bluuebunny/crossref_metadata_2025 huggingface dataset:
Temporal changes in FFR in initially deferred vessels in symptomatic patients
Authors: Shuja R , Payne J , Almomani A , Edupuganti M , Uretsky B , Hakeem A
Published: October 2024

Background

A sizeable proportion of deferred patients based on non ischemic FFR, continue to experience symptoms. Evaluation of serial temporal changes in FFR may help guide follow up and management in such patients.

Methods

Consecutive patients undergoing FFR evaluation in whom PCI was deferred were followed. Patients who had repeat angiographic evaluation for recurrent symptoms and who had FFR re-measured in the same artery were analyzed. In patients who had progression to ischemic FFR, we performed multivariate analysis to identify the factors most associated with accelerated progression.

Results

796 non-ischemic lesions in 559 patients, by FFR were deferred for medical management. Among them 48 patients with 56 lesions underwent repeat FFR evaluation at a mean follow up of 686 ± 418 days (range 30 to 1649) for persistent or recurrent symptoms. FFR value significantly changed from initial mean of 0.85 ± 0.04 to 0.82 ± 0.07 with a mean difference of 0.032 ± 0.01 (P = 0.003) (Figure 1a). 51 lesions were initially non ischemic with FFR > 0.80. Among these 22 (41%) lesions progressed to develop ischemia (FFR < 0.80) from an initial mean FFR of 0.85 ± 0.037 to 0.75 ± 0.051 with a mean difference of 0.1 ± 0.054 ( P <0.001) (Figure 1 b). Among the remaining 30 patients there was no significant change in FFR (0.87 ± 0.048 vs 0.87 ± 0.041; mean difference 0.006 ± 0.05; P = 0.54). Differences in baseline characteristics were as follows (lesion progression vs. none): Age (61±5 vs 63±5;p=0.12), stenosis (58±12 vs 52±10;p=0.07) FFR (0.84±0.04 vs 0.86±0.05;p=0.2); DM (29% ± 58%; p=0.07) smoking 43 ± 48%) prior MI/revascularization (90% vs. 79%; p=0.34) CKD 5% vs. 15%; p=0.24) ACS (38% vs. 38%) and LAD (38% vs. 36%).

Conclusion

Among lesions, initially deferred PCI based on non ischemic FFR, recurrence of symptoms should prompt re-evaluation of ischemia as a large proportion (~40%) of these lesions may demonstrate progression to ischemia (FFR<0.80).Factors associated with progressive decline in FFR warrant further study.Repeat FFR value changesRepeat FFR with ischemia development
The influence of epicardial resistance on Microvascular Resistance Reserve (MRR)
Authors: Mahendiran T , Bertolone D , Pijls N , Viscusi M , Bouisset F , Gallinoro E , Sonck J , Mizukami T , Collet C , De Bruyne B
Published: October 2024

Background

The optimal index of microvascular function should be specific for the microvascular compartment. Yet, coronary flow reserve (CFR), despite being widely used to diagnose coronary microvascular dysfunction (CMD), is influenced by both epicardial and microvascular resistance. Conversely, microvascular resistance reserve (MRR) adjusts for fractional flow reserve (FFR), and thus is theoretically independent of epicardial resistance.

Purpose

We tested the hypothesis that MRR, unlike CFR, is not influenced by increasing epicardial resistance, and thus is a more specific index of microvascular function.

Methods

In a cohort of 16 patients that had undergone proximal left anterior descending artery stenting, we created four grades of artificial stenosis (no stenosis, mild, moderate, and severe) using a coronary angioplasty balloon inflated to different degrees within the stent. For each stenosis grade, we calculated CFR and MRR using continuous thermodilution (64 measurements of each) in order to assess their response to changing epicardial resistance.

Results

Graded balloon inflation resulted in a significant sequential decrease in mean FFR (no stenosis: 0.82 ±0.05; mild: 0.72 ±0.04; moderate: 0.61 ±0.05; severe: 0.48 ±0.09, p<0.001). This translated into a linear decrease in mean hyperaemic coronary flow (no stenosis: 170.5 ±66.8 ml/min; mild: 149.8 ±58.8 ml/min; moderate: 124.4 ±53.0 ml/min; severe: 94.0 ±45.2 ml/min, p<0.001) (Figure 1). CFR exhibited a marked linear decrease with increasing stenosis (no stenosis: 2.5 ±0.9; mild: 2.2 ±0.8; moderate: 1.8 ±0.7; severe: 1.4 ±0.6), corresponding to a decrease of 0.3 for a decrease in FFR of 0.1 (p<0.001). Conversely, MRR exhibited a minimal decrease across all stenosis grades (no stenosis: 3.0 ±1.0; mild: 3.0 ±1.0; moderate: 2.9 ±1.0; severe: 2.8 ±1.0), corresponding to a decrease of just 0.05 for a decrease in FFR of 0.1 (p<0.001) (Figure 1).

Conclusion

MRR, unlike CFR, is minimally influenced by epicardial resistance, and thus should be considered the most specific index of microvascular function.Figure 1.Absolute blood flow (Q) vs FFRFigure 2.MRR/CFR vs FFR
Coexistence of coronary microvascular dysfunction and left ventricular hypertrophy can predict prognosis of patients with nonobstructive coronary arteries
Authors: Ito A , Murai T , Hishikari K , Yano H , Cho S , Ikeda H , Takahashi K , Masumoto H , Watanabe T , Matsumoto T , Takahashi A , Yonetsu T , Sasano T
Published: October 2024

Background

Previous studies have reported that coronary microvascular dysfunction (CMD) and left ventricular hypertrophy (LVH) were associated with adverse cardiovascular events. The aim of this study was to determine the prognostic impact of coexistence of abnormal coronary flow reserve (CFR) and left ventricular mass index (LVMI).

