The Value of Epicardial Adipose Tissue for Patients Treated with Percutaneous Coronary Intervention: A Systemic Review and Meta-analysis

BACKGROUND

Recently, some clinical researches have shown epicardial adipose tissue to play a pivotal role in prognosis for patients treated with percutaneous coronary intervention (PCI), but the results are still controversial. A systematic review and meta-analysis was conducted to investigate the value of epicardial adipose tissue for the prognosis of patients treated with PCI.

METHOD

A systematic search was performed using PubMed, Web of Science, and the Cochrane Library for studies evaluating the association of EAT and patients treated with PCI published up to January 2023. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the studies. Meta-analysis was performed using Review Manager V.5.3.

RESULT

Thirteen studies enrolling 3683 patients were eventually included in our study. The thickness or volume of EAT measured were significantly higher in the ISR group compared to those in the non-ISR group (the standard mean difference of 0.34, 95% CI, 0.18-0.49, p<0.0001; I2=36%). The incidence of no-reflow was significantly higher in the thicker EAT group compared to the thin EAT group (pooled relative ratio 1.52, 95% CI 1.29-1,80, p<0.0001; I2 =0%). Thicker EAT was significantly associated with MACEs (pooled relative ratio 1.50, 95% 1.18-1.90, p=0.008). A lower EAT volume was associated with larger infarct size in STEMI patients treated with primary PCI (standard mean difference -5.45, 95% CI -8.10, -2.80; p<0.0001; I2=0%).

CONCLUSION

In summary, our systemic review and meta-analysis suggests that high EAT is related to a significantly increased risk of non-reflow, MACEs, and decreased infarct size in patients with CAD treated with PCI. This paradox phenomenon demonstrates that the quality of EAT may play a more important role than the sole thickness or volume of EAT.

Antithrombotic Treatment in Coronary Artery Disease

Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.

Management of patients with cardiovascular diseases during Ramadan

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Water pipe tobacco smoking and risk of Coronary Artery Disease: A systematic review and meta-analyses

BACKGROUND

Water pipe smoking has become a vitally important public health issue in the world with untruthful assumed less harmful effect.

OBJECTIVE

The aim of this study was to systematically review the association of water pipe tobacco smoking and risk of coronary artery disease (CAD).

METHODS

Up to September 25, 2018, we electronically searched the PubMed, Embase, and ISI Web of Science with no time restriction. We included observational studies and excluded conference abstracts, editorials, case-reports, case series, and reviews. With fixed model effect, we conducted Meta-analysis to evaluate the association between Water pipe smoking and coronary artery disease. Heterogeneity among studies was assessed by I2 square test. Publication bias was assessed by Egger test. P<0.05 set as significant level.

RESULTS

Among 248 paper records identified through database search, 52 full texts were eligible for full text assessment whereas 49 papers were excluded. Additionally, three studies were eligible for meta-analysis, which involved 58,960 adults with 1334 in the water pipe smoker group. Risk of CAD was increased in water pipe smokers compared to individuals who had never smoked water pipe but the result did not reach statistical significance (OR=1.18, 95% CI: 0.98- 1.38, p=0.06). We found that heavy water pipe smoking (40 to 50 sessions of water-pipe smoking/year) was associated with CAD compared to lower smokers defined as less than 40 to 50 water pipe/year (OR=2.001, 95% CI: 1.13-2.87).

CONCLUSIONS

Heavy Water pipe smoking was associated to coronary artery disease on a clinical level. It seems very crucial to increase public awareness on adverse effects of water pipe smoking and its cessation in clinical setting.

[Functional assessment of coronary stenosis by fractional flow reserve]

Revascularization of coronary artery stenosis should be based on the objective evidence of ischemia. Coronary angiography provides excellent spatial and temporal resolution for the visualization of the coronary arteries, but is of limited value in defining the functional significance of a particular lesion.Fractional flow reserve (FFR) has become routine practice in the cardiac catheterization laboratory and is considered nowadays as the gold standard for invasive assessment of physiologic stenosis significance. This paper reviews the concepts behind the coronary physiology and FFR, its practical application and summarizes current evidence from key clinical trials.

Stress testing and non-invasive coronary angiography in patients with suspected coronary artery disease: time for a new paradigm

Diagnosis and management of coronary artery disease represents major challenges to our health care system, affecting millions of patients each year. Until recently, the diagnosis of coronary artery disease was possible only through cardiac catheterization and invasive coronary angiography. To avoid the risks of an invasive procedure, stress testing is often employed for an initial assessment of patients with suspected coronary artery disease, serving as a gatekeeper for cardiac catheterization. With the emergence of non-invasive coronary angiography, the question arises if such a strategy is still sensible, particularly, in view of only a modest agreement between stress testing results and the presence of coronary artery disease established by cardiac catheterization. Much data in support of the diagnostic accuracy and prognostic value of non-invasive coronary angiography by computed tomography have emerged within the last few years. These data challenge the role of stress testing as the initial imaging modality in patients with suspected coronary artery disease. This article reviews the clinical utility, limitations, as well as the hazards of stress testing compared with non-invasive coronary artery imaging by computed tomography. Finally, the implications of this review are discussed in relation to clinical practice.

