The Influence of Sex, Age, and Race on Coronary Artery Disease: A Narrative Review

Cardiovascular disease has remained one of the leading causes of mortality in the world. The basic pathophysiology of coronary artery disease (CAD) is a reduction of the blood flow in coronary vessels, leading to restricted blood flow to the heart muscle. Both modifiable and non-modifiable risk factors contribute to its multifactorial etiology. The clinical presentation ranges from asymptomatic to typical symptoms like chest pain, shortness of breath, and left arm or jaw pain. The purpose of this review is to investigate and analyze the variation of CAD depending on the biological sex, age, race, or ethnicity and how it might differ in the studied population while comparing the symptoms and prognosis of CAD. For this research, PubMed's database was used. A total of 926 articles were selected using pre-determined inclusion and exclusion criteria, with 74 articles eligible to be included in the narrative review. Studies were selected from the general population of patients with CAD, regardless of their severity, stage of diagnosis, and treatment plan. The scale for the assessment of non-systematic review articles (SANRA) was used to assess the quality of the study. As humans age, the incidence of CAD increases, and people over 75 are more likely to have multiple-vessel CAD. It has been observed that South Asians have the highest rate of CAD at 24%, while the White population has the lowest at 8%. The prevalence of CAD also depends on race, with the White population having the lowest rate at 3.2%, followed by Hispanics at 5%, Black women at 5.2%, and Black men at 5.7%. Younger Black women tend to have more chest pain. Men with CAD commonly experience chest pain, and women are more likely to present with atypical symptoms. Modifiable risk factors such as smoking and alcoholism are more commonly observed in young men than in young women. Coronary artery disease in the elderly, female, minority, and Black patients is associated with a higher mortality rate. Acknowledging the prevalence of certain risk factors, signs, results, and responses to treatment in certain socio-demographic groups, as well as the provision and accessibility of diagnosis and treatment, would lead to a better outcome for all individuals. The impact of this shift can range from an earlier diagnosis of CAD to a faster and more customized treatment plan tailored to each patient's individual requirements.

Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study

Background

Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries.

Objective

The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia.

Methods

We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis.

Results

In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022.

Conclusions

This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region.

Trial Registration

Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761

International Registered Report Identifier (IRRID)

RR1-10.2196/24595

Adventitial Microcirculation Is a Major Target of SARS-CoV-2-Mediated Vascular Inflammation

We report the case of a 77-year-old woman affected by coronavirus disease-19 (COVID-19) who developed an occlusive arterial disease of the lower limb requiring a left leg amputation. We studied the mechanisms of vascular damage by SARS-CoV-2 by means of a comprehensive multi-technique in situ analysis on the diseased popliteal arterial district, including immunohistochemistry (IHC), transmission electron microscopy (TEM) and miRNA analysis. At histological analyses, we observed a lymphocytic inflammatory infiltrate, oedema and endothelialitis of adventitial vasa vasorum while the media was normal and the intima had only minor changes. The vasa vasorum expressed the ACE2 receptor and factor VIII; compared with the controls, VEGFR2 staining was reduced. TEM analyses showed endothelial injury and numerous Weibel–Palade bodies in the cytoplasm. No coronavirus particle was seen. IL-6 protein and mRNA, together with miR-155-5p and miRs-27a-5p, which can target IL-6, were significantly increased compared with that in the controls. Our case report suggests an involvement of adventitial artery microcirculation by inflammation in the course of COVID-19. Without evident signs of current infection by SARS-CoV-2, endothelial cells show a spectrum of structural and functional alterations that can fuel the cardiovascular complications observed in people infected with SARS-CoV-2.

Implementation of coronary computed tomography angiography as nationally recommended first-line test in patients with suspected chronic coronary syndrome: impact on the use of invasive coronary angiography and revascularization

AIMS

To investigate the impact of applying coronary computed tomography angiography (CCTA), as the recommended first-line diagnostic test in patients with suspected chronic coronary syndrome (CCS) on the use of invasive coronary angiography (ICA) and revascularization practice.