Methods and results

This study included 297 patients who underwent intracoronary physiological assessment including CFR for suspected myocardial ischemia without significant stenosis in the epicardial coronary artery at our hospital from December 2019 to March 2023. Of 297 patients (female: n=89 [30%], age: 70±11 years), 93 (31%) had CMD (CFR<2.5) and 133 (45%) had LVH (LVMI>95 g/m2 for female and >115 g/m2 for male). We excluded patients with history of heart failure (HF). Patients were classified into 4 groups based on the cut-off values of CFR and LVMI: group 1 (no CMD nor LVH, n=109); group 2 (only LVH, n=95); group 3 (only CMD, n=55) and group 4 (both CMD and LVH, n=38). Patients of group 4 had a larger proportion of female (female 19%, 34%, 24% and 61% in group 1 to 4 respectively). There was no significant difference in left ventricular ejection fraction between patients of each groups. Clinical follow-up was performed for major adverse cardiovascular events (MACE) including cardiovascular death, myocardial infarction and hospitalization for new-onset HF. During a median follow-up of 753 days, the cumulative MACE-free survival rate at 2 year were 99.0%, 98.9%, 95.6% and 90.0% in groups 1 to 4. Group 4 showed significantly higher risk of MACE at 2 year compared with group 1 (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.3-5.3; p=0.009). Notably, Group 4 showed the highest incidence of hospitalization for new-onset HF than any other groups.

Conclusion

Patients with both CMD and LVH showed significantly higher risk for MACE and new onset of HF. The combined classification based on CFR and LVMI would identify the high-risk patients for MACE as well as new-onset HF.
Time and cause of death in patients after acute coronary syndrome
Authors: Yang J , Zhang R U I , Zhou M G , Liu F , Huo Y , Ge J
Published: October 2024

Background

Acute coronary syndrome (ACS) remains a substantial mortality burden despite enormous progress achieved in treatment and prevention in recent decades, yet systematic investigation of detailed causes of death among ACS patients remains limited.

Objective

This study aimed to describe the association between time and cause of death in patients after ACS using data from a large, multicenter, contemporary cohort.

Methods

Patients’ data from the China Chest Pain Database between 2015 and 2021 were linked to the China National Death Registration System Database using unique national IDs to obtain accurate vital status. Patients with documented death records were extracted into a merged database, which encompassed all deaths that occurred in the hospital and post-discharge out-of-hospital. Patients were enrolled with a discharge diagnosis of ACS. Cardiovascular (CV) mortality was defined as a death certificate with a CV diagnosis using the ICD-10 classification listed as the primary cause of death. A trend chi-square test was performed to assess the causes of death at different times after ACS.

Results

Among the 126,704 eligible patients, the mean age at baseline was 74 (66, 81) years old, 39.3% were women. Of these patients, 16,546 (13.1%) died during hospitalisation, 53,980 (42.6%) within the first six months after discharge, 19,664 (15.5%) from 6 to12 months after discharge, and 36,514 (28.8%) beyond 12 months after discharge. The most common cause of CV death was ischemic heart disease (70.1%), followed by ischemic stroke (7.1%) and hemorrhagic stroke (6.8%). The main causes of non-CV death were malignant tumours (37.1%) and respiratory disease (21.5%). For death in-hospital, within the first six months, from 6 to 12 months post-discharge, and beyond 12 months, the proportion of CV causes was 86.3%, 78.3%, 70.7%, and 67.9%, respectively (P<0.001). The proportion of deaths due to haemorrhagic stroke and aortic aneurysm/dissection increased progressively with time to death increasing (P<0.001). Meanwhile, the proportion of non-CV deaths continuously increased, reaching 13.7%, 21.7%, 29.3%, and 32.1%, respectively.

Conclusion

Despite cardiovascular diseases being the primary cause of death in patients after ACS, the causes of death vary among patients with different times of death, highlighting the importance of categorising patients into distinct population groups according to time after ACS for targeted cause-specific preventive strategies.
Epidemiology of recurrent myocardial infarction in the reperfusion era
Authors: Christensen D M , Zahir D , Garred C H , Nouhravesh N , Malik M E , Malmborg M , Sindet-Pedersen C , Kober L , Fosbol E , Schou M
Published: October 2024

Introduction

During the past decades, the incidence, management, and outcomes of myocardial infarction (MI) have improved considerably.(1-4) However, the characteristics and outcomes of patients who experience a recurrent MI are sparsely described.

Purpose

This study aimed to analyse the epidemiology and temporal trends of recurrent MI during the reperfusion era.

Methods

A nationwide registry-based cohort study was conducted, including all hospital admissions for recurrent MI in Denmark during 2000 to 2020. Descriptive statistics were used to analyse changes in patient characteristics and management. Survival analyses, taking competing risks into account when relevant, and multivariable Cox proportional hazards models adjusted for sex, age, comorbidities, and pre-recurrent MI pharmaceutical treatment were used to analyse the outcomes of interest: all-cause mortality, hospitalisation for heart failure (HHF), and additional recurrent MI.