Correlations between oxidative DNA damage, oxidative stress and coenzyme Q10 in patients with coronary artery disease

The correlation of coronary artery disease (CAD) with pro-oxidant/antioxidant balance and oxidative DNA damage was investigated. Seventy-seven patients with CAD and 44 healthy individuals as control were included in this study. The comparative ratios of ubiquinol-10/ubiquinone-10, 8-hydroxy-2(')-deoxyguanosine/deoxyguanosine and the level of MDA measured by HPLC and the activities of GPX and SOD by colorimetric approach in blood samples obtained from patients with CAD were unraveled.8-OHdG/dG ratios, serum MDA level and GPX activity were found significantly elevated level in serum of CAD patients compared to control group. The SOD activity was observed in stable levels in CAD patients. Ubiquinol-10/ubiquinone-10 ratio was significantly lower in patients with CAD than the controls. The positive correlation was observed between 8-OHdG/dG ratios in both MDA levels and GPX activity, while the significant negative correlation was seemed between the ratio of 8-OHdG/dG and ubiquinol-10/ubiquinone-10 as well as MDA levels and ubiquinol-10/ubiquinone-10 ratio. We conclude that, both the disruption of pro-oxidant/antioxidant balance and oxidative stress in DNA may play an important role in the pathogenesis of coronary artery disease.

The vulnerable plaque: the real villain in acute coronary syndromes

The term "vulnerable plaque" refers to a vascular lesion that is prone to rupture and may result in life-threatening events which include myocardial infarction. It consists of thin-cap fibroatheroma and a large lipid core which is highly thrombogenic. Acute coronary syndromes often result from rupture of vulnerable plaques which frequently are only moderately stenosed and not visible by conventional angiography. Several invasive and non-invasive strategies have been developed to assess the burden of vulnerable plaques. Intravascular ultrasound provides a two-dimensional cross-sectional image of the arterial wall and can help assess the plaque burden and composition. Optical coherent tomography offers superior resolution over intravascular ultrasound. High-resolution magnetic resonance imaging provides non-invasive imaging for visualizing fibrous cap thickness and rupture in plaques. In addition, it may be of value in assessing the effects of treatments, such as lipid-lowering therapy. Technical issues however limit its clinical applicability. The role of multi-slice computed tomography, a well established screening tool for coronary artery disease, remains to be determined. Fractional flow reserve (FFR) may provide physiological functional assessment of plaque vulnerability; however, its role in the management of vulnerable plaque requires further studies. Treatment of the vulnerable patient may involve systemic therapy which currently include statins, ACE inhibitors, beta-blockers, aspirin, and calcium-channel blockers and in the future local therapeutic options such as drug-eluting stents or photodynamic therapy.

Anomalies in the dosing of diltiazem

From early research, investigators understood that the dose of diltiazem required for the treatment of hypertension (commonly 360 mg/day) was greater than that required for the treatment of angina (commonly 240 mg/day). Nonetheless, studies of recent prescribing practices show that the 240 and 180 mg capsule strengths constitute more than 70% of the diltiazem prescriptions for hypertension. Physicians became accustomed to the lower antianginal doses of diltiazem for 7 years before a hypertension indication was approved. Subsequently, these dosing levels were reinforced by the production of once-a-day formulations with highest capsule strengths of 240 mg and 300 mg. These strengths were dictated by the sheer bulk of the formulations, which limited how much diltiazem could be inserted into the #00 capsule, the largest capsule that can be comfortably administered. An examination of the combined data from the six randomized, blinded, and placebo-controlled trials submitted to the FDA for the original new drug applications of the three formulations of diltiazem available in the United States shows a clear linear dose-response relationship between diltiazem dose and blood pressure lowering through the 480-540 mg/day range. It also demonstrates that the 90-120 mg/day range is the "no-effect dose." These conclusions are supported by a MEDLINE review of all other studies of multilevel dosing of higher dose levels of diltiazem. The data support the conclusion that diltiazem is generally underdosed, but when properly dosed may be the single most potent antihypertensive overall.

The esophagus as a source of non-cardiac chest pain

Many patients present with chest pain and are subsequently found to have normal coronary angiography; investigation of these patients frequently stops once coronary artery disease has been ruled out. It is now clear that considerable morbidity may be associated with failure to make a definite diagnosis in these patients, and that efforts to identify a cause for the pain should continue within appropriate limits. This paper presents the evidence in support of an esophageal cause of non-cardiac angina. The authors emphasize the difficulty in distinguishing between cardiac and esophageal angina on the basis of clinical history and suggest an approach to investigation.