METHODS AND RESULTS

We included all patients undergoing a first-time CCTA (n = 53555) and first-time ICA (n = 41451) from 2008 to 2017 due to suspected CCS in Western Denmark (3.3 million inhabitants). The number of CCTA procedures increased from 352 (2008) to 7739 (2017) (2098%), ICA examinations declined from 4538 to 3766 (17%). The average proportion of no- or non-obstructive coronary artery disease by CCTA was 77.5%. Referral to ICA after CCTA occurred in 16.9% of patients in 2008-10 vs. 13.9% in 2014-17 (P < 0.0001). Revascularization in patients referred to ICA after CCTA increased from 33.8% in 2008-10 vs. 44.4% in 2014-17 (P < 0.0001). The revascularization proportion in patients undergoing ICA with no preceding CCTA was 32.3% in 2008-10 vs. 33.3% in (2014-17) (P = 0.1063). Stratified by age, the overall revascularization proportion increased in the younger age groups and was unchanged or decreased in older age groups: <50 years: 60% increase, 50-59 years: 33% increase, 60-69 years: 0%, and >70 years: 9.5% decrease.

CONCLUSION

The introduction of CCTA as a first-line diagnostic test in patients with suspected CCS does not associate with increased use of invasive angiography and seems to have facilitated a more appropriate revascularization practice.

SPECT myocardial ischemia in the absence of obstructive CAD: Contribution of the invasive assessment of microvascular dysfunction

Coronary microvascular dysfunction has recently emerged as a major independent prognostic factor and can be invasively assessed by coronary flow reserve (CFR) and the index of microvascular resistance (IMR). The incremental prognostic value of myocardial ischemia from SPECT myocardial perfusion imaging (MPI) over clinical characteristics, cardiac risk factors, and stress test data for the prediction of hard cardiac events (myocardial infarction and cardiac death) has been well demonstrated over the last two decades regardless of the absence or presence of epicardial CAD. Recently developed semi-conductor, cardiac-dedicated cameras allow for decreased acquisition times and systematic procubitus and decubitus acquisitions thereby limiting the occurrence of false positives historically attributable to artefactual motion, attenuation, and digestive artifacts. It is therefore likely that pathophysiological causes rather than acquisition artifacts might underlie SPECT perfusion abnormalities. Here, we report four representative examples of patients presenting with ischemia in the setting of no obstructive CAD and normal fractional flow reserve together with elevated IMR and low CFR. The results indicate that ischemia from SPECT MPI could result from microvascular dysfunction in patients without obstructive CAD and should be considered as a prognostic factor for hard cardiac events.

Injection-Less Conductance Method for Vascular Sizing

Lumen vessel sizing is important for optimization of interventional outcomes for treatment of vascular disease. The objective of this study is to develop an injection-less method to determine the lumen diameter, using multiple frequencies that eliminates the need for saline injections. We utilize the same electrical conductance devices developed for the two-injection method. A mathematical electrical model was devised to estimate the lumen area and diameter of the arteries. In vitro experiments were used to validate the method for various lumen diameters with both 5-5-5 (peripheral) and 2-2-2 (coronary) spacing conductance guidewires. The majority of 11 vessel data fall within one standard deviation and all the data fall within two standard deviations. The results indicate that the two-frequency model can reasonably predict the lumen diameter in an in-vitro test set-up. Our findings show that this approach can potentially translate to in vivo which would enable pull-back to reconstruct the lumen area profile of the vessel.

OSA and atherosclerosis

Untreated obstructive sleep apnea (OSA) is increasingly recognized as a risk factor contributing to cardiovascular morbidity and mortality. Research in recent decades has uncovered many components of the complex pathological events leading to the atherosclerotic vascular diseases in OSA, which involve heightened oxidative stress as a result of intermittent hypoxia, vascular inflammation, activation of platelet and coagulation cascades, endothelial dysfunction and ultimately the formation of atherosclerotic plagues. The close association of OSA and conventional cardiovascular risk factors including hypertension, diabetes mellitus, dyslipidemia and obesity adds to the adverse cardiovascular sequelae. Further studies are required to clarify further on the pathophysiological processes, and the effect size of OSA therapy, and other potential preventive strategies.