Results

A total of n=55,722 admissions for recurrent MI between 2000 and 2020 were included. Median age at admission was 73 years, 68.0% were male, and 32.9% were patients with a 3rd or more recurrent MI. Between 2000-02 (n=9,490) and 2018-20 (n=5,520), patients admitted with a recurrent MI had an increased prevalence of comorbidities such as diabetes, chronic kidney disease, and cancer (Condensed Table 1). Likewise, the use of guideline directed management at the time of recurrent MI increased during the study period: percutaneous coronary intervention (PCI) from 12.8% to 47.2%, coronary angiography (CAG) from 21.8% to 68.0%, statins from 30.5% to 74.2%, and adenosine diphosphate (ADP) receptor inhibitors from 8.2% to 41.8%. Statistically significant linear calendar time trends were observed for all three outcomes (Figure 1). Between 2000-02 and 2018-20 (Figure 2), the absolute 1-year risk of mortality declined from 31.6% to 16.0% (adjusted hazard ratio [aHR]: 0.46 [95% CI: 0.43-0.50]). The absolute 1-year risk of an additional recurrent MI declined from 13.9% to 6.2% (aHR: 0.38 [0.34-0.43]). The absolute 1-year risk of HHF increased from 8.8% in 2000-02 to 10.5% in 2009-11 (aHR: 1.09 [0.99-1.21]), before declining to 7.4% in the final calendar year period (aHR: 0.75 [0.66-0.84]).

Interpretation and conclusion

Despite remarkable advances in the management and outcomes of patients experiencing recurrent MI during the reperfusion era, this remains a vulnerable, high-risk population. Special attention is warranted regarding the optimization of guideline directed care and prevention of heart failure following a recurrent MI.Figure 1Figure 2 & Condensed Table 1
Long-term clinical impact of routine follow-up coronary angiography of asymptomatic patients after complex percutaneous coronary intervention in the drug-eluting stent era
Authors: Kim H J , Jung Y S , Kim S O , Jung J C , Jung Y J , Park J I , Choi K U , Nam J H , Lee C H , Son J W , Kim U , Park J S
Published: October 2024

Background

Drug-eluting stent (DES) implantation has become the standard for treating coronary artery disease (CAD). While routine follow-up coronary angiography (FUCAG) post-percutaneous coronary intervention (PCI) is not recommended in the 2nd generation DES era, its efficacy and necessity in complex PCI remains unclear. This study aims to investigate the utility of FUCAG after complex PCI.

Methods

From 2014 to 2020, a study was conducted on patients at our university medical center who underwent complex PCI. Out of a total of 4,098 individuals, after excluding 848 individuals with a follow-up period of less than 4 years and 288 individuals who experienced an event within a year, a total of 2,962 was enrolled. Follow-up coronary angiography (FUCAG) was defined as angiography performed between 6- and 18-months post-index PCI for lesion evaluation. To adjust for any differences in baseline characteristics between the groups, propensity score matching (PSM) was implemented. The primary outcome was defined as Major Adverse Cardiac Events (MACE), comprising all-cause death, myocardial infarction, and target-lesion revascularization.

Results

PSM was conducted to correct the difference in baseline characteristics between the two groups. In the Kaplan-Meier analysis, there was no difference between FUCAG and clinical follow-up for MACE (Log-rank: P=0.410). Cox proportional regression analysis revealed a hazard ratio (HR) of 0.55 with a 95% confidence interval (CI) of 0.64-1.27, indicating no statistically significant difference.

Conclusions

In our study, FUCAG did not demonstrate a clinical benefit in patients who underwent complex PCI compared to clinical follow-up. Therefore, clinical follow-up may be considered post-PCI surveillance after complex PCI.
Quantitative myocardial blood flow distribution derived from CCTA and determination of myocardium at risk in the FAST TRACK CABG trial
Authors: Serruys P W , Kageyama S , Tsai T , Puskas J , Narula J , Doenst T , Teichgraber U , Tanaka K , De Mey J , La Meir M , Pontone G , Mushtaq S , Pompilio G , Andreini D , Onuma Y
Published: October 2024

Background

In the anatomic SYNTAX score derived from invasive coronary angiography, the ischemic impact of each stenotic coronary segment is weighed with a fixed score based on the severity of luminal diameter narrowing and the theoretical amount of blood flow supplied to the myocardium(1). This method neither accounts for individual variation nor reflects the true extent of myocardium ischemia.

Purpose

We aim to provide a quantitative CT SYNTAX score derived from coronary computed tomography angiography (CCTA) with customized percent blood flow distribution to the myocardium supplied by each stenotic coronary segment to determine the myocardium at risk of ischemia.

Methods

Patients with 3VD and/or left main coronary artery disease (CAD) were included in the first-in-human FAST TRACK CABG trial and received surgical revascularization guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT). The recently reported anatomic CT-SYNTAX score was calculated for all cases. The FFRCT value and percent myocardial blood flow distribution(%MBF) were computed for all 16 SYNTAX score segments using the validated method of Keulards et al(2). On the pre-CABG CCTA, the segments located distal to the site where the FFRCT value dropped below 0.80 were considered at risk of ischemia, and the individual weight point per segment was calculated as 6×%MBF for each segment. The SYNTAX score derived from %MBF is compared to the anatomic and functional CT-SYNTAX score.

Results

Out of 114 patients enrolled, FFRCT and %MBF were analyzable in 106 patients. After excluding vessels with total occlusion, the coronary flow distribution between the right and left coronary systems was 20.5% vs 79.5%, respectively, similar to the 1:5 ratio in the anatomic SYNTAX score. The anatomic and functional CT-SYNTAX scores were 43.6 and 41.1, respectively. The average total %MBF per patient was 72.0(19.1)%, and the average SYNTAX score derived from %MBF was 38.0. There is a strong correlation between functional SYNTAX score and SYNTAX score derived from %MBF (Peason’s R=0.93). Passing-Bablock regression trends showed that the functional SYNTAX score slightly overestimated the SYNTAX score derived from %MBF (Figure 1). The coronary segment weight varied significantly per individual, especially in the presence of total occlusion. Overall, the fixed weight of the anatomic SYNTAX score is a good surrogate for the individualized weighing based on %MBF (Figure 2).

