, electrocardiogram, troponin, and HEART score for each group. For ACS and SCS predictive performance, the test characteristics of HEART score was calculated using sensitivity, specificity, predictive value, likelihood ratio, and receiver operating characteristic (ROC) curve analysis.

Results

Of 207 patients, 112 had ACS. Among enrolled patients, 155 underwent imaging workup, of whom 67 had SCS. HEART score ≤3 had 93% sensitivity for ACS and 97% for SCS. HEART score ≥7 had 82% specificity for ACS and 83% for SCS. HEART score area under ROC curve for ACS was 0.706 (95% confidence interval, 0.627–0.776) and 0.737 (95% confidence interval, 0.660–0.804) for SCS.

Conclusion

HEART score was a fair predictor of ACS and SCS in ED patients who presented with chest symptoms and were admitted to the cardiology department. The predictive power of HEART score was better for SCS than for ACS.

Prognostic Value of Coronary CT Angiography for Predicting Poor Cardiac Outcome in Stroke Patients without Known Cardiac Disease or Chest Pain: The Assessment of Coronary Artery Disease in Stroke Patients Study

Objective

To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison to a clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemic stroke patients without chest pain.

Materials and Methods

This retrospective study included 1418 patients with acute stroke who had no previous cardiac disease and underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) were assessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed: low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognostic value of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS.

Results

The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%, respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS, and stenosis degree were positively associated with MACE (all p < 0.05). Patients with high-risk plaque type showed the highest incidence of MACE, followed by non-calcified, mixed, and calcified plaque, respectively (log-rank p < 0.001). Among the prediction models for MACE, adding stenosis degree to FRS showed better discrimination and risk reclassification compared to FRS or the FRS + CACS model (all p < 0.05). Furthermore, incorporating plaque type in the prediction model significantly improved reclassification (integrated discrimination improvement, 0.08; p = 0.023) and showed the highest discrimination index (C-statistics, 0.85). However, the addition of CACS on CCTA with FRS did not add to the prediction ability for MACE (p > 0.05).

Conclusion

Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS and FRS to risk stratify stroke patients without prior history of CAD better.

Left atrial appendage aneurysm: A case report

BACKGROUND

An aneurysm of the left atrial appendage is one of the rare but potentially hazardous heart defects. The risk of lethal complications grows with its size. To date, about 150 cases of this defect have been described in the literature. We present a case of left atrial appendage aneurysm with the deformation of the mitral valve and the left main coronary and circumflex artery, which required mitral valve annuloplasty and bifurcation stenting.

CASE SUMMARY

A 58-year-old man presented to our hospital complaining of shortness of breath, general weakness, dizziness during physical exertion, and fatigue. Based on the results of echocardiography, an aneurysm of the left atrium was suspected. A free-breathing real-time cine magnetic resonance imaging with electrocardiograph synchronization confirmed the diagnosis of left atrial appendage aneurysm. The patient underwent an aneurysmectomy via a median sternotomy with cardiopulmonary bypass. Intraoperative transesophageal echocardiography revealed relative mitral insufficiency that was corrected with an annuloplasty ring. Intraoperative coronary angiogram showed impaired blood flow in the left main coronary and circumflex artery and 60% stenosis. For this reason, bifurcation stenting was performed. The patient had an uneventful postoperative clinical course and was discharged from the hospital on the 10th day in a satisfactory condition.

CONCLUSION

Left atrial appendage aneurysm is a rare and dangerous heart pathology that requires surgery to prevent related complications.

Machine Learning-based Algorithm Enables the Exclusion of Obstructive Coronary Artery Disease in the Patients Who Underwent Coronary Artery Calcium Scoring

RATIONALE AND OBJECTIVES

An application of artificial intelligence to screen for obstructive coronary artery disease (CAD) after coronary artery calcium scoring (CACS) test.

MATERIALS AND METHODS

As an initial step we analyzed a group of 435 patients (23% male, mean age 61 ± 10) with low to moderate probability of CAD, who underwent clinically indicated CACS and coronary computed tomography angiography. Based on those data we elaborated a gradient boosting machine (GBM) model for prediction of obstructive CAD. Later the model was evaluated on a control group of 126 consecutive patients (31% male, mean age 59 ± 10).