Conclusion

CCTA-derived %MBF enabled clinicians to quantify the individualized myocardium at risk of ischemia or injury in patients with severe CAD. Retrospectively, the fixed weight score used in the anatomical SYNTAX score appeared to be a robust surrogate for myocardial blood flow distribution.Figure 1Figure 2
Risk factors for access site-related complications after distal transradial catheterization
Authors: Park J , Kim D K , Kim K H , Kim D I , Kim S H , You J N , Song Y S , Song Y J
Published: October 2024

Introduction

Distal transradial catheterization (dTRA) has emerged as a viable alternative to conventional transradial access for various interventional procedures.

Purpose

This study aims to identify the risk factors associated with access site-related complications following dTRA.

Methods

A total of 4,977 patients who underwent dTRA were included in this retrospective study. The patients were divided into two groups based on the occurrence of access site-related complications: Complication(+) group (n=272) and Complication(-) group (n=4,705). Various demographic, clinical, and procedural parameters were analyzed to identify potential risk factors. Univariate and multivariate logistic regression models were employed to determine the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each risk factor.

Results

The Complication(+) group exhibited a higher prevalence of male gender (53.7% vs. 68.4%, p<0.001), older age (68.140 ± 11.46 vs. 66.33 ± 11.90, p=0.014), lower body mass index (BMI) (24.35 ± 3.54 vs. 24.97 ± 3.55, p=0.005), larger sheath size (2.45 ± 0.24 vs. 2.40 ± 0.24, p<0.001), increased serum creatinine (Cr) levels (1.33 ± 1.76 vs. 1.10 ± 1.46, p=0.013), longer access time (209.26 ± 237.72 vs. 149.26 ± 143.98, p<0.001), prolonged hemostasis time (257.64 ± 202.40 vs. 197.60 ± 133.39, p<0.001), and extended procedure time (32.24 ± 29.07 vs. 23.04 ± 26.19, p<0.001). Additionally, the Complication(+) group received higher heparin doses (6275.48 ± 2971.05 vs. 5282.74 ± 2952.31, p<0.001) and had a higher incidence of multiple antiplatelet therapy (73.2% vs. 51.3%, p<0.001). However, no significant differences were observed in hypertension, dyslipidemia, diabetes mellitus, or smoking history between the two groups.

The multivariate analysis identified male gender (adjusted OR: 2.073, 95% CI: 1.376 - 3.123, p<0.001), and increased Cr levels (adjusted OR: 1.083, 95% CI: 1.024 - 1.144, p=0.005) as independent risk factors for access site-related complications after dTRA. Moreover, the use of multiple antiplatelet therapy was found to be significantly associated with an increased risk of complications (adjusted OR: 1.948, 95% CI: 1.420 - 2.671, p<0.001).

Conclusion

In patients undergoing dTRA, male gender, increased serum creatinine levels, and the use of multiple antiplatelet therapy were identified as independent risk factors for access site-related complications. These findings highlight the importance of careful patient selection and procedural optimization to minimize complications during dTRA.
Microcirculatory resistance after primary percutaneous coronary intervention predicts residual myocardial damage: a post hoc analysis from the CLEVER-ACS trial
Authors: Candreva A , Gotschy A , Stehli J , Klingenberg R , Heg D , Luescher T F , Matter C , Ruschitzka F , Manka R , Staehli B
Published: October 2024

Introduction

Coronary microvascular dysfunction has been associated with adverse cardiovascular events following acute myocardial infarction. This study evaluates the role of the angiography-derived index of microcirculatory resistance (angio-IMR) in predicting myocardial damage in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Material and Methods

In this post hoc analysis of the Controlled Level Everolimus in Acute Coronary Syndromes (CLEVER-ACS) trial, the associations between post-PCI angio-IMR of infarct-related coronary arteries (IRAs) and infarct size, microvascular obstruction (MVO), and left ventricle ejection fraction (LVEF) at 30 days as assessed with cardiac magnetic resonance (CMR) imaging were investigated. High post-PCI angio-IMR value was defined as a value >40 U. In non-IRAs angio-IMR was measured before the IRA-PCI.

Results

A total of 52 IRAs and 94 non-IRAs of 52 patients were included in the analysis. Post-PCI Angio-IMR was 41.5 (IQR 28.5–55.7) U in IRAs and pre-PCI Angio-IMR was 43.7 (31.7–54.0) U in non-IRAs (p = 0.70). Patients with high post-PCI angio-IMR (52%) exhibited a larger myocardial infarct size (36.0 [23.0–52.5] g vs. 14.5 [6.50–26.5] g, p < 0.001) and a lower LVEF (46.5 [39.5–49.5] % vs. 55.0 [48.0–61.4] %, p = 0.002) at 30 days as compared to those with low post-PCI angio-IMR values. Post-PCI angio-IMR correlated with myocardial infarct size (r = 0.45, p = 0.001) and extent of MVO (r = 0.40, p = 0.004) at 30 days. Post-PCI angio-IMR predicted myocardial infarct size (AUC = 0.78 [0.65–0.92], p = 0.001) and extent of MVO (AUC = 0.74 [0.60–0.89], p = 0.009) at 30 days.

Conclusion

In patients with STEMI undergoing PCI, post-PCI angio-IMR was identified as independent predictor of myocardial infarct size and extent of MVO at 30 days. The assessment of post-PCI angio-IMR values may represent a novel tool for early risk stratification of patients with STEMI.Central illustration
Relationship between diastolic hyperemia-free ratio and fractional flow reserve in patients with aortic valve stenosis
Authors: Nohara H , Egami Y , Abe M , Osuga M , Kawanami S , Kawamura A , Ukita K , Yasumoto K , Tsuda M , Okamoto N , Matsunaga Y , Yano M , Nishino M
Published: October 2024

Background

Diastolic hyperemia-free Ratio (DFR) is new resting index and uses a pragmatic definition by including areas below the average aortic pressure with negative slope. Aortic valve stenosis (AS) exhibits left ventricular hypertrophy and impaired microcirculation. The relationship between DFR and fractional flow reserve (FFR) in the patients with AS has not been yet investigated.

Purpose

We aimed to compare DFR and FFR in each of AS group and Non-AS group and to elucidate a suitable DFR cut-off value predicting less than 0.80 of FFR.

Methods

We enrolled 761 consecutive patients (1033 vessels) who underwent both DFR and FFR in the intermediate coronary artery stenosis between July 2020 and December 2023 in our hospital. We compared the DFR values with FFR values between AS group and Non-AS group. AS was defined as an aortic valve area of 1.5 cm2 or less, a mean aortic valve gradient of 20 mm Hg or more, or a peak aortic-jet velocity of 3.0 m/s or more.

Results

AS group consisted of 55 patients and Non-AS group consisted of 706 patients. A good correlation between DFR and FFR was observed in AS group (R=0.713; p < 0.0001) and Non-AS group (R=0.758; p < 0.0001). The patient backgrounds were similar between AS and Non-AS groups (Table). Regarding physiological findings, DFR in AS group was significantly lower than in Non-AS group (0.83 ± 0.12 vs. 0.88 ± 0.11, p < 0.0001), but FFR was similar (0.80 ± 0.07 vs. 0.81 ± 0.10, p = 0.12). Receiver operating characteristic curve showed that a suitable cut off value of DFR for equivalent FFR value of 0.80 was 0.85 in AS group and 0.89 in Non-AS group, respectively (Figure).

Conclusion

In the patients with AS, DFR may overestimate intermediate coronary artery stenosis and the suitable cut off value was 0.85.2024 ESC AS DFR Table2024 ESC AS DFR Figure
Simplification of coronary continuous thermodilution
Authors: Mahendiran T , Fawaz S , Keulards D , Viscusi M , Everaars H , Keeble T , Damman P , Knaapen P , Collet C , De Bruyne B
Published: October 2024

Background

Continuous coronary thermodilution with saline permits the accurate measurement of volumetric blood flow (Q) and absolute microvascular resistance. However, this requires repositioning of the temperature sensor by the operator to measure the entry temperature of the saline infusate, denoted as Ti.

Purpose

We evaluated if Ti could be predicted based upon known parameters without compromising the accuracy of calculated Q. This would significantly simplify the technique and render it completely operator independent.

Methods

In a derivation cohort of 371 patients with Q measured both at rest and during hyperaemia, multivariate linear regression was used to derive an equation for the prediction of Ti. Agreement of standard Q (calculated with measured Ti) and simplified Q (calculated with predicted Ti) was assessed in a validation cohort of 120 patients that underwent repeat Q measurements. The accuracy of simplified Q was assessed in a second validation cohort of 23 patients with [15O]H2O positron emission tomography (PET)-derived Q measurements.

Results

Simplified Q exhibited strong agreement with standard Q (r=0.94 [95% CI 0.93-0.95], ICC 0.94 [95% CI 0.92-0.95], both p<0.001) (Figure 1). Simplified Q exhibited excellent agreement with PET-derived Q (r=0.86 [95% CI 0.75-0.92], ICC=0.84 [95% CI 0.72-0.91], both p<0.001) (Figure 2). Compared with standard Q, there was no statistically significant difference between correlation coefficients (p=0.29) or standard deviations of absolute differences with PET-derived Q (p=0.85).

Conclusion

Assessing volumetric coronary flow by continuous thermodilution with predicted Ti instead of measured Ti does not compromise its accuracy when compared to [15O]H2O PET. It significantly simplifies the technique and renders absolute coronary flow measurements completely operator independent.Figure 1.AgreementFigure 2.Accuracy
Diagnostic performance of semi-quantitative echocardiographic evaluation in patients with aortic regurgitation: implications for clinical practice
Authors: Gauthier F , Pace N , Fraix A , Filippetti L , Dorr M , Lamiral Z , Maureira P , Selton-Suty C , Huttin O
Published: October 2024

Background

In current practice, screening for severe aortic regurgitation (AR) relies on qualitative and semi-quantitative echocardiographic parameters. No information is given on the diagnostic performance of each of these parameters.

Objectives

The purpose of this study was to investigate the diagnostic performance of semi-quantitative echocardiographic parameters in discriminating moderate from severe AR.

Methods

This single-center retrospective cohort study included 102 consecutive patients with chronic isolated moderate or severe AR. Patients were divided between severe and moderate AR using a combination of left ventricle (LV) dilatation, Proximal Isovelocity Surface Area (PISA) echocardiographic method and cardiovascular magnetic resonance (CMR). Receiver operator characteristic (ROC) curve analysis was performed to assess the diagnostic accuracy of vena contracta width (VC), pressure half-time (PHT) and diastolic flow reversal in descending aorta (DFR).

Results

Threshold value VC > 6mm provided a low sensitivity (40.4%) and an excellent 88.9% specificity for the diagnosis of severe AR. For PHT, the value < 200ms provided a poor sensitivity (2.0%) and an excellent 100% specificity. For DFR, the value ≥ 0.2m/s provided a low sensitivity (37.8%) and a good 78.6% specificity. These 3 parameters have a good positive predictive value (PPV) > 80% and a poor negative predictive value (NPV) < 40%. The area under the curve for the diagnosis of severe AR was 0.72, 0.72 and 0.59 for VC, PHT and DFR, respectively.