RESULTS

Stratified 10-fold cross-validation performed on the group of 435 patients demonstrated the GBM model's sensitivity at 100 ± 0% and specificity at 69.8 ± 3.6%, while the outcomes (confusion matrix) of a clinical application on the group of 126 patients were: 73 true negative, 0 false negative, 20 true positive, and 33 false positive.

CONCLUSION

The GBM algorithm showcased a considerably high discriminatory power for excluding the presence of obstructive CAD, with negative predictive value and positive predictive value of 100% and 38%, respectively.

Comparison of Stent Expansion Using a Volumetric Versus the Conventional Method Through Optical Coherence Tomography in an All-Comers Population

INTRODUCTION

A volumetric approach to measure stent expansion derived from optical coherence tomography (OCT) is superior in regards to clinical outcomes when compared to the conventional method. The current software already performs a semi-automatic assessment and it is available as a clinical tool, however data is still scarce. We evaluated the stent expansion analysis that uses a volumetric vessel model, called minimum expansion index - MEI and compared to the conventional model, which utilizes the minimum stent area expansion (MSAx) indexed to the references, and its potential impact on procedural decision-making strategy in percutaneous coronary intervention.

METHODS

This was a prospective, all-comers single center study, from all patients undergoing OCT-guided PCI between September 2018 and May 2019. We utilized the APTIVUE™ OPTIS 5.2 software (Abbott, Santa Clara, CA) to evaluate MEI and MSAx measurements after reference adjustments.

RESULTS

We included 100 patients with mean age of 64 ± 12.5 years, 68% were men, and the main arteries analyzed through OCT were LAD (48%), RCA (31%) and LCx (21%). The mean MEI was 77.6% ± 16.7% and the mean MSAx was 71.6% ± 16.9%. MEI location differed from MSAx in 70% of cases, and in those cases the mean distance between MEI and MSAx was 15.3 mm ± 12.4 mm. In 53% of the times, the stent underexpansion based on MEI was located proximally to the MSAx by 18.1 mm ± 11.8 mm. Furthermore, in 42% of the total cases, MEI would change the intervention strategy based on the stent underexpansion being in a different location ≥10 mm in comparison to MSAx (34%) associated with the discrepancy between expansion indexes for MEI and MSAx (22%).

CONCLUSION

We concluded that MEI location did not correlate to the conventional MSAx in two thirds of the cases. Moreover, compared to MEI, the MSAx assessment yielded lower expansion values in different stent positions, potentially changing the appropriate post-stent optimization, which thus would impact the decision-making strategy in almost half of the patients.

A HYbrid APproach Evaluating a DRug-Coated Balloon in Combination With a New-Generation Drug-Eluting Stent in the Treatment of De Novo Diffuse Coronary Artery Disease: The HYPER Pilot Study

OBJECTIVES

To assess feasibility, safety and efficacy of hybrid approach, consisting in a combination of modern drug-eluting stent (DES) and drug-eluting balloon (DCB), for treatment of de-novo diffuse coronary artery disease (CAD).

BACKGROUNDS

Contemporary DES are associated with a persistent risk of major cardiovascular events, due to in-stent thrombosis and restenosis. The hybrid approach, reducing the permanent metallic cage length, is supposed to mitigate the risk of device-related adverse events, especially in diffuse CAD.

METHODS

This is a prospective, non-randomized, observational, multicenter study intended to obtain data from 100 consecutive patients affected by de-novo diffuse CAD undergoing percutaneous coronary intervention with a hybrid approach, consisting in the combined use of DES and DCB in contiguous coronary segments. The study is recorded in ClinicalTrials.gov with the identifier: NCT03939468.

RESULTS

The primary endpoint is a device oriented composite end-point (DOCE) of cardiac death, target vessel myocardial infarction (TV-MI) and ischemia-driven target lesion revascularization (ID-TLR) in DES- and/or DCB-treated segment. DOCE will be assessed at 12-months follow-up.

CONCLUSIONS

This will be the first study investigating the feasibility, safety and efficacy of hybrid DES/DCB approach for the treatment of de-novo diffuse CAD. Here we describe the rationale and the design of the study.