Conclusion

Our study demonstrates that the semi-quantitative parameters VC, PHT and DFR are highly specific but poorly sensitive for diagnosing severe chronic AR. They can rule in severe AR but in presence of intermediate values, they are insufficient to rule out severe AR.Venn diagramDiagnostic performance
Coronary physiology: no complete diagnosis without acteylcholine
Authors: Kubik S , H-Ici D O , Joshi S , Manstein M , Paul C , Baerisch A , Kische S
Published: October 2024

Introduction

In up to 40% of patients with pectanginous symptoms, no obstructive coronary artery disease (NOCAD, no stenosis > 50%) can be detected as the cause, so that the terms ANOCA (angina with no obstructive CAD) or INOCA (ischemia with no obstructive CAD) have been defined.

In patients with acute myocardial infarction, 5-20% are diagnosed with MINOCA (myocardial infarction with no obstructive CAD). Microvascular dysfunction (CMD) or coronary spasm has been identified as one of the leading causes of these entities. Further clarification by determining the coronary flow reserve (CFR) an microvascular resistance (IMR) is used to diagnose CMD and is also included in the ESC guidelines. The indices can be determined using thermodilution or ultrasound/doppler wires methods. According to current recommendations, the acteylcholine provocation test is administered in cases of suspected coronary spasm. Despite extensive studies on the safety of ACh testing, many clinics refrain from testing for vasoconstriction disorder although microvascular coronary spasm has been shown to be the leading subgroup of CMD in registry studies.

Purpose

We want to investigate the necessity of a complete coronary physiological examination, consisting of CRF/IMR and ACh provocation test, when compared to testing without ACh.

Methods

All 299 patients who underwent complete physiological testing in our clinic between 2021 and 2024 due to ANOCA, INOCA or MINOCA were evaluated retrospectively. Patients completed a coronary physiological examination using thermodilution and an acetylcholine provocation test. The IMR, CFR, fractional flow reserve (FFR), resting full-cycle ratio (RFR) and the ACh test (defined as epicardial spasm >90% reduction in coronary diameter with symptoms and/or ischemic electrocardiographic changes, respectively no epicardial spasm >90% reduction in coronary diameter with symptoms and and ischemic electrocardiographic changes for microvascular spasm) are thus routinely measured.

Results

Of the total of 299 patients included, 244 (81%) were found to have impaired vasoconstriction with pathologic ACh testing, either alone or in combination with pathologic indices CFR/IMR. The leading finding of pathological spasms was microvascular coronary spasm (66%).

119 patients with normal CFR/IMR had a diagnosis of microvascular (72 patients) or macrovascular spasm (47 patients). 40% of the total patient cohort would have not had a compete diagnosis without the use of Ach testing.

Conclusion

Physiological testing without the systematic use of ACh testing will misdagnose a significant amout of patients with ANOCA/MINOCA/INOCA. ACh testing should be always performed to complete the diagnosis for these patients
Initial results of the READY registry: comparison of visual and physiological lesion characterization and the effect of hydrostatic pressure correction
Authors: Agoston A , Andreka J , Tar B , Tokar Z S , Kest M , Ruzsa Z , Koszegi Z S
Published: October 2024

We aimed to compare resting Pd/Pa, FFR, and distal RFR values with and without hydrostatic pressure correction. Our main goal was to assess the influence of this correction on cut-off value-based decision-making for each physiological parameter.

Data from patients enrolled in two centers of the READY registry (NCT04857762) were analyzed. Center 1 employed catheter and pressure sensor height differences defined from lateral angiographic projection for hydrostatic pressure correction, while Center 2 utilized average pressure differentials from published data.

In Center 1, the height difference underlying the hydrostatic pressure correction did not differ significantly from the average values published in previous publication (-5.22±1.1cm for LAD, 2.44±1.1cm for CX, and 1.63±2.8cm for RCA). Consequently, FFR and distal RFR values corrected with average pressure differentials rarely yielded different cut-off-based characterizations compared to individually measured corrections (2.4%).

A total of 42 measurements were evaluated in Center 1 (33 patients) and 40 measurements in Center 2 (40 patients). Stenoses were characterized using resting Pd/Pa (0.91 ± 0.05), FFR (0.80 ± 0.08), distal RFR (0.86 ± 0.09) and ΔRFR (0.07 ± 0.07) values.

Regarding all the investigated vessels, statistically significant differences were observed in FFR (0.80 ± 0.08 vs 0.81 ± 0.08; p < 0.001), distal RFR (0.86 ± 0.09 vs 0.87 ± 0.09; p < 0.001), and ΔRFR (0.053 ± 0.04 vs 0.047 ± 0.04; p = 0.014) before and after correction. These changes after hydrostatic correction were driven dominantly by the LAD measurements being LAD stenoses constituted the majority of the cases (73.2%).

Overall (n=82), hydrostatic pressure correction modified cut-off-based categorization in 24 (29.3%) cases for Pd/Pa, and 19 (23.2%) cases for both distal RFR and FFR measurements. Notably, ΔRFR assessment also changed in 22.2% of cases after correction. Among LAD stenoses (n=60), hydrostatic pressure correction altered cut-off-based characterization in 22 (36.7%), 19 (31.7%), and 17 (28.3%) cases of resting Pd/Pa, distal RFR, and FFR measurements, respectively. Hydrostatic pressure correction offers the potential to enhance the accuracy of intracoronary physiological measurements, especially for LAD stenoses. Our data suggest that the published average pressure differences of each coronary segment can be used for correction.Lateral view and delta RFRIndividual vs Average LAd correction
PCSK9 inhibitors and coronary atherosclerotic plaque modification: a meta-analysis
Authors: Theofilis P , Papanikolaou A , Vlachakis P K , Antonopoulos A S , Sagris M , Oikonomou E , Tsioufis K , Tousoulis D
Published: October 2024

Introduction

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have emerged as a promising class of medications, primarily recognized for their potent cholesterol-lowering effects. Beyond their established role in reducing low-density lipoprotein cholesterol levels, recent studies suggest a potential impact of PCSK9 inhibitors on the modification of coronary atherosclerotic plaques.

Purpose

The purpose of this meta-analysis is to comprehensively synthesize data from relevant clinical studies and trials that have investigated the effects of PCSK9 inhibitors on coronary atherosclerotic plaque characteristics.

Methods

We performed a literature search for studies assessing the evolution of coronary atherosclerotic plaques after treatment with a PCSK9 inhibitor compared to a control group. We excluded reviews, editorials, case reports/case series, and studies that did not use PCSK9 inhibitors or did not have a control group for comparison. The main outcomes of interest were the changes in percent atheroma volume (PAV), total atheroma volume (TAV), minimal fibrous cap thickness (FCT), lipid arch, as well as the number of patients with improved PAV at follow-up. Effect sizes are presented as standardized mean difference (SMD) or risk ratio (RR) with their corresponding 95% confidence intervals (CIs) and were pooled based on a random-effects model. Publication bias was assessed by funnel plot inspection and egger’s regression test.

Results

The literature search yielded 189 results. After application of the exclusion criteria, a total of 8 studies were selected for data extraction and inclusion in the meta-analysis. Concerning the intravascular ultrasound findings PCSK9 inhibitors induced greater reductions in PAV (SMD -2.70, 95% CI -5.24 to -0.15, p=0.04) (Figure 1) and TAV (SMD -2.46, 95% CI -4.68 to -0.23, p=0.03) (Figure 2), with a greater proportion of patients exhibiting an improvement in PAV (RR 1.30, 95% CI 1.20 to 1.41, p<0.01). Moving to optical coherence tomography parameters, patients treated with PCSK9 inhibitors had an increase in minimal FCT (SMD 2.09, 95% CI 0.12 to 4.07, p=0.04) and a lower lipid arch (SMD -0.64, 95% CI -0.97 to -0.32, p<0.01). Funnel plot inspection and egger’s regression test did not indicate the presence of publication bias.

Conclusion

This meta-analysis suggests that PCSK9 inhibitors use is associated with a favorable coronary atherosclerotic plaque remodeling.Figure 1Figure 2
Early CSWT relieves myocardial fibrosis by inhibiting TGF-Smad2/3-MMP-9
Authors: Wang Y , Li C H U N , Wang L U
Published: October 2024

Objective

To investigate the correlation between the improvement of cardiac function and myocardial fibrosis and the TGF-β1-Smad2/3-MMP-9 signaling pathway in acute myocardial infarction (AMI) rats after early treatment with extracorporeal cardiac shock wave therapy (CSWT).

Methods

Thirty SD rats were randomly divided into five groups: sham group (6 rats), AMI group (6 rats), AMI+CSWT group (6 rats), AMI+SB431542 group (6 rats), and AMI+SB431542+CSWT group (6 rats). AMI was induced in all groups except the sham group. The AMI+CSWT group and AMI+SB431542+CSWT group received CSWT treatment. Echocardiography was performed at 4 days and 62 days postoperatively to assess left ventricular ejection fraction (LVEF) in all groups. Additionally, cardiac tissues were sampled and evaluated for pathological changes and degree of fibrosis by HE staining and Masson staining. The TGF-β1-Smad2/3-MMP-9 signaling pathway and protein expression of COL-I and COL-III were detected in the infarcted border area.

Results

(1) At 4 days postoperatively, EF and FS were significantly lower, and LVESV was enlarged in the AMI group, AMI+CSWT group, AMI+SB431542+CSWT group, and AMI+SB431542 group compared to the sham group (p < 0.05). (2) At 62 days postoperatively, EF and FS were significantly lower, and LVEDV and LVESV were significantly higher in the AMI group compared to the sham group (p < 0.05). EF and FS were significantly higher, and LVEDV and LVESV were significantly lower in the AMI+CSWT group compared to the AMI group (p < 0.05). There was no significant difference in EF, FS, LVEDV, and LVESV between the AMI+CSWT group and the AMI+SB431542+CSWT group (p > 0.05). (3) Histological analysis showed that the AMI group had more blue-stained areas compared to the sham group, while the AMI+CSWT group had fewer blue-stained areas and more neatly arranged red areas compared to the AMI group (p < 0.05). (4) Collagen volume fraction (CVF) was significantly higher in the AMI group compared to the sham group (p < 0.05). CVF was significantly lower in the AMI+CSWT group compared to the AMI group (p < 0.05). There was no significant difference in CVF between the AMI+CSWT group and the AMI+SB431542+CSWT group (p > 0.05). (5) The expression levels of TGF-β1, Smad3, MMP-9, COL-I, and COL-III were significantly higher in the AMI group compared to the sham group (p < 0.05). The expression levels of these proteins were significantly reduced in the AMI+CSWT group compared to the AMI group (p < 0.05).

Conclusions

Early CSWT improves cardiac function and inhibits myocardial fibrosis associated with the TGF-β1-Smad2/3-MMP-9 signaling pathway.pathological changesdegree of fibrosis
Relative interventricular septal brightness for subtype diagnosis of cardiac amyloidosis: pixel brightness analysis using echocardiographic images
Authors: Sugimoto T , Kayama K , Kawada Y , Kikuchi S , Kitada S , Seo Y
Published: October 2024

Background

In the subtypes of cardiac amyloidosis (CA), transthyretin-related (ATTR) CA has been reported to exhibit a higher prevalence of microcalcifications in the interventricular septum (IVS) compared to other subtypes. Whether microcalcifications in the IVS can stratify CA subtypes remains unclear.

Methods

A total of 442 patients with CA: 76 light chain/ amyloid A (AL/AA) type; 255 wild type ATTR (ATTRwt) and 48 variant ATTR (ATTRv) and 19 patients with endomyocardial biopsy-confirmed hypertensive heart disease (HHD) were subjected to echocardiographic pixel brightness quantification of the IVS using open-access image analysis software. The IVS Brightness Index (IVSBI) was defined as the ratio of the average pixel brightness in the IVS to that in the left ventricular (LV) wall opposite the IVS (see figure 1).

Results

The IVSBI from apical 4-chamber view was higher in both the ATTRwt group (median 1.40, IQR 1.22 to 1.67) and the ATTRv group (1.59, 1.32 to 2.00) compared to the HHD group (1.20, 1.02 to 1.37) and the AL/AA group (1.25, 1.11 to 1.46), respectively (P <0.001, see figure 2). In the 273 CA patients undergoing myocardial technetium-99m-pyrophosphate scintigraphy, patients with positive results (1.41, 1.24 to 1.70) exhibited a higher IVSBI compared to those with negative (1.19, 1.09 to 1.46) (P = 0.006). In Cox proportional hazards analysis, age, gender and LV ejection fraction adjusted hazard ratio for the all-cause death of IVSBI (0.5 increase) was 2.0 (95% CI 1.2 to 3.5, P = 0.012) among ATTRwt patients (n=157).

Conclusions

An IVSBI obtained from the apical 4-chamber view could prove valuable in differentiating ATTR subtypes in CA, potentially revealing subtle septal calcifications. A prognostic value may be derived from the elevation of IVSBI in ATTRwt patients.figure 1figure 2
Antiplatelet agents in patients with intermediate coronary artery stenosis and deferred revascularization
Authors: Hong D , Lee S H , Kang D B , Lee J M
Published: October 2024

Background

There is no specific recommendation regarding optimal antiplatelet therapy after deferral of revascularization in patients with established coronary artery disease.

Objectives

The current study investigated safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis in whom revascularization was deferred based on fractional flow reserve (FFR).

Methods

In the Korean National Health Insurance Service database 2013-2020, we identified 4,657 patients who had intermediate coronary artery disease on angiography for which revascularization was deferred based on FFR. During this period, reimbursement criteria of FFR were patients with no previous evidence of myocardial ischemia and intermediate coronary artery stenosis (50-70%) by quantitative coronary angiography. Patients were then classified into two groups according to initiation of antiplatelet therapy after the index procedure. Primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during 5 years of follow-up. Primary safety outcome was any gastrointestinal bleeding.

Results

After propensity score matching in a 1:1 ratio, there were 1,634 patients in antiplatelet therapy group and 1,634 in no therapy group (total N=3,268). The risk of MACCE was similar between the two groups (24.8% vs. 24.7%; adjusted hazard ratio [aHR], 0.97; 95% confidence interval [CI], 0.84-1.13; P=0.745). However, the risk of any gastrointestinal bleeding was higher in antiplatelet therapy group than no therapy group (2.2% vs. 1.2%; aHR, 2.07, 95% CI, 1.08-4.00). These results were consistently found in subgroup analyses.

Conclusions

In patients with intermediate coronary artery stenosis with deferred revascularization based on FFR, antiplatelet therapy was not associated with reduced risk of ischemic events but increased risk of gastrointestinal bleeding.
Colchicine in patients with coronary disease undergoing coronary artery bypass surgery: a meta-analysis of randomized controlled trials
Authors: Kirov H , Caldonazo T , Festerling L , Medin D , Mukharyamov M , Fischer J , Runkel A , Doenst T
Published: October 2024

Background

Recent randomized evidence has shown that low dose colchicine lowers the risk of cardiovascular events in patients with chronic coronary artery disease (CAD). Colchicine has also been used in coronary artery bypass grafting (CABG) with individual studies suggesting protective effects for postoperative atrial fibrillation (POAF). We performed a meta-analysis of studies assessing the effect of colchicine on outcomes in CABG surgery.

Purpose

To determine the potential of colchicine for reducing post-operative atrial fibrillation or other adverse events in patients undergoing CABG.

Methods

We systematically searched three libraries (MEDLINE, Web of Science and The Cochrane Library) selecting all randomized control trials (RCT) including patients who underwent CABG and were randomized for pre- or perioperative administration of colchicine versus standard of care. Primary outcome was incidence of POAF. Inverse variance method (DerSimonian&Laird) and random effects model were performed. The leave-one-out analysis was carried out as a sensitivity analysis to address possible outliers.

Results

From 205 screened studies, five met the inclusion criteria and were selected. The data from 839 patients were included in the final analysis. Included studies were published between 2014 and 2022. The perioperative administration of colchicine was associated with reduction of POAF rates after CABG when compared to standard of care (relative risk; RR= 0.54, 95% confidence interval; CI, 0.40-0.73, p<0.01 – Fig. 1). The leave-one-out analysis confirmed the robustness of the analysis, with minimal variations of the confidence interval (Fig. 2).

Conclusions

This meta-analysis of randomized studies suggests that the perioperative administration of colchicine is associated with significant reduction of POAF rates after CABG.Forest plotLeave-one-out analysis